JACC publishes appropriate use criteria for treating severe aortic stenosis

Eleven organizations collaborated on the first appropriate use criteria (AUC) for treating patients with severe aortic stenosis (AS). Published online Oct. 17 in the Journal of the American College of Cardiology, the guidelines offer recommendations on when to use transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR) or neither—and when either technique may be appropriate.

“The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present,” wrote Robert O. Bonow, MD, MS, MACC, chair of the writing group, and colleagues. “This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.”

To develop the AUC, a multidisciplinary team of experts wrote up common clinical scenarios and had rating panelists score treatment options for each scenario based on the appropriateness of care. Some of the scenarios were revised and scored multiple times based on “robust discussion” and feedback, according to the document.

The AUC breaks down these scenarios and provides median appropriateness ratings for different treatment options—including TAVR and SAVR—or doing no intervention at all. It also provides definitions for low risk, intermediate risk and high risk AS patients.

The authors said the ratings should be used as guidelines rather than definitive endorsements for treatments. They also expect to adjust the AUC to account for technological and clinical advances.

“Some of these severe AS scenarios, particularly those rated May Be Appropriate and Rarely Appropriate, may require additional research and further evaluation to determine the best treatment options for individual patients,” wrote Bonow and co-authors. “It is important to reiterate that an AUC score of Rarely Appropriate should not prohibit a treatment or procedure from being provided to the patient, and an Appropriate AUC score should not mandate that a procedure be performed or treatment offered. As advances in technology and evidence-based medicine occur rapidly, and future studies of implementation of these criteria for severe AS are conducted, we expect further areas of exploration and elaboration to be identified.”