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APPROPRIATE USE CRITERIA

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria forCoronary Revascularization in PatientsWith Stable Ischemic Heart Disease

A Report of the American College of Cardiology Appropriate Use Criteria Task Force,American Association for Thoracic Surgery, American Heart Association,American Society of Echocardiography, American Society of Nuclear Cardiology,Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography,and Society of Thoracic Surgeons

CoronaryRevascularizationWriting Group

Manesh R. Patel, MD, FACC, FAHA, FSCAI, Cha

John H. Calhoon, MD

ir

Gregory J. Dehmer, MD, MACC, MSCAI, FAHA*James Aaron Grantham, MD, FACCThomas M. Maddox, MD, MSC, FACC, FAHA

This document was approved by the American College of Cardiology Cl

January 2017.

The American College of Cardiology requests that this document be cited

Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appr

ischemic heart disease: a report of the American College of Cardiology Appro

American Heart Association, American Society of Echocardiography, Americ

and Interventions, Society of Cardiovascular Computed Tomography, and S

This document has been reprinted in the Journal of Nuclear Cardiology an

Copies: This document is available on the World Wide Web site of the Am

please contact Elsevier Reprint Department, fax (212) 633-3820 or e-mail rep

Permissions: Multiple copies, modification, alteration, enhancement, and

permission of the American College of Cardiology. Requests may be compl

author-agreement/obtaining-permission).

David J. Maron, MD, FACC, FAHAPeter K. Smith, MD, FACCy

*Society for Cardiovascular Angiography and Interventions

Representative. ySociety of Thoracic Surgeons Representative.

Rating Panel

Michael J. Wolk, MD, MACC, Moderator

Manesh R. Patel, MD, FACC, FAHA, FSCAI,Writing Group LiaisonGregory J. Dehmer, MD, MACC, FSCAI, FAHA,Writing Group Liaison*Peter K. Smith, MD, FACC, Writing Group Liaison

James C. Blankenship, MD, MACC, MSCAIz

Alfred A. Bove, MD, PHD, MACCzSteven M. Bradley, MDxLarry S. Dean, MD, FACC, FSCAI*

Peter L. Duffy, MD, FACC, FSCAI*T. Bruce Ferguson, JR, MD, FACCzFrederick L. Grover, MD, FACCzRobert A. Guyton, MD, FACCkMark A. Hlatky, MD, FACCzHarold L. Lazar, MD, FACC{Vera H. Rigolin, MD, FACCzGeoffrey A. Rose, MD, FACC, FASE#Richard J. Shemin, MD, FACCkJacqueline E. Tamis-Holland, MD, FACCzCarl L. Tommaso, MD, FACC, FSCAI*

inical Policy Approval Committee on behalf of the Board of Trustees in

as follows: Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM,

opriate use criteria for coronary revascularization in patients with stable

priate Use Criteria Task Force, American Association for Thoracic Surgery,

an Society of Nuclear Cardiology, Society for Cardiovascular Angiography

ociety of Thoracic Surgeons. J Am Coll Cardiol 2017;69:XXXXX.

d the Journal of Thoracic and Cardiovascular Surgery.

erican College of Cardiology (www.acc.org). For copies of this document,

rints@elsevier.com.

/or distribution of this document are not permitted without the express

eted online via the Elsevier site (http://www.elsevier.com/about/policies/

http://www.acc.orgmailto:reprints@elsevier.comhttp://www.elsevier.com/about/policies/author-agreement/obtaining-permissionhttp://www.elsevier.com/about/policies/author-agreement/obtaining-permissionhttp://dx.doi.org/10.1016/j.jacc.2017.02.001

Patel et al. J A C C V O L . - , N O . - , 2 0 1 7

AUC for Coronary Revascularization in Patients With SIHD - , 2 0 1 7 :- -2

L. Samuel Wann, MD, MACC**John B. Wong, MDz

zAmerican College of Cardiology Representative.xAmerican Heart Association Representative.

kSociety of Thoracic Surgeons Representative. {AmericanAssociation for Thoracic Surgery Representative. #American Society

of Echocardiography Representative. **American Society of Nuclear

Cardiology Representative.

Appropriate UseCriteria TaskForce

John U. Doherty, MD, FACC, Co-ChairGregory J. Dehmer, MD, MACC, Co-Chair

Steven R. Bailey, MD, FACC, FSCAI, FAHANicole M. Bhave, MD, FACCAlan S. Brown, MD, FACCyyStacie L. Daugherty, MD, FACCMilind Y. Desai, MBBS, FACCClaire S. Duvernoy, MD, FACCLinda D. Gillam, MD, FACCRobert C. Hendel, MD, FACC, FAHAyyChristopher M. Kramer, MD, FACC, FAHAzzBruce D. Lindsay, MD, FACCyy

Warren J. Manning, MD, FACCManesh R. Patel, MD, FACC, FAHAxxRitu Sachdeva, MBBS, FACCL. Samuel Wann, MD, MACCyyDavid E. Winchester, MD, FACCMichael J. Wolk, MD, MACCyyJoseph M. Allen, MA

yyFormer Task Force member; current member during the writingeffort. zzFormer Task Force Co-Chair; current Co-Chair during thewriting effort. xxFormer Task Force Chair; current Chair during thewriting effort.

TABLE OF CONTENTS

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

Indication Development . . . . . . . . . . . . . . . . . . . . . . . . . -

Figure 1 AUC Development Process . . . . . . . . . . . . . . . . -

Scope of Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

3. ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

General Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

Assumptions for Rating Multiple Treatment Options . . -

4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

Table A. Revascularization to Improve SurvivalCompared With Medical Therapy . . . . . . . . . . . . . . . . . . -

Table B. Noninvasive Risk Stratification . . . . . . . . . . . . . -

5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

6. CORONARY REVASCULARIZATION IN PATIENTS

WITH STABLE ISCHEMIC HEART DISEASE:

APPROPRIATE USE CRITERIA (BY INDICATION) . . -

Section 1. SIHD Without Prior CABG . . . . . . . . . . . . . . . . -

Table 1.1 One-Vessel Disease . . . . . . . . . . . . . . . . . . . -

Table 1.2 Two-Vessel Disease . . . . . . . . . . . . . . . . . . . -

Table 1.3 Three-Vessel Disease . . . . . . . . . . . . . . . . . . -

Table 1.4 Left Main Coronary Artery Stenosis . . . . . . -

Section 2. Tables 2.1 and 2.2 SIHD With Prior CABG . . . -

Table 2.1 IMA to LAD Patent and Without SignificantStenoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

Table 2.2 IMA to LAD Not Patent . . . . . . . . . . . . . . . . -

Section 3. Table 3.1 SIHD Undergoing Procedures forWhich Coronary Revascularization May BeConsidered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

Table 3.1 Stable Ischemic Heart Disease UndergoingProcedures for Which Coronary RevascularizationMay Be Considered . . . . . . . . . . . . . . . . . . . . . . . . . . . -

7. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

APPENDIX A

ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS2017 Appropriate Use Criteria for CoronaryRevascularization in Patients With Stable IschemicHeart Disease: Participants . . . . . . . . . . . . . . . . . . . . . . . -

APPENDIX B

Relationships With Industry and Other Entities . . . . . . -

J A C C V O L . - , N O . - , 2 0 1 7 Patel et al.- , 2 0 1 7 :- - AUC for Coronary Revascularization in Patients With SIHD

3

ABSTRACT

The American College of Cardiology, Society for Cardio-vascular Angiography and Interventions, Society ofThoracic Surgeons, and American Association for ThoracicSurgery, along with key specialty and subspecialty soci-eties, have completed a 2-part revision of the appropriateuse criteria (AUC) for coronary revascularization. In priorcoronary revascularization AUC documents, indications forrevascularization in acute coronary syndromes and stableischemic heart disease (SIHD) were combined into 1 docu-ment. To address the expanding clinical indications forcoronary revascularization, and to align the subject matterwith the most current American College of Cardiology/American Heart Association guidelines, the new AUC forcoronary artery revascularization were separated into 2documents addressing SIHD and acute coronary syndromesindividually. This document presents the AUC for SIHD.

Clinical scenarios were developed to mimic patient pre-sentations encountered in everyday practice. These sce-narios included information on symptom status; risk levelas assessed by noninvasive testing; coronary diseaseburden; and, in some scenarios, fractional flow reservetesting, presence or absence of diabetes, and SYNTAX score.This update provides a reassessment of clinical scenariosthat the writing group felt were affected by significantchanges in the medical literature or gaps from prior criteria.The methodology used in this update is similar to the initialdocument but employs the recent modifications in themethods for developing AUC, most notably, alterations inthe nomenclature for appropriate use categorization.

A separate, ind