Cardiovascular societies release AUC for revascularization in patients with ACS

Several medical societies recently released updated appropriate use criteria (AUC) for coronary revascularization in patients with acute coronary syndromes (ACS).

The American College of Cardiology (ACC), American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography and the Society of Thoracic Surgeons sponsored the AUC.

The document was published online in the Journal of the American College of Cardiology on Dec. 21. Revascularization by PCI or CABG is the most commonly used therapy for patients with ACS, according to the writing group.

“This update provides a reassessment of clinical scenarios that the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria,” Manesh R. Patel, MD, chair of the writing group, said in a news release. “The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making and ultimately lead to better patient outcomes.”

The societies previously combined indications for revascularization in ACS and stable ischemic heart disease in one AUC document, which was first released in 2009 and last updated in 2012. They recently decided to separate the documents for ACS and stable ischemic heart disease. They plan on releasing the updated criteria for patients with ischemic heart disease at an undisclosed date this year.

Since the last document was published in 2012, societies have published new guidelines for ST-segment elevation MI (STEMI), non-ST-segment elevation MI (NSTEMI) and unstable angina, according to the writing group members. They also noted that there were updates on the stable ischemic heart disease guideline and a combined update on the PCI and STEMI guideline. During that time period, there have been numerous clinical trials published and diagnostic technologies approved, as well.

For this document, the writing group developed 17 clinical scenarios that resembled encounters physicians saw in everyday practice. An independent rating panel scored the scenarios on a scale of 1 to 9. Scores of 1 to 3 indicated coronary revascularization was considered rarely appropriate, scores of 4 to 6 indicated coronary revascularization might be appropriate and scores of 7 to 9 indicated coronary revascularization was considered appropriate.

Of the scenarios, 10 were considered appropriate, six were considered as possibly being appropriate and one was considered rarely appropriate.

The rating panel defined a scenario as being appropriate “when the potential benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the potential negative consequences of the treatment strategy.”

The writing group mentioned that revascularization in clinical scenarios with STEMI and NSTEMI were considered appropriate. Clinical scenarios with unstable angina and intermediate- or high-risk features were also deemed appropriate.

The writing group consisted of cardiovascular health outcomes researchers, interventional cardiologists, cardiothoracic surgeons and general cardiologists.

“The publication of AUC reflects one of several ongoing efforts by the ACC and its partners to assist clinicians who are caring for patients with cardiovascular diseases and in support of high-quality cardiovascular care,” Patel and Michael J. Wolk, the moderator of the appropriate use criteria task force, wrote in the document. “The ACC/American Heart Association 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 ACC and American Heart Association. However, in many areas, variability remains in the use of cardiovascular procedures, raising questions of over- or under-use. The AUC provide a practical standard upon which to assess and better understand variability.”