Restructured appropriate use criteria offer detailed guidance on when to use an invasive procedure to improve blood flow to the heart, and how to choose the best procedure for each patient.

Researchers at Duke University (Durham, NC, USA) and other institutions updated the appropriate use criteria, replacing a previous set from in 2009. The criteria are based on over 200 clinical scenarios that reflect common heart problems seen in everyday cardiology practice. The scenarios were rated by an expert panel composed of interventional cardiologists, heart surgeons, noninterventional cardiologists, physicians who treat patients with cardiovascular disease (CVD), health outcomes researchers, and a medical officer from a health plan. Panelists assigned a score to each scenario indicating whether an invasive procedure to restore blood flow to the heart would be considered appropriate, inappropriate, or uncertain.

The updated criteria reaffirm that coronary artery bypass graft (CABG) is appropriate for patient scenarios with coronary artery disease (CAD) involving two vessels to include the proximal left anterior descending (LAD) and all variations of three-vessel and left main CAD. Angioplasty is appropriate in patients with CAD in all three heart arteries only if the severity of CAD burden is low. It is uncertain whether PCI is appropriate in patients with three- vessel coronary artery disease and an intermediate to high disease burden. The appropriateness of PCI is also deemed uncertain in patients with blockages in the left main coronary artery, alone or with blockages in other arteries and low CAD burden. However, PCI is considered inappropriate in patients with blockages in the left main coronary artery with intermediate to high disease burden.

The updated criteria were published online on January 30, 2012, in the Journal of the American College of Cardiology.

“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 assistant professor of cardiology Manesh Patel, MD. “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 updated criteria were jointly 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 (AHA; Dallas, TX, USA), American Society of Nuclear Cardiology, Heart Failure Society of America, and Society of Cardiovascular Computed Tomography.

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