Hints of What’s to Come in New Coronary Revascularization AUC

CHICAGO, IL—Ahead of the impending release of the updated appropriate use criteria (AUC) for coronary revascularization, experts gathered last week at the American College of Cardiology (ACC) 2016 Scientific Sessions to debate what’s working and what’s not.

At the AUC-dedicated session, writing group member Gregory J. Dehmer, MD (Baylor Scott & White Health, Central Texas, Temple, TX), also gave a preview of what’s to come. As recently reported by TCTMD, clinicians have a lot on their wish lists.

“I’m really up here on this thin ice,” Dehmer said at the start of his presentation, “because this document is embargoed. . . . If I say too much, a lightning bolt comes through the ceiling and Heart House destroys me, or there’s a drone flying over that will catch me.”

But he did reveal some details.

One Document Becomes Two

First, the terms “may be appropriate” and “rarely appropriate” will officially replace “uncertain” and “inappropriate” in the updated document, bringing it in line with wording revised by the ACC task force for AUC methodology in 2013, Dehmer confirmed.

The slate of people developing the revisions also has shifted, he said. In 2016, four of the seven writing group members are “rookies” new to the process and the rating panel consists of five interventionalists, five surgeons, six cardiologists and one internist/outcomes specialist. “This actually was a criticism of the earlier document,” Dehmer noted, specifically that the majority of the 2009 panel members—which included only four interventionalists and four surgeons—“were physicians not engaged in revascularization. [Now] the balance of power has changed.”

Finally—in what is perhaps the most dramatic change of all—the document will be split into two parts, with one devoted to acute coronary syndromes and the other to stable ischemic heart disease. This decision was made to help facilitate harmonization with the 2015 guideline update for STEMI, which upgraded nonculprit PCI to a class IIb recommendation, he explained.

Among other updates, the ACS document will include specific scenarios related to complete revascularization, Dehmer said, including successful treatment of the culprit artery by primary PCI followed by immediate revascularization of the nonculprit artery in the same procedure (PRAMI) and by primary PCI or fibrinolysis followed by revascularization of one or more nonculprit arteries during the same hospitalization (CvLPRIT, DANAMI3-PRIMULTI).

More Details on Treating Stable Disease

The document for stable ischemic heart disease, meanwhile, will also address concerns that have been raised.

Some have said the existing AUC lack specific enough criteria for determining risk prior to ordering a stress test and also that they are unable to adequately assess appropriateness in stable patients without such testing. For instance, in a 65-year-old man with several risk factors and “absolutely classic” angina symptoms, Dehmer said, “many clinicians would say, ‘I don’t need a stress test. This guy needs a heart catheterization and maybe needs a PCI. Why do I need a stress test?’” As solutions, the updated document will provide enchanced data collection to allow more precise assessment of risk and better integrate other forms of imaging including fractional flow reserve, intravascular ultrasound, and optical coherence tomography.

Also, due to issues with variability in assessment of angina burden among patients and physicians, “we have gotten rid of using [Canadian Cardiovascular Society] class,” Dehmer noted.

Perhaps the biggest topic in need of revisiting, he stressed, is “maximal” anti-anginal therapy being specified as two medications. “There’s not a day that goes by in our cath lab that I don’t get some grief from my colleagues on this,” Dehmer said. “The things that we have heard is that that’s not how the real world of cardiology is practiced, the doses were never provided, and that people were manipulating the medicines to just beat the system. . . . And in some cases patients who were felt to obviously need a revascularization procedure were coming off the table and getting started on a second medicine, only to come back for a second procedure that perhaps could’ve been avoided. That is changing.”

Asymptomatic patients with stable ischemic heart disease will now be classified according to whether they are or are not on anti-anginal therapy. “The assumption,” Dehmer emphasized, “is that all patients are on optimal medical therapy, which includes managing lipids, blood pressure, and diabetes, and so forth.” Additionally, those with symptoms will be broken down into three groups: those not on anti-anginal drugs, those taking one (beta-blocker preferred), and those taking two anti-anginal medications. Various options, depending on the category, include initiating an anti-anginal drug, adding another anti-anginal, continuing or intensifying the existing therapy, performing PCI, or performing CABG.

There also will be dedicated sections for patients with prior CABG and those undergoing other types of procedures (eg, renal transplantation, TAVR, or mitral repair) “for which coronary revascularization might be considered,” he reported.

As for exactly when the new AUC would be released, Dehmer did not say. The gears are turning, however. For example, a fresh data collection form for the NCDR CathPCI Registry, Version 5.0, that enables practitioners to calculate the appropriateness of a given procedure has been developed but is awaiting full approval. “It’s going to take time before that comes out,” he said, predicting that the form will be available late this year or early next year.

According to Dehmer, the ACS document has been approved by the writing group and is now working its way through the various professional societies for their signoff and feedback. The document for stable disease “still needs a little work,” he noted. While there may be some “tweaking to the tables” that were shared at the ACC meeting, “that document is also moving along. We’re hope to have these out by the end of this year.”

Taxation Without Representation?

Ajay Kirtane, MD (NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY), who co-chaired the session in Chicago, said AUC can be described as “a form of taxation without representation.”

This is because, he said, “the folks writing them, although very well intentioned and thoughtful, are not elected. There’s no review of this by the practicing physician. . . . I think in some respects that engenders some of the frustration seen, where we have cardiologists out there who are working every day and then these documents get imposed. And there are ramifications [from] these documents, not only for them but also more importantly for their patients.

Suggesting the possibility of an open comment period, Kirtane asked panelist Ralph Brindis, MD (University of California, San Francisco), who debated on behalf of the AUC during the session, how best to handle that disconnect.

Unlike in the development of clinical practice guidelines, where suggestions made by expert reviewers and others “do influence the final document,” the AUC process is different, Brindis explained. “The challenge [here is that] you could have an open comment period for the various scenarios, but once the voting is done, it’s a done deal. So we have a problem there.”

Despite the difficulties involved in developing AUC, he said, “I still think we could do it better, even in the ‘flawed environment’ that we have, than if other people [outside of cardiology] were to try to do it to us.” Brindis commented that, based on Dehmer’s presentation, the revascularization AUC seem to be evolving well from infancy into adulthood.

A member of the audience suggested that the Heart Team approach be incorporated into the AUC, with the possibility that a team’s judgment might “trump” the appropriateness rating.

Patient preference also came up, with Dehmer reporting that a particular challenge in revising the AUC was how to handle situations where preference diverged from appropriateness. “Boy, we went around the block 25 times on how to do that,” Dehmer commented, suggesting that there will probably be an additional document devoted to this question.

 

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