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Chapter 66. Appropriate Use Criteria for Revascularization

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A 64-year-old man presents to the emergency department with a history of chest pain that began 2 days ago and has now been worsening for the past 3 hours. Electrocardiogram (ECG) shows ST elevations in leads II, III, and aVF and ST depressions and T inversions in V1 to V3. The patient is taken to the cath lab immediately and found to have a 100% occlusion of the right coronary artery, a 70% stenosis of the first obtuse marginal (OM1) branch, and an 80% stenosis of the proximal left anterior descending artery (LAD). The occluded right artery is stented successfully. The operator then proceeds to stent the LAD and OM1 branches. How would the appropriateness of the interventions on the nonculprit lesion be classified?

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A. Appropriate

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B. May be appropriate

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C. Rarely appropriate

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D. Indeterminate

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The correct answer is C

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Nonculprit lesion percutaneous coronary intervention (PCI) at the time of ST-segment elevation myocardial infarction (STEMI) in the absence of hemodynamic compromise is classified as rarely appropriate by the Appropriate Use Criteria, which were developed before Preventive Angioplasty in Acute Myocardial Infarction (PRAMI).

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A 72-year-old man with hypertension and hypercholesterolemia presents with stable angina for 3 months. He is able to walk 3 blocks before getting tired. ECG shows Q waves inferiorly. Medications include aspirin, a β-blocker, and a statin. A stress test shows a fixed inferior defect. Cardiac catheterization shows a 100% occlusion of a very large OM branch filling by collaterals from a diagonal and no other significant disease. The ejection fraction is 45% with an akinetic inferior wall. PCI and stenting of the OM is successful. At 1-month follow-up, the chest pain syndrome has resolved. How would the appropriateness of this procedure be classified?

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A. Appropriate

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B. May be appropriate

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C. Rarely appropriate

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D. Indeterminate

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The correct answer is C

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This patient has no stress test, is not on at least 2 antianginal medications, and is asymptomatic. Performing PCI of a chronic total occlusion in this setting cannot be rationalized.

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A 58-year-old attorney presents with severe chest pain that occurs only when he is in court. He is able to play racquetball at his club and golf on the weekends without limitation. He smokes 1 pack per day, has hypertension, and has never had a lipid panel checked. He takes a baby aspirin but refuses to take ...

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