CLINICAL
NEWS
American College of Cardiology Extended Learning
What’s Been the Impact of AUC in PCI?
T
he American College of Cardiology (ACC)
and the American Heart Association
(AHA) have an ongoing 30-year commitment to produce clinical practice guidelines to
provide evidence-based recommendations across a
number of clinical conditions, diagnostic tests, and
therapeutic interventions.
In 2005, partly in response to concerns about
the increased use of cardiovascular imaging and
procedures, the two organizations partnered to
create appropriate use criteria (AUC) to aid clinical decision-making using case scenarios that
provide real-world specifics for applying guideline
recommendations.
In 2009, the ACC and AHA, along with other
professional societies (the Society for Cardiovascular Angiography and Interventions, Society
of Thoracic Surgeons, American Association
for Thoracic Surgery, and the American Society
of Nuclear Cardiology, to name a few) released
AUC for coronary revascularization.1 Chaired by
Manesh R. Patel, MD, an Assistant Professor and
Assistant Director of the Cardiac Catheterization
Laboratory at Duke University Medical Center,
Durham, NC, the document critically examined
the evidence in an effort to improve patient selection for PCI and address concerns about potential
overuse. Specifically, studies demonstrated that
one in six non-acute PCIs were classified as inappropriate—although more recent AUC documents
use the term “rarely appropriate”—suggesting
that the benefits of the procedure are unlikely to
outweigh the risks.
It was also anticipated that AUC might
reduce the tremendous variations in cardiology practice across the country that cannot
be readily explained by differences in patient
characteristics or by disease severity. So, what’s
happened?
IMPACT OF AUC
To listen to an interview with Manesh
R. Patel, MD, on
appropriateness
criteria in patients
with CAD, scan the
code. The interview
was conducted by
Spencer B. King,
III, MD.
In late 2015, Dr. Patel and colleagues reported their analysis
of almost 2.7 million PCI
procedures at 766 hospitals.2
Using National Cardiovascular Data Registry (NCDR®)
data, they applied the 2012
Appropriate Use Criteria for
Coronary Revascularization to
these procedures and noted
that the volume of non-acute
procedures decreased (from
89,704 in 2010 to 59,375 in
2014), whereas the number
of acute procedures was
similar (377,540 in 2010 vs.
374,543 in 2014).
Compared to 2010, they
noted a shift in the patients
undergoing non-acute pro-
28 CardioSource WorldNews
cedures, with those undergoing PCI in 2014
showing more severe angina, more antianginal
agents prior to PCI, and more high-risk findings
on pre-PCI noninvasive testing. The classification
of non-acute PCIs as inappropriate declined from
26% in 2010 to 13% in 2014, although hospitallevel variation in PCIs classified as inappropriate
did not change substantially, with an interquartile
range of 5.9%–22.9% (median:12.6%).
The authors said the findings suggest that clinicians are doing a better job of identifying and limiting non-acute PCI procedures to those patients
most likely to benefit from revascularization.
In an accompanying editorial,3 Robert A. Harrington, MD, noted that, while there has been
some appropriate criticism of cardiology practices
that overuse imaging technologies and even coronary revascularization procedures, “the majority
of practicing U.S. cardiologists typically respond to
data, evidence, and guidelines in a positive manner
of adoption and change.”
CURRENT APPROACH “NOT OK”
There’s still one issue that needs work, as Dr. Patel
himself recently noted: current risk stratification
for patients with chest pain is poor. In patients
with intermediate pre-test probability of CAD, the
guidelines say to consider a stress test; if there is
chest pain, a nondiagnostic ECG, and negative cardiac markers, stress myocardial perfusion imaging
is an option as is stress echo; computed tomography (CT) angiography is another option.
He said the significant variability in PCI
around the U.S. (and the world) may, in part,
be driven by noninvasive tests, such as echo,
radionuclide imaging, CT, and cardiac magnetic
resonance. Not only are there more options,
there is direct-to-consumer marketing of cardiac
imaging benefits.
Dr. Patel said evidence of noninvasive imaging
exists but is limited. One thing is certain: what
passes today for usual imaging and care patterns
(multiple tests with repeat testing) will not be OK
in the near future. Both CT-fractional flow reserve
(FFR) and invasive FFR co-registration are emerging opportunities.4,5 ■
REFERENCES:
1. Patel MR, Dehmer GJ, Hirshfeld JW, et al. J Am Coll
Cardiol. 2009;53(6):530-53.
2. Desai NR, Bradley SM, Parzynski CS, et al. JAMA.
2015;314:2045-53.
3. Harrington RA. JAMA. 2015;314:2029-31.
4. Douglas PS, Pontone G, Hlatky MA, et al. Eur Heart J.
2015;36:3359-67.
5. Douglas PS, Hoffman U, Patel MR, et al. N Engl J Med.
2015;372:1291-300.
Take-aways
• The practice of interventional cardiology has
evolved since the introduction of Appropriate Use
Criteria in 2009, but there remain large hospital-tohospital variations in the use of PCI.
• One problem is that current risk stratification for
patients with chest pain is poor; another major
issue is the variety of noninvasive technologies
availab le, with direct-to-consumer marketing of
cardiac imaging benefits.
• One thing is certain: usual imaging and care
patterns (multiple tests with repeat testing) will not
be OK in the future.
April 2016