Chapter 66: Appropriate Use Criteria for Revascularization

INTRODUCTION

The Appropriate Use Criteria for Revascularization (AUC) is a vital instrument supporting high-quality interventional practice that presents, in a pragmatic format, the optimal application of the evidence base and existing guidelines to patient selection for percutaneous coronary intervention (PCI). It is a meaningful response to concerns of overutilization, serves as a quality metric, and establishes the relative roles of coronary artery bypass graft surgery (CABG) and medical therapy in patients with both stable ischemic heart disease (SIHD) and acute coronary syndromes (ACS). The original AUC¹ and a focused update² set the standard of practice regarding optimal patient selection for PCI. The AUC has broad implications for the future of cardiovascular health care, especially in regard to case selection, treatment options, and reimbursement. In the future, it will become the foundation for tethering payment decisions and quality assessment to patient-centered therapeutic decision making. Limitations of the first version have been extensively articulated, and a subsequent revision has been published improve the criteria so they more meticulously take into account how interventional cardiologists evaluate scientific data and apply those conclusions to individual revascularization decisions.

WHY DO APPROPRIATE USE CRITERIA EXIST?

Today’s generation is the recipient of a myriad of astonishing bioengineering, pharmacologic, and technical innovations over the last 3 decades. These advancements have resulted in the growth and maturity of a new field of treatment for coronary artery disease (CAD). The exponential growth in the number of PCI procedures has resulted in an unprecedented escalation in the cost of health care: approximately 600,000 PCIs are performed in the United States each year³ at a cost exceeding $12 billion. However, this expense is not accompanied by a measurable outcomes benefit.⁴ Moreover, the wide geographic variability of the use of PCI in the United States^5,6 has been interpreted as a demonstration that patients are not being referred for the procedure strictly based on scientific evidence. The divergence in cost versus benefit logically demands a formal evaluation of PCI utilization.

The value of PCI in ACS (ST-segment elevation myocardial infarction [STEMI], non–ST-segment elevation myocardial infarction [NSTEMI], and unstable angina) has been definitively demonstrated: by eliminating the causative coronary obstruction, PCI significantly reduces mortality and recurrent myocardial infarction in this setting. However, in SIHD, there is no proven survival benefit or reduction in subsequent myocardial infarction versus medical therapy. PCI in this circumstance reduces or relieves angina but does not contribute to improvement in hard end points. Furthermore, since patients who undergo PCI are exposed to the risk of periprocedural complications, including death, stroke, bleeding, and myocardial infarction, a judicious approach to case selection is required. Deciding which patients are likely to benefit from PCI is as much a matter of clinical judgment as the application of clinical evidence (clinical trials, registries, meta-analyses, retrospective studies confirmed by additional data).⁷ In contemporary practice, the decision of whether PCI, medical ...