Updated appropriate use criteria (AUC) for coronary revascularization in patients with stable ischemic heart disease (SIHD) contain several important changes from the original version published in 2012. The new criteria, developed by the ACC, the Society for Cardiovascular Angiography and Interventions, The Society of Thoracic Surgeons and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, were published March 10 in the Journal of the American College of Cardiology.

Among the biggest changes, the new criteria now use the new terms “appropriate care,” “may be appropriate care,” and “rarely appropriate care” to rate the clinical scenarios, bringing them in line with AUC developed after 2013. In response to comments from stakeholders, the composition of the rating panel was also changed slightly to include five cardiac surgeons, five interventional cardiologists, six cardiologists not directly involved with performing revascularization, and one outcomes researcher.

Other changes include replacing prior recommendations mandating two antianginal drugs for medical therapy with a step–wise use of antianginals – an approach more applicable to real–world treatment patterns, according to Gregory J. Dehmer, MD, MACC, writing group member and co–chair of ACC’s AUC Task Force. The use of the Canadian Cardiovascular Society Classification of angina was also replaced with a simplified pattern that groups patients based on whether they have or don’t have ischemic symptoms. Expanded use of fractional flow reserve for lesion assessment is incorporated into the update AUC as well. Lastly, a new table was added to evaluate revascularization in patients being considered for kidney transplantation or percutaneous valve therapies.

In general, the writing group rated revascularization by PCI or CABG surgery as rarely appropriate as a first step in patients with a low burden of coronary disease (e.g., single–vessel disease), low–risk findings on noninvasive testing, and/or no antianginal therapy. However, in patients with two–vessel to three–vessel and left main disease, revascularization by PCI or CABG was rated as may be appropriate care or appropriate care, with CABG consistently rated as appropriate care for intermediate or high disease complexity (SYNTAX >=22) even in patients with ischemic symptoms who are not on antianginal therapy. The writing group noted that “CABG surgery was consistently rated as appropriate care and PCI as rarely appropriate care for left main bifurcation disease with intermediate or high disease burden in other vessels.” Repeat CABG surgery was also felt to be rarely appropriate in patients with a functional patent internal mammary artery to the left anterior descending in all but one indication, with both PCI and CABG being rated as either may be appropriate or appropriate in the other indications.

“These new AUC 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,” said Writing Committee Chair Manesh R. Patel, MD, FACC. “The document provides a framework for how patients and providers can think about revascularization in the stable setting and will help health systems and medical societies judge quality of care.”

AUC for SIHD are a culmination of a two–part revision of the original AUC for coronary revascularization. The first part, AUC addressing revascularization in patients with acute coronary syndrome, was published in December 2016. The new criteria will be integrated into ACC’s CathPCI Registry.