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Revascularization guidelines updated
2 February 2012
MedWire News: Updated appropriate-use criteria for coronary revascularization have been released, following the publication of new clinical data and identification of gaps in data collection.
The new criteria, an update of the previous revascularization criteria published in 2009, offer detailed guidance on when to use an invasive procedure to improve blood flow to the heart and how to choose the most appropriate procedure for each patient.
“This document helps patients, physicians, and payers determine when it’s reasonable to do a procedure that is intended to improve the patient’s quality of life, health status, and long-term survival,” said lead author, Manesh Patel (Duke University, Durham, North Carolina, USA), in an associated press release.
“It can also assist patients and physicians with health-related discussions and shared decision-making, so that patients are confident they are getting the right procedures for them.”
The new criteria were developed by the American College of Cardiology Foundation, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, and Society of Cardiovascular Computed Tomography.
The previous criteria identified 180 clinical scenarios to reflect patient presentations encountered in everyday practice. These scenarios were rated by a panel of interventional cardiologists, heart surgeons, noninterventional cardiologists, health outcomes researchers, and a medical officer.
Using a modified Delphi exercise, they assigned a score from 1 to 9 to each scenario to indicate whether revascularization was appropriate (score of 7–9), inappropriate (score of 1–3), or uncertain (score of 4–6) in terms of patient outcomes and survival.
The updated criteria state that coronary artery bypass graft surgery is appropriate for patients with coronary artery disease involving two vessels to include the proximal left anterior descending coronary artery (LAD) and all variations of three-vessel and left main coronary artery disease.
Percutaneous coronary intervention (PCI) is appropriate in patients with coronary artery disease in all three arteries only if the coronary artery disease burden is low.
However, it is uncertain whether PCI is appropriate in patients with three-vessel coronary artery disease and an intermediate or high disease burden.
The value of PCI is also uncertain for patients with blockages in the left main coronary artery, either alone, or with blockages in other arteries and low coronary artery disease burden.
According to the criteria, PCI is inappropriate for patients with intermediate or high disease burden and blockages in the left main coronary artery.
Co-author Peter Smith, also from Duke University, explained in a press statement: “The new ratings that have changed PCI from inappropriate to uncertain for low burden left main disease and from uncertain to appropriate for low burden three-vessel disease should result in careful selection of high-risk surgery patients for PCI.”
“Surgeons and cardiologists will now work together to maximize the benefit and minimize the risk for these patients who are at high risk for premature mortality.”
Patel added: “We hope physicians, surgeons, caregivers, and patients have a conversation in each individual case about the best way to improve patient outcomes.”
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