ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography FREE

Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Moderator

Gregory J. Dehmer, MD, FACC, FACP, FSCAI, FAHA, Writing Group Liaison^⁎

Manesh R. Patel, MD, FACC, Writing Group Liaison

Peter K. Smith, MD, FACC, Writing Group Liaison‡

Charles E. Chambers, MD, FACC, FSCAI^⁎

T. Bruce Ferguson Jr, MD, FACC, FAHA§

Mario J. Garcia, MD, FACC∥

Frederick L. Grover, MD, FACC§

David R. Holmes Jr, MD, FACC, FSCAI†

Lloyd W. Klein, MD, FACC, FSCAI, FAHA†

Marian C. Limacher, MD, FACC, FACP, FAHA†

Michael J. Mack, MD, FACC§

David J. Malenka, MD, FACC, FAHA†

Myung H. Park, MD, FACC¶

Michael Ragosta III, MD, FACC, FSCAI^⁎

James L. Ritchie, MD, FACC, FAHA†

Geoffrey A. Rose, MD, FACC, FASE#

Alan B. Rosenberg, MD†

Andrea M. Russo, MD, FACC, FHRS^⁎⁎

Richard J. Shemin, MD, FACC, FAHA§

William S. Weintraub, MD, FACC, FAHA††

Michael J. Wolk, MD, MACC, Chair

Steven R. Bailey, MD, FACC, FSCAI, FAHA

Pamela S. Douglas, MD, MACC, FAHA

Robert C. Hendel, MD, FACC, FAHA, FASNC

Christopher M. Kramer, MD, FACC, FAHA

James K. Min, MD, FACC

Manesh R. Patel, MD, FACC

Leslee Shaw, PhD, FACC, FASNC

Raymond F. Stainback, MD, FACC, FASE

Joseph M. Allen, MA

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain.

In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

The American College of Cardiology Foundation (ACCF), in collaboration with the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and other societies, developed and published in 2009 appropriate use criteria (AUC) for certain clinical scenarios in which coronary revascularization could be used in an effort to address the rational use of coronary revascularization in the delivery of high-quality care. This document is the first focused update of the original document and includes new literature published since the original document and gaps noted during implementation.

The publication of AUC reflects one of several ongoing efforts by the ACCF and its partners to assist clinicians caring for patients with cardiovascular diseases and in support of high-quality cardiovascular care. The ACCF/American Heart Association (AHA) clinical practice guidelines provide a foundation for summarizing evidence-based cardiovascular care and, when evidence is lacking, provide expert consensus opinion that is approved in review by the ACCF and AHA. However, in many areas, variability remains in the use of cardiovascular procedures, raising questions of over- or underuse. The AUC provide a practical standard upon which to assess and better understand variability.

We are grateful to the technical panel and its chair, Frederick A. Masoudi, MD, MSPH, FACC, FAHA, a professional group with a wide range of skills and insights, for their thoughtful and thorough deliberation of the merits of coronary revascularization for various clinical scenarios. We would also like to thank the parent AUC Task Force and the ACCF staff, Joseph M. Allen and Lea Binder, for their exceptionally skilled support in the generation of this document.

Manesh R. Patel, MD, FACC

Chair, Coronary Revascularization Writing Group

Michael J. Wolk, MD, MACC

Chair, Appropriate Use Criteria Task Force

This report is a focused update of the AUC for coronary revascularization published in 2009 (1). The increasing prevalence of coronary artery disease (CAD), continued advances in surgical and percutaneous techniques for revascularization and concomitant medical therapy for CAD, and the costs of revascularization have resulted in heightened interest regarding the appropriate use of coronary revascularization. Clinicians, payers, and patients are interested in the specific benefits of revascularization. Inappropriate revascularization may be harmful to patients and generate unwarranted costs to the healthcare system, whereas appropriate revascularization procedures can improve patients' clinical outcomes.

As in the original AUC document, the same classification scheme with ratings of appropriate, uncertain, and inappropriate was used. The uncertain category can cause confusion in the interpretation of the AUC and can imply several meanings within its definition. First, the rating of uncertain is used when pertinent literature is either not available or when true discrepancies exist. Second, it is impossible to include every relevant piece of clinical information (e.g., age, sex, diabetes) in the individual clinical scenarios. Attempting to do that may result in an unmanageable number of clinical scenarios and thus compromise the usefulness of the AUC in daily practice. The practice of medicine is full of uncertainties that require a thoughtful clinician to use his or her best judgment about each patient to reach decisions about management. Therefore, a rating of uncertain may be assigned by members of the technical panel if clinical information not provided might affect their individual rating, causing a shift into either the appropriate or inappropriate category.

A rating of uncertain means simply what the name implies, and depending on additional factors, it can be appropriate or inappropriate to perform revascularization. The writing group emphasizes that uncertain indications are not inappropriate. Rather, they reflect clinical scenarios that are reasonable for performing revascularization, but additional clinical factors should be considered or further research is needed to more definitively define the benefits of treatment for patients.

All prior AUC publications have reflected an ongoing effort to critically and systematically create, review, and categorize the appropriateness of certain cardiovascular diagnostic tests, whereas the AUC for coronary revascularization remains the only document addressing treatment. The writing group and technical panel members for this update are identical to the initial AUC (with only 1 exception) and comprised of members from relevant professional societies including both practicing interventional cardiologists and a cardiothoracic surgeon.

For the majority of clinical scenarios, the technical panel only considered the appropriate use of revascularization irrespective of whether this was accomplished by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). However, in a select subgroup of clinical scenarios in which revascularization is generally considered appropriate, the appropriateness of PCI and CABG, individually, was considered. In this subgroup, it was recognized that a focused update could be necessary following publication of the SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) trial (2). Therefore, in this update, the writing group identified 4 indications possibly affected by results of the SYNTAX trial for reexamination. The writing group also split 2 of the indications to represent levels of disease burden, recognizing, however, that the ability to reproducibly quantify the SYNTAX score in routine clinical practice has challenges. Also in this subgroup, the variables of diabetes and depressed left ventricular function were included in the initial AUC, but these were combined for the update because all indications with these variables were rated the same in the previous scores by the technical panel.

In addition, since the publication of the original document, efforts to implement data collection protocols related to the AUC indications identified a gap in the clinical scenarios related to lower-risk unstable angina/non–ST-segment elevation myocardial infarction (UA/NSTEMI) patients and asymptomatic patients with 1- or 2-vessel CAD not involving the proximal left anterior descending artery (LAD) in whom no noninvasive testing had been performed. Although limited new evidence is available for these patient populations since publication, the writing group developed indications to address these previous omissions.

A detailed description of the methods used for rating the selected clinical indications is found in a previous publication, “ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging” (3). Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise. The technical panel is created from nominations given by multiple relevant professional societies and provider-led organizations as well as from health policy and payer communities. To preserve objectivity, technical panels are created so as to not include a majority of individuals whose livelihood is tied to the technology under evaluation.

In making its appropriate use determinations, the technical panel is provided with summaries of the relevant evidence from the medical literature and practice guidelines. Panelists are first asked individually, and then collectively, to assess the benefits and risks of a test or procedure in the context of the potential benefits to patients' outcomes and an implicit understanding of the associated resource use and costs. After the rating process, the final appropriate use ratings are summarized using an established rigorous methodology (4).

Appropriate use criteria are based on current understanding of the technical capabilities and potential patient benefits of the procedures examined. The AUC are also developed to identify common clinical scenarios—but they cannot possibly include every conceivable patient presentation. The term indication is used interchangeably with clinical scenario in the document for brevity and does not imply that a procedure should necessarily be performed. Some patients seen in clinical practice are not represented in these appropriate use criteria or have additional extenuating features that would alter the appropriateness of treatment as compared with the clinical scenarios presented. Additionally, although AUC indications and ratings are shaped by the guidelines, the AUC often contain more detailed clinical scenarios than the more generalized situations covered in clinical practice guidelines, and thus, subtle differences between these 2 guidance tools may be possible. To minimize this possibility, the coronary revascularization criteria were updated in conjunction with members of the ACCF/AHA PCI and CABG revascularization guideline committees.

Appropriate use criteria are intended to assist patients and clinicians, but are not intended to diminish the acknowledged difficulty or uncertainty of clinical decision making and cannot act as substitutes for sound clinical judgment and practice experience. Rather, the aim of these criteria is to allow assessment of utilization patterns for a test or procedure. Comparing utilization patterns across a large subset of provider's patients can allow for an assessment of a provider's management strategies with those of his/her peers. The ACCF and its collaborators believe that an ongoing review of one's practice using these criteria will help guide a more effective, efficient, and equitable allocation of healthcare resources, and ultimately, better patient outcomes.

The indications went through external review by multisociety and specialty representation for the 2009 document. Because of the narrow focus, the indications were not sent for external review for this update.

As previously described, the indications for coronary revascularization were developed considering the following common variables:

The clinical scenarios developed include coronary anatomy, as this is the focus of much of the previous literature on coronary revascularization. However, the writing group recognizes that for everyday patient care, symptom status, ischemic burden, and level of medical therapy often play a critical role in decision making even before the coronary anatomy has been defined by angiography. It is important to note that the indications focus on revascularization, percutaneous or surgical, and do not address diagnostic catheterization or coronary angiography; these criteria are currently under development.

Stakeholders were given the opportunity to participate in the AUC process by submitting nominees from their organizations through a call for nominations announced in the summer of 2006. From this list of nominees, the AUC Task Force and writing group selected technical panel members to ensure an appropriate balance with respect to expertise. The 17-member technical panel was composed of 4 interventional cardiologists, 4 cardiovascular surgeons, 8 members representing noninterventional cardiologists, other physicians who treat patients with cardiovascular disease, health outcome researchers, and 1 medical officer from a health plan. For the update of the AUC for coronary revascularization, the same technical panelists (with 1 exception) from the original document published in 2009 were reconvened to rerate the 15 clinical scenarios included in the focused update.

The technical panel members first rated indications independently. Then, the technical panel participated in 2 conferences calls for a discussion of each indication. After the discussion, panelists independently provided their final scores for each indication. Each panelist had equal weight in producing the final result for the indications and was not forced into consensus. For each indication, the median numerical score was determined and then assigned to an appropriate use category.

For the conference calls, each technical panelist received a personalized rating form that indicated his/her rating for each indication and the distribution of de-identified ratings of other members of the panel. In addition, the moderator received a summary rating form with similar information (including panelist identification), along with other statistics reflecting the level of agreement among technical panel members. The level of agreement among panelists, as defined by RAND, was analyzed for each indication based on the BIOMED rule for a panel of 14 to 16 (a simplified RAND method for determining disagreement) (4). Per the BIOMED definition, agreement was defined as an indication where 4 or fewer panelists' ratings fell outside the 3-point region containing the median score. Disagreement was defined as a situation where at least 5 panelists' ratings fell in both the appropriate and the inappropriate categories. Because the technical panel had 17 representatives, which exceeded the 16 addressed in this rule, an additional level of agreement analysis as described by RAND was performed that examined the interpercentile range compared with interpercentile range adjusted for symmetry (4). This information was used by the moderator to guide the technical panel's discussion by highlighting areas of differences among the panelists.

In developing these appropriate use criteria for coronary revascularization, the technical panel was asked to assess whether coronary revascularization for each indication was appropriate, uncertain, or inappropriate using the following definition of appropriate use:

Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure.

The technical panel scored each indication on a scale from 1 to 9 as follows:

The division of these scores into 3 levels of appropriateness is somewhat arbitrary, and the numeric designations should be viewed as a continuum. Further, there is diversity in clinical opinion for particular clinical scenarios, such that scores in the intermediate level of appropriateness should be labeled uncertain, because critical patient or research data may be lacking or discordant. This designation serves as a prompt to the field to carry out definitive research investigations whenever possible. It is anticipated that the AUC reports will continue to be revised as further data are generated and information from the implementation of the criteria is accumulated.

To prevent bias in the scoring process, care was taken in providing objective, nonbiased information, including guidelines and key references, to the technical panel.

Specific assumptions are provided that were considered by the technical panel in rating the relevant clinical scenarios for the appropriate use of revascularization:

A complete set of definitions of terms used throughout the clinical scenarios is listed in Appendix A. These definitions were provided to and discussed with the technical panel prior to the rating of indications.

As previously stated, the indications assume that patients are receiving risk factor modification according to guideline-based recommendations. For the purposes of the clinical scenarios presented, maximal antianginal medical therapy is defined as the use of at least 2 classes of therapies to reduce anginal symptoms.

Stress testing is commonly used for both diagnosis and risk stratification of patients with coronary artery disease. Using criteria defined for traditional exercise stress tests (14):

Examples of findings from noninvasive studies and their associated level of risk for cardiac mortality are presented in (Table a2) (13). As noted in the footnote to this table, for certain low-risk findings, there may be additional findings that alter the assessment of risk, but these relationships have not been well studied. Implicit in these risk definitions is a measure of the amount of myocardium at risk, or ischemic myocardium. For the purpose of the indications for coronary revascularization, stress test findings are presented by these risk criteria. For patients without stress test findings, please refer to the note below on invasive methods of determining hemodynamic significance. Assume that when prior testing (including an imaging procedure) is referenced in an indication, the testing was performed correctly and with sufficient quality so as to produce a meaningful and accurate result within the limits of the test performance.

For the purposes of the clinical scenarios in this document, patients with both typical and atypical angina are classified by the feature of the CCS grading system presented below. Patients with noncardiac chest pain should be considered to be asymptomatic.

At least 1 of the following:

Variables (1 point each)

Risk of death or ischemic event through 14 days

The writing group evaluated the previous 180 clinical scenarios and identified those where reevaluation, expansion, or consolidation was felt necessary (Table 5). Nine of the 15 updated indications met the definition of agreement as described above. There were no ratings where the technical panel held such opposing viewpoints that the technical panel's votes were determined to be in “disagreement” as defined by the strict RAND definitions and described previously in the Methods section.

As the majority of the original clinical scenarios and ratings were not rerated in this update, (Table 5) represents the focused update indications. In addition, the entire list of 171 clinical scenarios and their appropriateness scores are shown below in (Tables 1, 2, 3, 4). (Figures 1, 2, 3, 4, 5) demonstrate gradients in appropriate use rating by increasingly severe symptom status and ischemic risk, and by the method of revascularization. These are also presented in a format similar to the original document. In addition to the changes reflected in (Table 5), the fractional flow reserve (FFR) cut point was updated from 0.75 to 0.80 in indication 22 to reflect new literature since the publication of the original document and to maintain consistency with guidelines (18).

Recognizing that variability in revascularization methods is often based upon patient factors and local practice patterns, the majority of indications are not intended to distinguish between the specific modes of revascularization (i.e., PCI vs. CABG). However, the writing group recognized that among patients with extensive or complex atherosclerosis, the mode of revascularization is also of interest when revascularization is deemed appropriate. Therefore, (Table 4) presents clinical scenarios where the technical panelists were asked to consider the appropriate use of PCI and CABG as the revascularization method independently of each other (such that each modality would receive separate scores based on each specific clinical indication). These ratings are not intended to be a competitive ranking of PCI versus CABG, or to prioritize a specific approach when both are rated to have the same level of appropriateness.

Many of the known clinical factors that increase the risk of revascularization are shared between CABG and percutaneous methods. In the original AUC for revascularization, clinical scenarios were developed that included diabetes and LV function to stratify patients, but when rated, these features did not result in different ratings and thus were not used in this focused update. However, in an attempt to further stratify patients, the SYNTAX score is used in some of the new clinical scenarios.

The clinical scenarios below specifically apply to patients with multivessel CAD. It is assumed for these clinical scenarios that all patients have unacceptable levels of symptoms despite appropriate medical therapy and evidence of intermediate- to high-risk findings on noninvasive testing. In other words, the technical panel assumed that revascularization is appropriate and focused on rating the merit of the different modes with the intent of complete coronary revascularization for each indication.

In addition, it is assumed that no unusual extenuating circumstances exist (inability to comply with antiplatelet agents, patient is do not resuscitate status, patient preference strongly favoring 1 therapy or comorbidities likely to markedly increase procedural risk substantially). As such, the technical panel rated the appropriateness of PCI and CABG based on the information in the indication alone, assuming other variables are not present that would impact the decision.

The ultimate objective of AUC is to improve patient care and health outcomes. The ACCF and its collaborators believe that careful blending of a broad range of clinical experiences and available evidence-based information will help guide a more efficient and equitable allocation of healthcare resources in cardiovascular revascularization. This approach is not intended to diminish the acknowledged difficulty or uncertainty of clinical decision making. Appropriate use criteria are not substitutes for sound clinical judgment and practice experience. It is acknowledged that some patients seen in clinical practice may not be represented in the AUC or have extenuating features when compared with the clinical scenarios presented.

Since the publication of the original coronary revascularization AUC, there has been substantial national focus on the variability and appropriateness of coronary revascularization. The 2009 AUC specifically for coronary revascularization by PCI has been mapped to the National Cardiovascular Data, Registry (NCDR) CathPCI registry data, and each institution's benchmarked results are now provided to member facilities in quarterly reports as a test quality metric. This initial assessment of PCI appropriateness within the NCDR data was also published by Chan and colleagues (19). Hospitals and operators are encouraged to review their specific reports as part of a quality improvement program to ensure data accuracy and increase the use of appropriate revascularization. Additionally, the SYNTAX trial, which was not formally published until 2009, was anticipated to possibly have an impact on the AUC. Despite calls for earlier updates of specific clinical scenarios, such as the isolated left main coronary artery revascularization, the writing group awaited the peer-reviewed publication of both the original trial data and the intermediate-term follow-up.

This focused update highlights 2 specific areas that were felt to require reconsideration: 1) specific indications that represent gaps identified when mapping the 2009 AUC to the CathPCI registry; and 2) re-evaluation of the indications for the treatment of multivessel CAD with symptoms by method (PCI and CABG) of revascularization as a result of data from the SYNTAX trial.

The 2009 AUC document only had 1 clinical scenario for UA/NSTEMI and high-risk features, which was graded as appropriate. The ratings for these new clinical scenarios (Indications 9 and 10) focus on patients with UA/NSTEMI and low- or intermediate-risk features as determined by the TIMI score. Revascularization in such patients with a low-risk score was graded as uncertain, meaning that revascularization may be reasonable, with the caveat that there is limited data on clinical benefit. For patients with an intermediate-risk score, revascularization was rated appropriate as it was for patients at high risk (Figure 1).

In the 2009 AUC document, the clinical scenario of an asymptomatic patient without prior bypass surgery and with 1- or 2-vessel disease not involving the proximal LAD in whom no noninvasive testing had been performed was not evaluated because this clinical scenario was felt to be uncommon. However, for future mapping of the AUC to the CathPCI registry, the appropriateness of this clinical scenario was graded in this focused update and determined to be inappropriate. This did not affect the appearance of (Figures 2, 3, 4) below because they include indications that were not updated.

In this group of ratings, it is assumed that revascularization is appropriate, and the technical panel rated the appropriateness of the mode of revascularization independently for CABG and PCI (Figure 5). The writing group and technical panel felt some quantification of CAD burden, either by description or SYNTAX score, could be helpful to clinicians. CABG was rated as appropriate in all of the new clinical scenarios developed, whereas PCI was rated as appropriate only in patients with 2-vessel CAD with involvement of the proximal LAD and in patients with 3-vessel disease with a low CAD burden. PCI for 3-vessel disease with a high CAD burden, however, was rated as uncertain. PCI for isolated left main stenosis is now graded as uncertain, as are scenarios with 3-vessel CAD with intermediate to high CAD burden and left main stenosis and additional CAD with low CAD burden. PCI is considered inappropriate for left main stenosis and additional CAD with intermediate to high CAD burden.

Although the appropriate use ratings reflect a general assessment of when revascularization may or may not be useful for specific patient populations, physicians and other stakeholders should continue to acknowledge the pivotal role of clinical judgment in determining whether revascularization is indicated for an individual patient. For example, the rating of a revascularization indication as inappropriate or uncertain should not preclude a provider from performing revascularization procedures when there are patient- and condition-specific data to support that decision. Indeed, this may reflect optimal clinical care, if supported by mitigating patient characteristics. Likewise, uncertain indications require individual physician judgment and understanding of the patient to better determine the usefulness of revascularization for a particular clinical scenario. The ranking of uncertain (4 to 6) should not be viewed as excluding the use of revascularization for such patients. Finally, there may be clinical scenarios in which the use of coronary revascularization for an indication considered to be appropriate does not always represent reasonable practice, such that the benefit of the procedure does not outweigh the risks. Accordingly, the AUC are intended to evaluate overall patterns of care regarding revascularization rather than adjudicating specific cases. In situations where there is substantial variation between the appropriate use rating and what the clinician believes is the best recommendation for the patient, further considerations or actions such as a second opinion may be appropriate. It is not anticipated that all physicians or facilities will have 100% of their revascularization procedures deemed appropriate. However, related to the overall patterns of care, if the national average of appropriate procedure ratings is 80%, e.g., and a physician or facility has only a 40% rate of appropriate procedures, further examination of the patterns of care may be warranted and helpful.

The writing group did not feel the focused update needed to address any clinical scenarios in patients with stable ischemic heart disease and prior CABG. These indications from the prior document show a pattern similar to that seen in patients without prior CABG; the presence of high-risk findings on noninvasive testing, higher severity of symptoms, or an increasing burden of disease in either the bypass grafts or native coronaries increased the likelihood of an appropriate rating. The only inappropriate ratings in patients with prior CABG were noted in patients receiving no or minimal anti-ischemic therapy or having low-risk findings on noninvasive testing. More uncertain ratings occurred in this group of patients, reflecting their higher complexity, higher risk, and the limited availability of published evidence regarding management outcome.

There are many potential applications for the AUC. Clinicians can use the ratings for decision support or as an educational tool when considering the need for revascularization. Moreover, these criteria can be used to facilitate discussion with patients and/or referring physicians about the need for revascularization. Facilities and payers may choose to use these criteria either prospectively in the design of protocols or pre-authorization procedures, or retrospectively for quality reports. It is hoped that payers would use these criteria to ensure that their members receive necessary, beneficial, and cost-effective cardiovascular care, rather than for other purposes.

It is expected that services performed for appropriate indications will receive reimbursement. In contrast, services performed for inappropriate indications may require additional documentation to justify payment because of the unique circumstances or the clinical profile that may exist in such a patient. This additional documentation should not be required for uncertain indications. It is critical to emphasize that the writing group, technical panel, AUC Task Force, and clinical community do not believe an uncertain rating justifies denial of reimbursement for revascularization. Rather, uncertain ratings are those in which the available data vary and many other factors exist that may affect the decision to perform or not perform revascularization. The opinions of the technical panel often varied for these indications, reflecting that additional research is needed. Indications with high clinical volume that are rated as uncertain identify important areas for further research. The AUC writing group and technical panel favor the collaborative interaction of cardiac surgeons and interventional cardiologists Heart Team approach regarding revascularization decisions in complex patients or coronary anatomy.

When evaluating physician or facility performance, AUC should be used in conjunction with efforts that lead to quality improvement. Prospective pre-authorization procedures, if put in place, are most effective once a retrospective review has identified a pattern of potential inappropriate use. Because these criteria are based on current scientific evidence and the deliberations of the technical panel, they should be used prospectively to generate future discussions about reimbursement, but should not be applied retrospectively to cases completed before issuance of this report or documentation of centers/providers performing an unexpectedly high proportion of inappropriate cases as compared with their peers.

The writing group recognizes that these criteria will be evaluated during routine clinical care. To that end, specific data fields such as symptom status, presence or absence of acute coronary syndrome, history of bypass surgery, extent of ischemia on noninvasive imaging, CAD burden, and degree of antianginal therapy are anticipated to provide sufficient detail to determine individual appropriate use ratings. Because a reasonable and tolerated dose of antianginal therapy may vary significantly among different patients, the writing group continues to recommend the use of 2 classes of antianginal therapies as a minimum standard for medical therapy. The writing group also recognizes all data (e.g., visual assessment of stenosis severity, interpretation of noninvasive imaging, symptom severity) collected to assess appropriate use relies on its content accurately reflecting actual patient characteristics. Any current variability in these data points need to be addressed before accurate determination of appropriate use can be provided.

The primary objective of this report is to provide guidance regarding the suitability of coronary revascularization for diverse clinical scenarios. As with previous AUC documents, consensus among the technical panel members was desirable, but an attempt to achieve complete agreement within this diverse panel would have been artificial and was not the goal of the process. Two rounds of ratings with substantial discussion among the technical panel members between the ratings did lead to some consensus among panelists. However, further attempts to drive consensus would have diluted true differences in opinion among panelists and, therefore, was not undertaken. Moreover, remarkable concordance between the appropriateness ratings from the original criteria and 85 cardiologists not participating in the process, and blinded to the initial results, has been documented (20).

Future research analyzing patient outcomes for indications rated as appropriate will help ensure the equitable and efficient allocation of resources for coronary revascularization. Review of appropriateness patterns may also improve understanding of regional variations in the use of revascularization as highlighted in the Dartmouth Atlas Project (21). Further exploration of the indications rated as uncertain will help generate the information required to further define the appropriate use of coronary revascularization. Additionally, the criteria will need to be updated with the publication of ongoing trials in coronary revascularization and new clinical practice guidelines. For additional information and discussion of the literature, please see the ACCF/AHA PCI and CABG guidelines (12- 13).

In conclusion, this document represents the current understanding of the clinical benefit of coronary revascularization with respect to health outcomes and survival. It is intended to provide a practical guide to clinicians and patients when considering revascularization. As with other AUC, the results of some of these ratings will require research and further evaluation to provide the greatest information and benefit to clinical decision making.

Angina is a syndrome typically noted to include discomfort in the chest, jaw, shoulder, back, or arm that is aggravated by exertion or emotional stress and relieved by nitroglycerin. The quality of the discomfort, provoking factors, and relieving factors are used to define typical, atypical, and noncardiac chest pain. Atypical angina is generally defined by 2 of the above 3 characteristics, and noncardiac chest pain is generally defined as chest pain that meets 1 or none of the above criteria. These definitions are presented below.

The writing group assumes that noninvasive assessments of coronary anatomy (i.e., cardiac computed tomography, cardiac magnetic resonance angiography) provide anatomic information that is potentially similar to x-ray angiography. However, these modalities do not currently provide information on ischemic burden and are not assumed to be present in the clinical scenarios.

The writing group recognizes that not all patients referred for revascularization will have previous noninvasive testing. In fact, there are several situations in which patients may be appropriately referred for coronary angiography based on symptom presentation and a high pretest probability of coronary artery disease. In these settings, there may be situations where angiography shows a coronary narrowing of questionable hemodynamic importance in a patient with symptoms that can be related to myocardial ischemia. In such patients, the use of additional invasive measurements (such as fractional flow reserve or intravascular ultrasound) at the time of diagnostic angiography may be very helpful in further defining the need for revascularization and substituted for stress test findings (Table a2).

See the earlier Methods section of the report for a description of technical panel selection, indication development, scope of indications, and rating process.

The American College of Cardiology Foundation and its partnering organizations rigorously avoid any actual, perceived, or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the technical panel. Specifically, all panelists are asked to provide disclosure statements of all relationships that might be perceived as real or potential conflicts of interest. These statements were reviewed by the AUC Task Force, discussed with all members of the technical panel at the face-to-face meeting, and updated and reviewed as necessary. A table of disclosures by all participants, who are listed in Appendix C, in the Appropriate Use Criteria for Coronary Revascularization can be found in Appendix D. In addition, to ensure complete transparency, complete disclosure information—including relationships not pertinent to this document—is available online as a document supplement.

The technical panel members were asked to refer to the relevant guidelines for a summary of the relevant literature, guideline recommendation tables, and reference lists provided for each indication table when completing their ratings (Online Appendix).

Manesh R. Patel, MD, FACC—Chair, Appropriate Use Criteria for Coronary Revascularization Writing Group—Assistant Professor of Medicine, Division of Cardiology, Assistant Director, Cardiac Catheterization Lab, Duke University Medical Center, Durham, NC

Gregory J. Dehmer, MD, FACC, FACP, FSCAI, FAHA—Past President, Society for Cardiovascular Angiography and Interventions; Professor of Medicine, Texas A&M School of Medicine; and Director, Cardiology Division, Scott & White Clinic, Temple, TX

John W. Hirshfeld, MD, FACC—Professor of Medicine, Hospital of The University of Pennsylvania, Department of Medicine, Cardiovascular Medicine Division, Philadelphia, PA

Peter K. Smith, MD, FACC—Professor and Chief, Thoracic Surgery, Duke University, Durham, NC

John A. Spertus, MD, MPH, FACC—Professor, UMKC School of Medicine, Director of CV Education and Outcomes Research, MidAmerica Heart Institute of St. Luke's Hospital, Kansas City, MO

Frederick A. Masoudi, MD, MSPH, FACC, FAHA—Moderator for the Technical Panel—Associate Professor of Medicine (Cardiology), University of Colorado Denver, Aurora, CO

Ralph G. Brindis, MD, MPH, FACC, FSCAI^⁎—Methodology Liaison for the Technical Panel—Regional Senior Advisor for Cardiovascular Disease, Northern California Kaiser Permanente; Clinical Professor of Medicine, University of California at San Francisco; Chief Medical Officer and Chairman, NCDR Management Board, American College of Cardiology Foundation, Washington, DC

Gregory J. Dehmer, MD, FACC, FACP, FSCAI, FAHA—Writing Group Liaison for the Technical Panel—Past President, Society for Cardiovascular Angiography and Interventions, Professor of Medicine, Texas A&M School of Medicine; and Director, Cardiology Division, Scott & White Clinic, Temple, TX

Manesh R. Patel, MD, FACC—Writing Group Liaison for the Technical Panel—Assistant Professor of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC

Peter K. Smith, MD, FACC—Writing Group Liaison for the Technical Panel—Professor and Division Chief, Cardiothoracic Surgery, Duke University, Durham, NC

Karen J. Beckman, MD, FACC*—Professor of Medicine, University of Oklahoma Health Science Center, Cardiac Arrhythmia Research Institute, Oklahoma City, OK

Charles E. Chambers, MD, FACC, FSCAI—Professor of Medicine and Radiology, Penn State University, Hershey Medical Center, Hershey, PA

T. Bruce Ferguson Jr., MD, FACC, FAHA—Chairman, Department of Cardiovascular Sciences, East Carolina Heart Institute, Greenville, NC

Mario J. Garcia, MD, FACC—Professor of Medicine, Chief, Division of Cardiology Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY

Frederick L. Grover, MD, FACC—Professor and Chair, Department of Surgery, University of Colorado School of Medicine, Denver Veterans Affairs Medical Center, Denver, CO

David R. Holmes Jr., MD, FACC, FSCAI—Professor of Medicine, Mayo Clinic, Rochester, MN

Lloyd W. Klein, MD, FACC, FSCAI, FAHA—Advocate Illinois Masonic Medical Center, Chicago, IL

Marian C. Limacher, MD, FACC, FACP, FAHA—Senior Associate Dean for Faculty Affairs and Professional Development, AHA Endowed Professor of Cardiovascular Research, University of Florida College of Medicine, Gainesville, FL

Michael J. Mack, MD, FACC—Medical Director Cardiovascular Surgery, Baylor Healthcare System, Dallas, TX

David J. Malenka, MD, FACC, FAHA—Professor of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH

Myung H. Park, MD, FACC—Associate Professor of Medicine and Director, Pulmonary Vascular Diseases Program, University of Maryland School of Medicine, Division of Cardiology, Baltimore, MD

Michael Ragosta III, MD, FACC, FSCAI—Director, Cardiac Catheterization Laboratory, Professor of Medicine, University of Virginia, Charlottesville, VA

James L. Ritchie, MD, FACC, FAHA—Consultant, Seattle Veterans Hospital, Bend, OR

Geoffrey A. Rose, MD, FACC, FASE—Director of Imaging, Sanger Heart & Vascular Institute, Clinical Professor of Medicine, University of North Carolina at Chapel Hill, Charlotte, NC

Alan B. Rosenberg, MD—Vice President, Clinical Pharmacy and Medical Policy, WellPoint, Inc., Chicago, IL

Andrea M. Russo, MD, FACC, FHRS†—Professor of Medicine, University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School, Director, Cardiac Electrophysiology and Arrhythmia Services, Cooper University Hospital, Camden, NJ

Richard J. Shemin, MD, FACC, FAHA—Professor of Surgery, UCLA David Geffen School of Medicine, Chief, Division of Cardiothoracic Surgery; Executive Vice Chair, Department of Surgery; and Co-Director, Cardiovascular Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA

William S. Weintraub, MD, FACC, FAHA—Chief, Section of Cardiology, Director, Christiana Center for Outcomes Research, Christiana Care Health System, Newark, DE

Stephan Achenbach, MD, FACC, FESC—Professor of Medicine, Department of Cardiology, University of Giessen, Giessen, Germany

Joseph S. Alpert, MD, FACC, MACP, FAHA—Professor of Medicine and Director of Coronary Care, Cardiac Rehabilitation, and the Chest Pain Unit, University of Arizona Health Network, Tucson, AZ; Editor-in-Chief, The American Journal of Medicine

H. Vernon Anderson, MD, FACC, FAHA—Professor of Medicine, Cardiology Division, University of Texas Health Science Center, Houston, TX

Elliott M. Antman, MD, FACC, FAHA—Professor of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Associate Dean for Clinical/Translational Research, Harvard Medical School, Boston, MA

Lee M. Arcement, MD, MPH, FACC, FCCP—Chief of Cardiology, Chabert Medical Center, Houma, LA; Division Director of Heart Failure Disease Management, Louisiana State University Health Care Services, Baton Rouge, LA

R. Morton Bolman III, MD, FACC—Professor of Surgery, Harvard Medical School, and Chief, Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA

Javed Butler, MBBS, MPH, FACC, FAHA—Professor of Medicine and Director, Heart Failure Research, Emory University, Atlanta, GA

Jun R. Chiong, MD, MPH, FACC, FCCP—Associate Professor of Medicine Medical Director, Advanced Heart Failure Program Loma Linda University Medical Center, Loma Linda, CA

G. William Dec, MD, FACC, FAHA—Professor of Medicine, Harvard Medical School and Chief, Cardiology Division, Massachusetts General Hospital, Boston, MA

David P. Faxon, MD, FACC—Vice Chair of Medicine for Strategic Planning, Department of Medicine, Brigham and Women's Hospital, Boston, MA

Raymond J. Gibbons, MD, FACC—Professor of Medicine, Mayo Clinic, Rochester, MN

Robert A. Guyton, MD, FACC—Professor of Surgery and Chief of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA

Alice K. Jacobs, MD, FACC—Professor of Medicine, Boston University School of Medicine; Director, Cardiac Catheterization Laboratories and Interventional Cardiology, Boston Medical Center, Boston, MA

John A. Kern, MD, FACS—Professor of Surgery, Co-Director Heart and Vascular Center, University of Virginia Health System, Charlottesville, VA

Lloyd W. Klein, MD, FACC, FSCAI, FAHA—Professor of Medicine, Rush University Medical Center, Chicago, IL

Michael J. Mack, MD, FACC—Director, Cardiopulmonary Research Science Technology Institute, Baylor Healthcare System, Dallas, TX

L. Brent Mitchell, MD, FACC, FRCPC—Professor and Head, Department of Cardiac Sciences, Calgary Health Region and University of Calgary; Director, Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada

Marc R. Moon, MD, FACC—Joseph C. Bancroft Professor of Surgery, Barnes-Jewish Hospital/Washington University, St. Louis, MO

Douglass A. Morrison, MD, PhD, FACC, FSCAI—Professor of Medicine, Director, Cardiac Catheterization Lab, Yakima Heart Center, Yakima, WA

Reid T. Muller, MD, FACC, FACP—Albany Associates in Cardiology, St. Peter's Hospital, Albany, NY

Sherif F. Nagueh, MD, FACC—Professor of Medicine, Methodist DeBakey Heart and Vascular Center, Houston, TX

Navin C. Nanda, MD, FACC—Distinguished Professor of Medicine and Cardiovascular Disease and Director, Heart Station/Echocardiography Laboratories, University of Alabama at Birmingham, Birmingham, AL

William C. Nugent, MD—Professor and Chief, Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH

Myung H. Park, MD, FACC—Associate Professor of Medicine and Director, Pulmonary Vascular Diseases Program, University of Maryland School of Medicine, Division of Cardiology, Baltimore, MD

Michael Poon, MD, FACC—Associate Clinical Professor of Medicine, Cabrini Medical Center, New York, NY

John D. Puskas, MD, FACC—Professor of Surgery (Cardiothoracic) and Associate Chief of Cardiothoracic Surgery, Emory University; Chief of Cardiac Surgery, Emory Crawford Long Hospital, Atlanta, GA

J. Scott Rankin, MD—Associate Clinical Professor, Vanderbilt University, Nashville, TN

Rita F. Redberg, MD, MSc, FACC, FAHA—Professor of Medicine, University of California at San Francisco School of Medicine, Division of Cardiology, San Francisco, CA

Michael W. Rich, MD, FACC, FAHA—Professor of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO

Craig R. Smith, MD, FACC—Johnson & Johnson Distinguished Professor and Valentine Mott Professor of Surgery, Chairman, Department of Surgery, College of Physicians & Surgeons of Columbia University, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY

Barry F. Uretsky, MD, FACC, FSCAI, FAHA—Clinical Professor of Medicine, University of Arkansas for Medical Sciences, Director, Interventional Cardiology, Central Arkansas Veterans Health System, Little Rock, AR

Edward D. Verrier, MD, FACC, FACS, FAHA—K. Alvin & Shirley Merendino Endowed Professor of Cardiovascular Surgery, Vice Chairman for Clinical Affairs, Department of Surgery, University of Washington, Surgical Director, Joint Council on Thoracic Surgery Education, Seattle, WA

Susan J. Zieman, MD, PhD, FACC—Medical Officer, Geriatrics Branch, Division of Geriatrics and Clinical Gerontology, National Institute on Aging/National Institutes of Health, Bethesda, MD

Michael J. Wolk, MD, MACC—Chair, Task Force, Past President, American College of Cardiology Foundation and Clinical Professor of Medicine, Weill-Cornell Medical School, New York, NY

Steven R. Bailey, MD, FACC, FSCAI, FAHA—Chair, Division of Cardiology, Professor of Medicine and Radiology, Janey Briscoe Distinguished Chair, University of Texas Health Sciences Center, San Antonio, TX

Pamela S. Douglas, MD, MACC, FAHA, FASE—Past President, American College of Cardiology Foundation; Past President American Society of Echocardiography; and Ursula Geller Professor of Research in Cardiovascular Diseases, Duke University Medical Center, Durham, NC

Robert C. Hendel, MD, FACC, FAHA, FASNC—Chair, Appropriate Use Criteria for Radionuclide Imaging Writing Group—Director of Cardiac Imaging and Outpatient Services, Division of Cardiology, Miami University School of Medicine, Miami, FL

Christopher M. Kramer, MD, FACC, FAHA—Professor of Medicine and Radiology and Director, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA

James K. Min, MD, FACC—Director of Cardiac Imaging Research and Co-Director of Cardiac Imaging, Cedars-Sinai Heart Institute, Los Angeles, CA

Manesh R. Patel, MD, FACC—Assistant Professor of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC

Leslee Shaw, PhD, FACC, FASNC—Professor of Medicine, Emory University School of Medicine, Atlanta, GA

Raymond F. Stainback, MD, FACC, FASE—Medical Director of Noninvasive Cardiac Imaging, Texas Heart Institute at St. Luke's Episcopal Hospital; Clinical Associate Professor of Medicine, Baylor College of Medicine, Houston, TX

Joseph M. Allen, MA—Director, TRIP (Translating Research Into Practice), American College of Cardiology Foundation, Washington, DC

American College of Cardiology Foundation