Physicians, patients and health insurers have now a practical tool for weighing the factors to decide whether it is appropriate to treat chest pain with medical therapy alone or prescribe medical therapy and also perform revascularisation.
The document “Appropriateness Criteria for Coronary Revascularization” appears in the 10 February, 2009 issue of the Journal of the American College of Cardiology, in the 5 January, 2009 online issue of Catheterization and Cardiovascular Interventions and Circulation: Journal of the American Heart Association, and online on the Society for Cardiovascular Angiography and Interventions website.
“One of the strengths of this document is that it provides a framework for thinking about clinical scenarios and having a discussion about coronary revascularisation,” said Dr Manesh R Patel, Duke University and the Duke Clinical Research Institute in Durham, USA, and chair of the appropriateness criteria writing group. “These recommendations describe when coronary revascularisation would be expected to improve a patient’s health status.”
The new appropriateness criteria are the first to focus on cardiac treatment, rather than on diagnostic testing. They were jointly developed by the American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and American Society of Nuclear Cardiology. They have been endorsed by the American Society of Echocardiography, Heart Failure Society of America, and Society of Cardiovascular Computed Tomography.
Appropriateness criteria differ from clinical guidelines both in their purpose and their format. While guidelines provide a comprehensive summary of evidence from clinical trials, appropriateness criteria focus on the types of patients cardiologists see in the clinic and hospital every day. Clinical studies may not have included such patients and, therefore, scientific evidence may not be readily available. Appropriateness criteria also present information in easily understood clinical scenarios that characterise patients according to four critical features:
- The severity and type of symptoms;
- How much cholesterol plaque has built up and in which arteries;
- How much of the heart muscle, according to stress testing, is being starved for blood and oxygen (a condition known as ischemia); and
- Whether the patient is already taking the right heart medications in the right dosages.
In developing the appropriateness criteria, a 17-member technical panel made up of general cardiologists, interventional cardiologists, cardiac surgeons, internal medicine specialists, health services researchers and others sifted through approximately 180 clinical scenarios, scoring each according to whether revascularization was appropriate, inappropriate or uncertain.
“This was quite a serious undertaking,” said Dr Peter K Smith, a cardiac surgeon member of the writing committee on behalf of The Society of Thoracic Surgeons. “The process involved extensive review and debate of the available body of evidence, and resulted in remarkable consensus between specialties.” Smith is also professor and chief of cardiothoracic surgery at Duke University.
Revascularisation was considered appropriate if the expected improvements in survival, symptoms, functional status and/or quality of life outweighed the possible risks. In most cases, the panel considered revascularization as either bypass surgery or a catheter procedure. Because evidence is available to support either procedure for patients with advanced coronary disease, each method of revascularisation was independently rated.
The panel determined that revascularisation would be inappropriate in a patient who had plaque build-up in one or two arteries, experienced symptoms only during heavy exercise, had a small amount of heart muscle at risk, and was not taking medication to help control symptoms. However, they deemed revascularisation appropriate if a similar patient had severe symptoms despite already taking the best available heart medication.
Appropriateness criteria are not intended to diminish the importance of clinical judgment in evaluating individual patients, nor to include every possible type of patient. Instead, one of their most important uses will be in evaluating patterns of care, and in helping to reduce the large variation in rates of revascularisation that has been observed throughout the USA.
“For physicians who look at the appropriateness criteria and conclude that 95 to 100% of the revascularisation procedures they perform would be graded as appropriate – terrific,” said Dr Gregory J Dehmer, Texas A&M University College of Medicine, Scott & White Clinic, both in Temple, USA, and writing committee member. “But for those who find that only 60 or 70% of their procedures are appropriate and the rest are inappropriate, this document provides a very powerful message and gives them a benchmark for improving their practice.”
It is also hoped that health insurers will use the appropriateness criteria in developing consistent payment and preauthorisation policies and in conducting quality reviews.
“In the arena of cardiovascular science, we have a fair amount of data on revascularisation and its ability to improve how patients feel or long they live,” Patel said. “As a group that includes general cardiologists, interventionalists and surgeons, we are saying: For these common clinical scenarios, here is when it is appropriate – in most patients – to perform revascularisation.”