American College of Cardiology update appropriate use criteria for performing coronary revascularisation in patients with stable disease

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The American College of Cardiology (ACC), along with several partnering organisations, has released updated appropriate use criteria for performing coronary revascularisation in patients with stable ischemic heart disease. This update is the second of a two-part revision for coronary revascularisation. The first part updated appropriate use criteria for coronary revascularisation in patients with acute coronary syndromes and was published last December.

For this update, the format of the document has been modified to address concerns and improvements suggested by physicians and professional organisations. The rating panel members included an increased percentage of physicians directly involved in performing revascularisation procedures, such as interventional cardiologists and cardiothoracic surgeons.

Prior recommendations mandating two antianginal drugs for medical therapy have been replaced by a step-wise use of antianginals. This starts ideally with a guideline-directed beta-blocker as first-line therapy, with other antianginals used to escalate therapy as clinically necessary. This is integrated with the determination of appropriateness for percutaneous coronary intervention or coronary artery bypass grafting as medical therapy is advanced. Writing committee members said they felt this approach was more applicable to real-world treatment patterns.

The updated criteria now place a greater emphasis on global risk assessments for future events and non-invasive testing results. According to the writing committee, the criteria should be used as an overall guide, and physicians should evaluate each case on an individual basis. Patients should ask their providers if their proposed revascularization is appropriate.

Manesh R Patel (Duke Heart Center, Duke University, Durham, USA), chair of the writing committee for the document, says: “These new appropriate use criteria are an important advance in the efforts of the partnering societies to improve the quality of cardiovascular care and deliver the right care to the right patients. The document provides a framework for how patients and providers can think about revascularisation in the stable setting and will help health systems and medical societies judge quality of care.”

These appropriate use criteria are a product of a partnership between the ACC, the American Association for Thoracic Surgery, the American Heart Association, American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography and The Society of Thoracic Surgeons. The criteria have been published in the Journal of the American College of Cardiology.