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Journal of the American College of Cardiology Vol. 53, No. 6, 2009© 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00P

APPROPRIATENESS CRITERIA

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 AppropriatenessCriteria for Coronary RevascularizationA Report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, Societyfor Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Associationfor Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology

Endorsed by the American Society of Echocardiography, the Heart Failure Society of America,and the Society of Cardiovascular Computed Tomography

ublished by Elsevier Inc. doi:10.1016/j.jacc.2008.10.005

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CoronaryRevascularizationWriting Group

evascularization. J Am Coll CThis article has been cop

anesh R. Patel, MD, Chair

regory J. Dehmer, MD, FACC, FACP,FSCAI, FAHA*

ardiol 2009;53:530–53.ublished in the February 10, 2009, issue of Cir-

of Cardiologyhealthpermissi

eter K. Smith, MD, FACC‡ohn A. Spertus, MD, MPH, FACC†

Society for Cardiovascular Angiography and Interventions Represen-

John W. Hirshfeld, MD†tative; †American College of Cardiology Foundation Representative;‡Society of Thoracic Surgeons Representative

Technical Panel Frederick A. Masoudi, MD, MSPH, FACC,Moderator

Ralph G. Brindis, MD, MSH, FACC,FSCAI, Methodology Liaison

Gregory J. Dehmer, MD, FACC, FACP,FSCAI, FAHA, Writing Group Liaison*

Manesh R. Patel, MD, Writing Group LiaisonPeter K. Smith, MD, FACC, Writing Group

Liaison‡

Karen J. Beckman, MD, FACC§Charles E. Chambers, MD, FACC, FSCAI,

FAHA*T. Bruce Ferguson, JR, MD, FACC, FAHA�Mario J. Garcia, MD, FACC¶Frederick L. Grover, MD, FACC�David R. Holmes, JR, MD, FACC, FSCAI*

Lloyd W. Klein, MD, FACC, FSCAI, FAHA†Marian Limacher, MD, FACC†Michael J. Mack, MD�David J. Malenka, MD, FACC†Myung H. Park, MD, FACC#Michael Ragosta, III, MD, FACC, FSCAI*James L. Ritchie, MD, FACC, FAHA†Geoffrey A. Rose, MD, FACC, FASE**Alan B. Rosenberg, MD†Richard J. Shemin, MD, FACC, FAHA�William S. Weintraub, MD, FACC, FAHA††

*Society for Cardiovascular Angiography and Interventions Representative;†American College of Cardiology Foundation Representative; §HeartRhythm Society Representative; �American Association for Thoracic Sur-gery/Society of Thoracic Surgeons Representative; ¶Society of Cardiovas-cular Computed Tomography Representative; #Heart Failure Society ofAmerica Representative; **American Society of Echocardiography Repre-sentative; ††American Heart Association Representative

ACCFAppropriatenessCriteria TaskForce

Michael J. Wolk, MD, MACC, Chair

Ralph G. Brindis, MD, MPH, FACC,FSCAI‡‡

Joseph M. Allen, MA

Pamela S. Douglas, MD, MACC, FAHA, FASERobert C. Hendel, MD, FACC, FAHAManesh R. Patel, MDEric D. Peterson, MD, MPH, FACC, FAHA

‡‡Former Task Force Chair during this writing effort

lease see accompanying editorial by Drs. W. Douglas Weaver, Timothy Gardner,nd Joseph Babb immediately following this document.

This document was approved by the American College of Cardiology Foundationoard of Trustees in May 2008.The American College of Cardiology Foundation requests that this document be

ited as follows: Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA.CCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary

culation and the February 15, 2009, issue of Catheterization and CardiovascularInterventions.

Copies: This document is available on the World Wide Web site of the AmericanCollege of Cardiology (www.acc.org). For copies of this document, please contactElsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected].

Permissions: Modification, alteration, enhancement, and/or distribution of thisdocument are not permitted without the express permission of the American College

Foundation. Please contact Elsevier’s permission department [email protected].

http://www.acc.org

mailto:[email protected]

mailto:[email protected]

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531JACC Vol. 53, No. 6, 2009 Patel et al.February 10, 2009:530–53 Appropriateness Criteria for Coronary Revascularization

TABLE OF CONTENTS

bstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .531

reface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .532

ntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533

ethods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533

Indication Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533

Scope of Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .533

Panel Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534

Rating Process and Scoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534

eneral Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .534

Table A. CAD Prognostic Index . . . . . . . . . . . . . . . . . . . . . . . . . . .535

efinitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535

Table B. Grading of Angina Pectoris by the CanadianCardiovascular Society Classification System . . . . . . .536

bbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .536

esults of Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .536

oronary Revascularization AppropriatenessCriteria (By Indication). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .537

Table 1. Patients With Acute Coronary Syndromes . . . . . . .537

Table 2. Patients Without Prior Bypass Surgery . . . . . . . .538

Table 3. Patients With Prior Bypass Surgery(Without Acute Coronary Syndromes) . . . . . . . . . . . . . .540

ating Revascularization Methods . . . . . . . . . . . . . . . . . . . . . . .540

Mode of Revascularization for High Severity ofCAD (Indications 60 to 73) . . . . . . . . . . . . . . . . . . . . . . . . . . .540

Mortality Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541

Advanced CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541

Table 4. Method of Revascularization: AdvancedCoronary Disease, CCS Angina Greater Than orEqual to Class III, and/or Evidence of Intermediate-to High-Risk Findings on Noninvasive Testing . . . . . . . . . .541

iscussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541

Clinical Judgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .542

General Themes in Appropriateness Criteria forRevascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .542

Acute Coronary Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .542

Stable Ischemic Heart Disease Without Prior CABG. . . . . .542

Stable Ischemic Heart Disease With Prior CABG . . . . . . .544

PCI and CABG in Patients With Advanced CAD . . . . . . . . .544

Application of Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .545 r

ppendix A: Additional Coronary RevascularizationDefinitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .546

Table A1. Clinical Classification of Chest Pain . . . . . . . . .546

Table A2. Noninvasive Risk Stratification . . . . . . . . . . . . . . .546

ppendix B: Additional Methods . . . . . . . . . . . . . . . . . . . . . . . . . .546

Relationships With Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .547

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .547

ppendix C: ACCF/SCAI/STS/AATS/AHA/ASNC2009 Appropriateness Criteria for CoronaryRevascularization Participants . . . . . . . . . . . . . . . . . . . . . . . . .547

ppendix D: ACCF/SCAI/STS/AATS/AHA/ASNC2009 Coronary Revascularization AppropriatenessCriteria Writing Group, Technical Panel, TaskForce, and Indication Reviewers—Relationships With Industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549

eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .552

bstract

he American College of Cardiology Foundation (ACCF),ociety for Cardiovascular Angiography and Interventions,ociety of Thoracic Surgeons, and the American Associationor Thoracic Surgery, along with key specialty and subspecialtyocieties, conducted an appropriateness review of commonlinical scenarios in which coronary revascularization is fre-uently considered. The clinical scenarios were developed toimic common situations encountered in everyday practice

nd included information on symptom status, extent of med-cal therapy, risk level as assessed by noninvasive testing, andoronary anatomy. Approximately 180 clinical scenarios wereeveloped by a writing committee and scored by a separateechnical panel on a scale of 1 to 9. Scores of 7 to 9 indicatehat revascularization was considered appropriate and likely tomprove health outcomes or survival. Scores of 1 to 3 indicateevascularization was considered inappropriate and unlikely tomprove health outcomes or survival. The mid range (4 to 6)ndicates a clinical scenario for which the likelihood thatoronary revascularization would improve health outcomes orurvival was considered uncertain. For the majority of thelinical scenarios, the panel only considered the appropriate-ess of revascularization irrespective of whether this wasccomplished by percutaneous coronary intervention (PCI) ororonary artery bypass graft surgery (CABG). In a selectubgroup of clinical scenarios in which revascularization isenerally considered appropriate, the appropriateness of PCInd CABG individually as the primary mode of revasculariza-ion was considered.

In general, the use of coronary revascularization for patientsith acute coronary syndromes and combinations of significant

ymptoms and/or ischemia was viewed favorably. In contrast,
evascularization of asymptomatic patients or patients with

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532 Patel et al. JACC Vol. 53, No. 6, 2009Appropriateness Criteria for Coronary Revascularization February 10, 2009:530–53

ow-risk findings on noninvasive testing and minimal medicalherapy were viewed less favorably. It is anticipated that theseesults will have an impact on physician decision making andatient education regarding expected benefits from revascular-zation and will help guide future research.

reface

he publication of appropriateness criteria reflects one ofeveral ongoing efforts by the ACCF and its partners to assistlinicians caring for patients with cardiovascular diseases toeliver high-quality cardiovascular care. The American Collegef Cardiology (ACC)/American Heart Association (AHA)ractice guidelines provide a foundation for summarizingvidence-based cardiovascular care and, when evidence isacking, provide expert consensus opinion that is approved ineview by the ACCF and AHA. However, in many areas,arked variability remains in the use of cardiovascular proce-

ures, raising questions of over- or under-use. One reason forhis variability is a paucity of large randomized clinical trialsonducted assessing the value of technology for specific pa-ients, including cardiac imaging, catheterization, and coronaryevascularization. As such, there are many instances in practicehere the guidelines provide no recommendation, or alterna-

ively, a Level C recommendation (expert opinion). For otherreas, evidence is available but variability in clinical practiceemains. In either case, appropriateness criteria provide practicalools to measure this variability to examine utilization patterns.

Appropriateness criteria are developed to serve as a supple-ent to ACC/AHA guideline documents. Appropriateness

riteria are designed to examine the use of diagnostic andherapeutic procedures to support efficient use of medicalesources during the pursuit of quality medical care. Therocess of appropriateness criteria development has been de-ned previously (1). Briefly, the appropriateness criteria writingroup combines specific clinical characteristics to create proto-ypical patient scenarios. These scenarios are then provided to

separate technical panel for appropriateness rating. Theechnical panel is created from nominations given by multipleelevant professional societies and provider-led organizations asell as from health policy and payer communities. To preservebjectivity, the technical panels are created so as to not include

majority of individuals whose livelihood is tied to theechnology under study.

In making its appropriateness determinations, the technicalanel is provided with summaries of the relevant evidence fromhe medical literature and practice guidelines. They are thensked first individually and then collectively to assess theenefits and risks of a test or procedure in the context of theotential benefits to patients’ outcomes and an implicit under-tanding of the associated resource use and costs. After theanking process, the final appropriateness ratings are summa-ized using an established rigorous methodology (2).

Appropriateness criteria are based on current understanding
f the technical capabilities and potential patient benefits of the i
rocedures examined. Future evidence development may re-uire these ratings to be updated. The appropriateness criteriare also developed to identify common clinical scenarios—buthey cannot possibly include every conceivable clinical situa-ion. Thus, some patients seen in clinical practice are notepresented in these appropriateness criteria or have additionalxtenuating features compared with the clinical scenariosresented. Additionally, although appropriateness criteria in-ications and ratings are shaped by the practice guidelines, theppropriateness criteria often contain more detailed scenarioshan the more generalized situations covered in clinical practiceuidelines, and thus, subtle differences between these 2 guid-nce tools is possible.

Finally, appropriateness criteria are intended to assistatients and clinicians, but are not intended to diminish thecknowledged difficulty or uncertainty of clinical decisionaking and cannot act as substitutes for sound clinical

udgment and practice experience. Rather, the aim of theseriteria is to allow assessment of utilization patterns for aest or procedure. Comparing utilization patterns across aarge subset of provider’s patients can allow for an assess-

ent of a provider’s management strategies with those ofis/her peers. The ACCF and its collaborators believe that anngoing review of one’s practice using these criteria will helpuide a more effective, efficient, and equitable allocation ofealth care resources, and ultimately, better patient outcomes.In developing these appropriateness criteria for coronary

evascularization, the technical panel was asked to assesshether coronary revascularization for each indication was

ppropriate, uncertain, or inappropriate using the followingefinition of appropriateness:

Coronary revascularization is appropriate when the ex-ected benefits, in terms of survival or health outcomessymptoms, functional status, and/or quality of life) exceedhe expected negative consequences of the procedure.

The technical panel scored each indication on a scalerom 1 to 9 as follows:

Appropriate: Score 7 to 9Appropriate for the indication provided, meaning coro-

ary revascularization is generally acceptable and is a rea-onable approach for the indication and is likely to improvehe patients’ health outcomes or survival.

Uncertain: Score 4 to 6Uncertain for the indication provided, meaning coronary

evascularization may be acceptable and may be a reasonablepproach for the indication but with uncertainty implyinghat more research and/or patient information is needed tourther classify the indication.

Inappropriate: Score 1 to 3Inappropriate for the indication provided, meaning cor-

nary revascularization is not generally acceptable and is notreasonable approach for the indication and is unlikely to

mprove the patients’ health outcomes or survival.

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It is acknowledged that grouping these scores into 3 cate-ories is somewhat arbitrary and that the numeric designationshould be viewed as a continuum. Since some diversity inlinical opinions for particular clinical scenarios will exist orvailable research is limited or conflicting, scores in thentermediate level of appropriateness are labeled “uncertain.”his identifies the need for targeted investigations to clarify theest therapy in these circumstances. It is anticipated that theseppropriateness criteria will require updates as further data areenerated and information from the implementation of theseriteria accumulates.

To prevent bias in the scoring process, the technical panelas deliberately comprised of physicians with varying perspec-

ives on coronary revascularization and not comprised solely ofxperts (e.g., interventional cardiologists or cardiovascular sur-eons) in the particular procedure under evaluation. Suchxperts, while offering important clinical and technical insights,ight have a natural tendency to rate the indications within

heir specialty as more appropriate than nonspecialists. Inddition, care was taken in providing objective, nonbiasednformation, including national practice guidelines and a broadange of key references, to the technical panel.

We are grateful to the technical panel, a professionalroup with a wide range of skills and insights, for theirhoughtful and thorough deliberation of the merits oforonary revascularization for various indications. In addi-ion to our thanks to the technical panel for their dedicatedork and review, we would like to offer special thanks to theany individuals who provided a careful review of the draft

ndications: to Peggy Christiansen, the ACCF librarian, forer comprehensive literature searches; to Karen Caruth,ho continually drove the process forward; to Lindsey Law

nd Kennedy Elliott, who helped map these criteria withxisting ACC/AHA practice guidelines; and to Maneshatel, MD, the chair of the writing committee, for hisedication, insight and leadership.

Frederick A. Masoudi, MD, MSPH, FACCModerator, Coronary Revascularization Technical Panel

Ralph G. Brindis, MD, MPH, FACC, FSCAIChair, Appropriateness Criteria Task Force

ntroduction

his report addresses the appropriateness of coronary revas-ularization. The increasing prevalence of coronary arteryisease (CAD), advances in surgical and percutaneousechniques for revascularization as well as concomitantedical therapy for CAD, and the costs of revascularization

ave resulted in heightened interest regarding the appropri-teness of coronary revascularization. Clinicians, payers, andatients are interested in the specific benefits of revascular-zation. Importantly, inappropriate use of revascularization

ay be potentially harmful to patients and generate unwar-anted costs to the health care system, whereas appropriate
rocedures should likely improve patients’ clinical outcomes. b
All prior appropriateness criteria publications from theCCF and collaborating organizations have reflected anngoing effort to critically and systematically create, review,nd categorize the appropriateness of certain cardiovasculariagnostic tests. This document presents the first attempt toevelop appropriateness criteria for therapeutic procedures:n this case, 2 distinct approaches to coronary artery revas-ularization. This is an important shift to the explicitonsideration of the potential benefits and risks of a thera-eutic procedure. This document presents the results of thisffort, but it is critical to understand the background andcope of this document before interpreting the rating tables.

ethods

riefly, this process combines evidence-based medicine, guide-ines, and practice experience by engaging a technical panel in a

odified Delphi exercise as previously described by RAND (2).

ndication Development

he writing group for the coronary revascularization indi-ations was comprised of members from the relevant pro-essional societies including both practicing interventionalardiologists and a cardiothoracic surgeon. Recognizingariability in many patient factors, local practice patterns,nd a lack of data comparing PCI with CABG in allossible clinical scenarios, the technical panel was asked toate the majority of clinical indications only for the appro-riateness of revascularization and not to distinguish be-ween the specific modes of revascularization (i.e., PCIersus CABG). In addition, the writing group identifiedndications for patients with advanced coronary disease andymptoms, where revascularization is generally consideredo be appropriate. In this section, PCI and CABG werendependently evaluated for appropriateness.

Once the indications were drafted, reviewers from allarticipating collaborators and stakeholders, including car-iovascular and surgical societies, provided feedback regard-ng the clinical indications for coronary revascularization.hese comments led to substantial improvements and

hanges in the clinical scenarios.

cope of Indications

he indications contained in this report are purposefullyroad and intended to represent the most common patientcenarios for which coronary revascularization is considered.he development of these clinical scenarios re-emphasized

o the writing group the complexity of the decision-makingrocess for revascularization and the number of variableshat inform this decision. The writing group estimated thatver 4,000 separate clinical scenarios would be required toncorporate all permutations of these variables. However,roviding that level of granularity to this framework would
e cumbersome and likely degrade the purpose of these

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riteria. As this was not a viable option, the indications wereeveloped considering the following common variables:

. The clinical presentation (e.g., acute coronary syndrome,stable angina, and so on);

. Severity of angina (asymptomatic, Canadian Cardiovas-cular Society [CCS] Class I, II, III, or IV);

. Extent of ischemia on noninvasive testing and thepresence or absence of other prognostic factors, such ascongestive heart failure (CHF), depressed left ventricularfunction, or diabetes;

. Extent of medical therapy; and. Extent of anatomic disease (1-, 2-, 3-vessel disease, with

or without proximal left anterior descending artery[LAD] or left main coronary disease).

The clinical indications developed include coronary anat-my, as this is the focus of much of the previous literaturen coronary revascularization. However, the writing groupecognizes that for everyday patient care, symptom status,schemic burden, and level of medical therapy often play aritical role in decision making even before the coronarynatomy has been defined by angiography.

Please note that the indications focus on revascularization,ercutaneous or surgical, and therefore do not address diag-ostic catheterization or coronary angiography. Additionally,he clinical scenarios presented are not inclusive of everyossible clinical situation. For example, the use of coronaryevascularization for patients with multivessel disease includingor more occluded vessels and clinical symptoms or ischemiaas not included as a separate indication since other variationsf multivessel disease are present.

anel Selection

takeholders were given the opportunity to participate inhe appropriateness criteria process by submitting nomineesrom their organizations through a call for nominationsnnounced in the summer of 2006. From this list ofominees, the task force and writing group selected techni-al panel members to ensure an appropriate balance withespect to expertise. The 17-member technical panel wasomposed of 4 interventional cardiologists, 4 cardiovascularurgeons, 8 members representing cardiologists, other phy-icians who treat patients with cardiovascular disease, healthutcome researchers, and 1 medical officer from a health plan.

ating Process and Scoring

he panel members first rated indications independently.hen the panel met for a discussion of each indication.fter the face-to-face discussion, panel members then

ndependently provided their final scores for each indica-ion. Each panel member had equal weight in producing thenal result for the indications and was not forced intoonsensus. For each indication, the median numerical score
as determined.
At the face-to-face meeting, each panelist received aersonalized rating form that indicated his/her rating forach indication and the distribution of deidentified ratingsf other members of the panel. In addition, the moderatoreceived a summary rating form with similar informationincluding panelist identification), along with other statisticseflecting the level of agreement among panel members.he level of agreement among panelists, as defined byAND, was analyzed for each indication based on theIOMED rule for a panel of 14 to 16 (a simplified RANDethod for determining disagreement) (2). Per theIOMED definition, agreement was defined as an indica-

ion where 4 or fewer panelists’ ratings fell outside the-point region containing the median score. Disagreementas defined as a situation where at least 5 panelists’ ratings

ell in both the appropriate and the inappropriate categories.ecause the panel had 17 representatives, which exceeded

he 16 addressed in this rule, an additional level of agree-ent analysis as described by RAND was performed that

xamines the interpercentile range compared to interpercen-ile range adjusted for symmetry (2). This information wassed by the moderator to guide the panel’s discussion byighlighting areas of differences among the panelists.

eneral Assumptions

pecific assumptions are provided that were considered byhe technical panel in rating the relevant clinical indicationsor the appropriateness of revascularization:

1. Each clinical indication includes the patient’s clinicalstatus/symptom complex, ischemic burden by noninva-sive functional testing when presented, burden of cor-onary atherosclerosis as determined by angiography,and intensity of medical therapy in the determination ofthe appropriateness of coronary revascularization.

2. Assume coronary angiography has been performedwhen these findings are presented in the clinical indi-cations. The panel should rate the appropriateness ofrevascularization based upon the clinical features andcoronary findings, and not the appropriateness of diag-nostic coronary angiography.

3. Assume left main coronary artery stenosis (greater than orequal to 50% luminal diameter narrowing) or proximalLAD stenosis (greater than or equal to 70% luminaldiameter narrowing) is not present unless specificallynoted. Assume no other significant coronary artery steno-ses are present except those noted in the clinical scenario.

4. The clinical scenarios should be rated based on thepublished literature regarding the risks and benefits ofpercutaneous and surgical coronary revascularization.Note that specific patient groups not well represented inthe literature are not presented in the current clinicalscenarios. However, the writing group recognizes thatdecisions about coronary artery revascularization in
such patients are frequently required. Examples of such

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patients include those with end-stage renal disease oradvanced age.

5. Clinical outcome is related to the extent of coronaryartery disease (Table A) (3). Based on this observationand clinical guideline recommendations regarding “bor-derline” angiographic stenoses (50% to 60%) in epicar-dial (non-left main) locations, a significant coronarystenosis for the purpose of the clinical scenarios isdefined as:

• greater than or equal to 70% luminal diameternarrowing, by visual assessment, of an epicardialstenosis measured in the “worst view” angiographicprojection.

• greater than or equal to 50% luminal diameternarrowing, by visual assessment, of a left mainstenosis measured in the “worst view” angiographicprojection.

6. All patients are receiving standard care, includingguideline-based risk factor modification for primary orsecondary prevention in cardiovascular patients unlessspecifically noted (5–9).

7. Despite the best efforts of the clinician, all patients maynot achieve target goals for risk factor modification.However, a plan of care to address risk factors isassumed to be occurring in patients represented in theindications. For patients with chronic stable angina, thewriting group recognizes that there is a wide variance inthe medical therapy for angina. The specific definitionof maximal anti-ischemic medical therapy is presentedin the definition section.

8. Operators performing percutaneous or surgical revascu-larization have appropriate clinical training and experi-ence and have satisfactory outcomes as assessed by

able A. CAD Prognostic Index

Extent of CAD

PrognosticWeight(0–100)

5-YearSurvival Rate

(%)*

-vessel disease, 75% 23 93

1-vessel disease, 50% to 74% 23 93

-vessel disease, �95% 32 91

-vessel disease 37 88

-vessel disease, both �95% 42 86

-vessel disease, �95% proximal LAD 48 83

-vessel disease, �95% LAD 48 83


-vessel disease 56 79

-vessel disease, �95% in at least 1 63 73

-vessel disease, 75% proximal LAD 67 67


Assuming medical treatment only. CAD indicates coronary artery disease; LAD, left anteriorescending coronary artery. From Califf RM, Armstrong PW, Carver JR, et al. Task Force 5.tratification of patients into high-, medium-, and low-risk subgroups for purposes of risk factoranagement. J Am Coll Cardiol. 1996;27:964–1047 (4).

quality assurance monitoring (10–12). p

9. Revascularization by either percutaneous or surgicalmethods is performed in a manner consistent withestablished standards of care (10–12).

0. In the clinical scenarios, no unusual extenuating cir-cumstances exist (such as inability to comply withantiplatelet agents, do not resuscitate status, patientunwilling to consider revascularization, technically notfeasible to perform revascularization, or comorbiditieslikely to markedly increase procedural risk substan-tially), unless specifically noted.

efinitions

complete set of definitions of terms used throughout thendication set are listed in Appendix A. These definitionsere provided and discussed with the technical panel prior

o ratings of indications.

aximal Anti-Ischemic Medical Therapy

s previously stated, the indications assume that patientsre receiving risk factor modification according to guideline-ased recommendations. For the purposes of the clinicalcenarios presented, maximal antianginal medical therapys defined as the use of at least 2 classes of therapies toeduce anginal symptoms.

tress Testing and Risk of Findings ononinvasive Testing

tress testing is commonly used for both diagnosis and risktratification of patients with coronary artery disease. Usingriteria defined for traditional exercise stress tests (13):

Low-risk stress test findings: associated with a cardiacmortality of less than 1% per year;

Intermediate-risk stress test findings: associated with a1% to 3% per year cardiac mortality;

High-risk stress test findings: associated with a greaterthan 3% per year cardiac mortality.

Examples of findings from noninvasive studies and theirssociated level of risk for cardiac mortality are presented inable A2 (12). As noted in the footnote to this table, for

ertain low-risk findings, there may be additional findingshat alter the assessment of risk, but these relationships haveot been well studied. Implicit in these risk definitions is aeasure of the amount of myocardium at risk, or ischemicyocardium. For the purpose of the clinical indications for

oronary revascularization, stress test findings are presentedy these risk criteria. For patients without stress testndings, please refer to the note below on invasive methodsf determining hemodynamic significance. Assume thathen prior testing (including an imaging procedure) is

eferenced in an indication, the testing was performedorrectly and with sufficient quality so as to produce aeaningful and accurate result within the limits of the test

erformance.

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For the purposes of the clinical indications in thisocument, patients with both typical and atypical angina arelassified by the feature of the CCS grading system pre-ented in Table B. Patients with noncardiac chest painhould be considered to be asymptomatic.

igh-Risk Features for Short-Term Risk of Death oronfatal MI for UA/NSTEMI (15)

t least 1 of the following:

History—Accelerating tempo of ischemic symptoms inpreceding 48 hoursCharacter of pain—Prolonged ongoing (greater than 20minutes) rest painClinical findingsX Pulmonary edema, most likely due to ischemiaX New or worsening mitral regurgitation murmurX S3 or new/worsening ralesX Hypotension, bradycardia, tachycardiaX Age greater than 75 years

ElectrocardiogramX Angina at rest with transient ST-segment changes

greater than 0.5 mmX Bundle-branch block, new or presumed newX Sustained ventricular tachycardia

able B. Grading of Angina Pectoris by the Canadianardiovascular Society Classification System

lass I

rdinary physical activity does not cause angina, such as walking, climbingstairs. Angina (occurs) with strenuous, rapid, or prolonged exertion at workor recreation.

lass II

light limitation of ordinary activity. Angina occurs on walking or climbingstairs rapidly, walking uphill, walking or stair climbing after meals or in cold,or in wind, or under emotional stress, or only during the few hours afterawakening. Angina occurs on walking more than 2 blocks on the level andclimbing more than one flight of ordinary stairs at a normal pace and innormal condition.

lass III

arked limitations of ordinary physical activity. Angina occurs on walking oneto two blocks on the level and climbing one flight of stairs in normalconditions and at a normal pace.

lass IV

nability to carry on any physical activity without discomfort—anginalsymptoms may be present at rest.

rom Campeau L. Grading of angina pectoris [letter]. Circulation. 1976;54:522–3 (14). Copyright976 American Heart Association, Inc. Reprinted with permission.

Cardiac markerX Elevated cardiac Troponin T, Troponin I, or crea-

tine kinase-MB (e.g., Troponin T or I greater than0.1 ng per ml)

bbreviations

ABG � coronary artery bypass graftingAD � coronary artery diseaseCS � Canadian Cardiovascular SocietyCT � cardiac computed tomographyHF � congestive heart failureCG � electrocardiogramFR � fractional flow reserveF � heart failure

VUS � intravascular ultrasoundAD � left anterior descending arteryIMA � left internal mammary arteryV � left ventricularVEF � left ventricular ejection fractionI � myocardial infarctionTG � nitroglycerinCI � percutaneous coronary interventionDA � patent ductus arteriosusTEMI � ST-segment elevation myocardial infarctionA/NSTEMI � unstable angina/non–ST-segment eleva-

ion myocardial infarction

esults of Ratings

he final ratings for coronary revascularization (Tables 1 to 4)re listed by indication sequentially as obtained from secondound rating sheets submitted by each panelist. Figures dem-nstrating trends in appropriateness rating by symptom status,schemic risk, and method of revascularization are also presented.

There was generally less variation in ratings for the indica-ions labeled as either appropriate or inappropriate, with 76%nd 70%, respectively showing agreement as defined previouslyn the Methods section. There was, however, greater variabilityn the rating scores for indications defined as uncertain,uggesting wide variation in opinion. Several indications failedo meet the definition of agreement noted above. There wereo ratings where the panel held such opposing viewpoints thathe panel’s votes were determined to be in “disagreement” asefined by the strict RAND definitions described previously inhe Methods section.

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oronary Revascularization Appropriateness Criteria (By Indication)

able 1. Patients With Acute Coronary Syndromes

IndicationAppropriateness

Score (1–9)

1. ● STEMI A (9)*

● Less than or equal to 12 hours from onset of symptoms

● Revascularization of the culprit artery

2. ● STEMI A (9)

● Onset of symptoms within the prior 12 to 24 hours

● Severe HF, persistent ischemic symptoms, or hemodynamic or electrical instability present

3. ● STEMI I (3)

● Greater than 12 hours from symptom onset

● Asymptomatic; no hemodynamic instability and no electrical instability

4. ● STEMI with presumed successful treatment with fibrinolysis A (9)

● Evidence of HF, recurrent ischemia, or unstable ventricular arrhythmias present

● One-vessel CAD, presumed to be the culprit artery

5. ● STEMI with presumed successful treatment with fibrinolysis U (5)

● Asymptomatic; no HF or no recurrent ischemic symptoms, or no unstable ventricular arrhythmias

● Normal LVEF

● One-vessel CAD presumed to be the culprit artery

6. ● STEMI with presumed successful treatment with fibrinolysis A (8)

● Asymptomatic; no HF, no recurrent ischemic symptoms, or no unstable ventricular arrhythmias at time of presentation

● Depressed LVEF

● Three-vessel CAD

● Elective/semi-elective revascularization

7. ● STEMI with successful treatment of the culprit artery by primary PCI or fibrinolysis I (2)

● Asymptomatic; no HF, no evidence of recurrent or provokable ischemia or no unstable ventricular arrhythmias duringindex hospitalization

● Normal LVEF

● Revascularization of a non-infarct related artery during index hospitalization

8. ● STEMI or NSTEMI and successful PCI of culprit artery during index hospitalization A (8)

● Symptoms of recurrent myocardial ischemia and/or high-risk findings on noninvasive stress testing performed afterindex hospitalization

● Revascularization of 1 or more additional coronary arteries

9. ● UA/NSTEMI and high-risk features for short-term risk of death or nonfatal MI A (9)

● Revascularization of the presumed culprit artery

10. ● UA/NSTEMI and high-risk features for short-term risk of death or nonfatal MI A (9)

● Revascularization of multiple coronary arteries when the culprit artery cannot be clearly determined

11. ● Patients with acute myocardial infarction (STEMI or NSTEMI) A (8)

● Evidence of cardiogenic shock

● Revascularization of 1 or more coronary arteries

Subscripted numbers are a reflection of the continuum as per the appropriateness criteria methodology and should not be interpreted as “degrees of appropriateness or inappropriateness.”

T


able 2. Patients Without Prior Bypass Surgery

Appropriateness Score (1–9)

CCS Angina Class

Indication Asymptomatic I or II III or IV

12. ● One- or 2-vessel CAD without involvement of proximal LAD I (1)* I (2) U (5)

● Low-risk findings on noninvasive testing

● Receiving no or minimal anti-ischemic medical therapy

13. ● One- or 2-vessel CAD without involvement of proximal LAD I (2) U (5) A (7)


● Receiving a course of maximal anti-ischemic medical therapy

14. ● One- or 2-vessel CAD without involvement of proximal LAD I (3) U (5) U (6)

● Intermediate-risk findings on noninvasive testing


15. ● One- or 2-vessel CAD without involvement of proximal LAD U (4) A (7) A (8)



16. ● One- or 2-vessel CAD without involvement of proximal LAD U (6) A (7) A (8)

● High-risk findings on noninvasive testing


17. ● One- or 2-vessel CAD without involvement of proximal LAD A (7) A (8) A (9)



18. ● One- or 2-vessel CAD without involvement of proximal LAD † U (5) A (7)

● No noninvasive testing performed

19. ● One- or 2-vessel CAD with borderline stenosis “50% to 60%” † I (2) I (3)

● No noninvasive testing performed

● No further invasive evaluation performed (i.e., FFR, IVUS)

20. ● One- or 2-vessel CAD with borderline stenosis “50% to 60%” I (3) U (6) A (7)

● No noninvasive testing performed or equivocal test results present

● FFR less than 0.75 and/or IVUS with significant reduction in cross-sectional area

21. ● One- or 2-vessel CAD with borderline stenosis “50% to 60%” I (1) I (2) I (2)

● No noninvasive testing performed or equivocal test results present

● FFR or IVUS findings do not meet criteria for significant stenosis

22. ● Chronic total occlusion of 1 major epicardial coronary artery, without other coronary stenoses I (1) I (2) I (3)



23. ● Chronic total occlusion of 1 major epicardial coronary artery, without other coronary stenoses I (1) U (4) U (6)



24. ● Chronic total occlusion of 1 major epicardial coronary artery, without other coronary stenoses I (3) U (4) U (6)



25. ● Chronic total occlusion of 1 major epicardial coronary artery, without other coronary stenoses U (4) U (5) A (7)

● Intermediate-risk criteria on noninvasive testing


26. ● Chronic total occlusion of 1 major epicardial coronary artery, without other coronary stenoses U (4) U (5) A (7)



27. ● Chronic total occlusion of 1 major epicardial coronary artery, without other coronary stenoses U (5) A (7) A (8)

● High-risk criteria on noninvasive testing


28. ● One-vessel CAD involving the proximal LAD U (4) U (5) A (7)



29. ● One-vessel CAD involving the proximal LAD U (4) A (7) A (8)


● Receiving maximal anti-ischemic medical therapy

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able 2. Continued


CCS Angina Class

Indication Asymptomatic I or II III or IV

30. ● One-vessel CAD involving the proximal LAD U (4) U (6) A (7)



31. ● One-vessel CAD involving the proximal LAD U (5) A (8) A (9)



32. ● One-vessel CAD involving the proximal LAD A (7) A (8) A (9)



33. ● One-vessel CAD involving the proximal LAD A (7) A (9) A (9)



34. ● Two-vessel CAD involving the proximal LAD U (4) U (6) A (7)



35. ● Two-vessel CAD involving the proximal LAD U (5) A (7) A (8)









38. ● Two-vessel CAD involving the proximal LAD A (7) A (8) A (9)



39. ● Two-vessel CAD involving the proximal LAD A (8) A (9) A (9)



40. ● Three-vessel CAD (no left main) U (5) U (6) A (7)

● Low-risk findings on noninvasive testing including normal LV systolic function


41. ● Three-vessel CAD (no left main) U (5) A (7) A (8)

● Low-risk findings on noninvasive testing including normal LV systolic function


42. ● Three-vessel CAD (no left main) A (7) A (7) A (8)




● Intermediate risk findings on noninvasive testing








46. ● Three-vessel CAD (no left main) A (8) A (9)Q A (9)

● Abnormal LV systolic function

47. ● Left main stenosis A (9) A (9) A (9)

Subscripted numbers are a reflection of the continuum as per the appropriateness criteria methodology and should not be interpreted as “degrees of appropriateness or inappropriateness.” †Indicateshat the writing group felt the likelihood of the clinical scenario was so low that rating should not be performed.

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ating Revascularization Methods

ode of Revascularization for High Severity of CADIndications 60 to 73)ecognizing a large range of variability in revascularizationethods often based upon patient factors and local practice

able 3. Patients With Prior Bypass Surgery (Without Acute Co

Indication

48. ● One or more stenoses in saphenous vein graft(s)● Low-risk findings on noninvasive testing including norm● Receiving no or minimal anti-ischemic medical therapy

49. ● One or more stenoses in saphenous vein graft(s)

● Low-risk findings on noninvasive testing including norm

● Receiving a course of maximal anti-ischemic medical th













54. ● One or more lesions in native coronary arteries without

● All bypass grafts patent and without significant disease





















● High-risk finding on noninvasive testing


Subscripted numbers are a reflection of the continuum as per the appropriateness criteria methohat the writing group felt the likelihood of the clinical scenario was so low that rating should n

atterns, the majority of clinical indications were not intended c

o distinguish between the specific modes of revascularizationi.e., PCI versus CABG). However, the committee recognizedhat among patients with extensive or complex atherosclerosishe mode of revascularization is also of interest when revascu-arization is deemed appropriate. Therefore, Table 4 presentsomplex scenarios where the features of revascularization are

ry Syndromes)


CCS Angina Class

Asymptomatic I or II III or IV

ystolic functionI (3) U (4) U (6)

U (4) U (6) A (7)

ystolic function

U (4) U (6) A (7)

U (4) A (7) A (8)

U (6) A (7) A (7)

A (7) A (8) A (9)

s grafts † I (3) U (6)

ystolic function

s grafts I (3) U (5) A (7)

ystolic function

s grafts I (3) U (5) A (7)

s grafts U (4) U (6) A (8)

s grafts U (6) A (7) A (8)

s grafts U (5) A (8) A (9)

and should not be interpreted as “degrees of appropriateness or inappropriateness.” †Indicateserformed.

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ppropriateness of PCI and CABG as the revascularizationethod independently of each other (such that each modalityould receive separate scores based on each specific clinical

ndication).

ortality Risk

any of the known clinical factors that increase the risk ofevascularization are shared between CABG and percuta-eous methods. For the indications presented below, theuideline-based features of diabetes and depressed left

ndications. These criteria should be useful to clinicians,

hdphga

Subscripted numbers are a reflection of the continuum as per the appropriateness criteria methodolo

dvanced CAD

he clinical scenarios below specifically apply to patientsith advanced CAD. It was assumed for these clinical

cenarios that all patients have unacceptable levels of symp-oms despite appropriate medical therapy and evidence ofntermediate- to high-risk findings on noninvasive testing.n other words, the technical panel assumed that revascu-arization is appropriate and focused on rating the merit ofhe different modes with the intent of complete coronary

entricular systolic function were used to stratify patients. revascularization for each indication.

able 4. Method of Revascularization: Advanced Coronary Disease,* CCS Angina Greater Than or Equal to Class III, and/orvidence of Intermediate- to High-Risk Findings on Noninvasive Testing


Indication

PCIAppropriateness

Rating

CABGAppropriateness

Rating

60. ● Two-vessel CAD with proximal LAD stenosis A (8)* A (8)

● No diabetes and normal LVEF

61. ● Two-vessel CAD with proximal LAD stenosis A (7) A (8)

● Diabetes

62. ● Two-vessel CAD with proximal LAD stenosis A (7) A (8)

● Depressed LVEF

63. ● Three-vessel CAD U (6) A (8)



● Diabetes


● Depressed LVEF

66. ● Isolated left main stenosis I (3) A (9)



● Diabetes


● Depressed LVEF

69. ● Left main stenosis and additional CAD I (3) A (9)



● Diabetes


● Depressed LVEF

72. ● Prior bypass surgery with native 3-vessel disease and failure of multiple bypass grafts A (7) U (6)

● LIMA remains patent to a native coronary artery

● Depressed LVEF

73. ● Prior bypass surgery with native 3-vessel disease and failure of multiple bypass grafts U (6) A (8)

● LIMA was used as a graft but is no longer functional

● Depressed LVEF

gy and should not be interpreted as “degrees of appropriateness or inappropriateness.”

iscussion

he ratings developed in this report provide an assessmentf the appropriateness of the use of coronary revasculariza-ion for the clinical scenarios presented in each of the

ealth care facilities, third-party payers engaged in theelivery of cardiovascular services, and most importantly,atients. Experience with previous appropriateness criteriaas shown their value across a broad range of situations,uiding care of individual patients, educating caregivers, and
ffecting policy decisions regarding reimbursement.

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linical Judgment

hese indications are intended to provide guidance foratients and clinicians. This approach is not intended toiminish the acknowledged difficulty or uncertainty oflinical decision making. Appropriateness criteria are notubstitutes for sound clinical judgment and practice experi-nce. The writing group recognizes that many patients seenn clinical practice may not be represented in these appro-riateness criteria or have extenuating features when com-ared with the clinical scenarios presented. However, theseriteria provide a framework for discussions regarding re-ascularization between patients and physicians.

Although these ratings provide a general assessment ofhen revascularization may or may not be likely to improveealth outcomes or survival, physicians and other stakehold-rs should continue to acknowledge the pivotal role oflinical judgment in determining whether revascularizations indicated for an individual patient. For example, theating of a revascularization indication as “uncertain” shouldot preclude a provider from performing a revascularizationrocedure when there are patient- and condition-specificata to support that decision. Uncertain indications require

ndividual physician judgment and understanding of theatient to better determine the usefulness of the procedureor a particular scenario. Indeed revascularization may be theorrect treatment, if supported by mitigating characteristicsf the patient. Therefore, these criteria provide a frameworkor discussion regarding revascularization upon which thepecific clinical characteristics of an individual patient muste superimposed. Ranking of an indication as uncertain (4o 6) should not be viewed as excluding the use ofevascularization for such patients. Although it is consid-red unlikely, an indication rated as “inappropriate” may inare circumstances be the best therapy for an individualatient. In contrast, a clinical situation rated as “appropri-te” may not always represent reasonable practice in apecific patient with extenuating circumstances. Appropri-teness also does not equate to medical necessity. Sharedhysician/patient decision making for many scenarios woulde expected and may result in the patient deferring coronaryevascularization while maintaining medical therapy.

These ratings are intended to evaluate the appropriate-ess of specific patient scenarios to determine overallatterns of care regarding revascularization. In situationshere there is substantial variation between the appropri-

teness rating and what the clinician believes is the bestecommendation for the patient, further considerations orctions, such as a second opinion, may be appropriate.

oreover, it is not anticipated that all physicians or facilitiesill have 100% of their revascularization procedures deemed

ppropriate. However related to the overall patterns of care,f the national average of appropriate procedure ratings is0%, for example, and a physician or facility has only a 40%ate of appropriate procedures, further examination of the
atterns of care may be warranted and helpful. p
eneral Themes in Appropriateness Criteriaor Revascularization

he purpose of coronary revascularization should be tomprove health outcomes for the patients undergoing therocedure. As such, the technical panel was asked to rateach specific clinical indication with emphasis on the benefitmparted to health outcomes (symptoms, functional status,nd/or quality of life) or survival. It should be noted that theppropriateness Criteria for Coronary Revascularization

ontain no scenarios rated as “appropriate” that correlateith Class III recommendations in guideline documents.ikewise, no “inappropriate” appropriateness criteria indi-ations correlate with Class I guideline recommendations.lthough multiple clinical and anatomic factors could haveeen included in the clinical scenarios, the writing groupocused on symptom status, degree of medical therapy,xtent of ischemia by noninvasive testing, and finally, theresence and location of significant coronary stenoses.everal themes were identified in reviewing the results for theppropriateness Criteria for Coronary Revascularization.

cute Coronary Syndromes

he technical panel rated the majority of clinical scenariosn these patients as appropriate for revascularization (Figure). However, there were 2 notable exceptions that receivednappropriate ratings. First, in patients with STEMI pre-enting greater than 12 hours from symptom onset withoutngoing symptoms of ischemia or clinical instability, imme-iate revascularization was deemed inappropriate. By exten-ion, this also implies that the need for immediate angiog-aphy on presentation in such patients is unnecessary.econd, after successful treatment of the culprit artery byCI or fibrinolysis, revascularization of nonculprit arteriesefore hospital discharge in patients without clinical insta-ility, with no evidence of recurrent or provokable ischemia,nd with a normal LVEF was rated as inappropriate.

table Ischemic Heart Disease Without Prior CABG

n general, the presence of high-risk findings on noninvasiveesting, higher severity of symptoms, or an increasingurden of CAD tended to elevate the rating to appropriate.nappropriate ratings tended to cluster among groups re-eiving no or minimal anti-ischemic treatment with low-isk findings on noninvasive testing. Figures 2 to 4 illustratehe interplay of these elements in determining appropriate-ess. Four clinical scenarios (18 to 21) were included inhich no functional testing was performed. Although the

bility to couple the anatomic findings from coronaryngiography with the physiologic evaluation available fromhe various diagnostic testing modalities is ideal, the writingroup recognized that there are patients who undergongiography without such testing. Revascularization wasated appropriate in such patients if they had 1- or 2-vesselisease with or without involvement of the proximal LADnd class III or IV angina. The level of medical therapy
atients were receiving in this particular scenario was not

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pecifically considered and was thus left to the judgment ofhe clinician. However, consistent with the pattern of careeveloped in these appropriateness criteria, a trial of medicalherapy before performing revascularization may be appro-riate in some patients. The remaining three scenarios

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Post - Index Hospitalization

igure 1. Acute Coronary Syndromes*

The fact that the use of coronary revascularization for a particular condition is listeherapeutic modalities that may be equally effective. See the most current ACC/AHAisease; HF, heart failure; I, inappropriate; LVEF, left ventricular ejection fraction;ncertain; and UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction.

igure 2. Appropriateness Ratings by Low-Risk Findings on NoninvPatients Without Prior Bypass Surgery)

indicates appropriate; CTO, chronic total occlusion; I, inappropriate; Int., intervention; Mencertain; and vz., vessel.

nvolved patients found to have so-called intermediateeverity stenoses. The ratings in these settings reflect thebility of additional evaluations performed in the catheter-zation laboratory (such as FFR or IVUS) to identifyignificant stenoses beyond their appearance by angiography

STEMI

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A

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arrhythmias present

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ventricular arrhythmias

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rent myocardial ischemia ngs on non-invasive stress fter index hospitalization

Revascularization of non-culprit vessel(s)

I

is figure (appropriate, uncertain, inappropriate) does not preclude the use of otherSTEMI and STEMI guidelines (15,16). A indicates appropriate; CAD, coronary arterypercutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; U,

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lone. In patients without noninvasive testing, revascular-zation of intermediate stenoses without further documen-ation of significance by FFR or IVUS was rated asnappropriate. Revascularization of such patients who dem-nstrate abnormal IVUS or FFR findings and are highlyymptomatic was deemed appropriate.

table Ischemic Heart Disease With Prior CABG

imilar to the pattern seen in patients without prior CABG,he presence of high-risk findings on noninvasive testing,igher severity of symptoms, or an increasing burden ofisease in either the bypass grafts or native coronaries

igure 3. Appropriateness Ratings by Intermediate-Risk FindingPatients Without Prior Bypass Surgery)

CS indicates Canadian Cardiovascular Society, other abbreviations as in Figure 2.

igure 4. Appropriateness Ratings by High-Risk Findings on NoPatients Without Prior Bypass Surgery)

bbreviations as in Figures 2 and 3.

ended to increase the likelihood of an appropriate rating.he only inappropriate ratings in patients with prior CABGere noted in patients receiving no or minimal anti-

schemic therapy or having low-risk findings on noninvasiveesting. More uncertain ratings occurred in this group ofatients, reflecting their higher complexity, higher risk, andhe limited availability of published evidence regardinganagement outcome.

CI and CABG in Patients With Advanced CAD

n this group of ratings, it was assumed that revasculariza-ion was necessary, and the technical panel rated the

Noninvasive Imaging Study and CCS Class I or II Angina

sive Imaging Study and CCS Class III or IV Angina

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ppropriateness of the mode of revascularization (Table 4,igure 5). CABG was rated as appropriate in all of thelinical scenarios developed, whereas PCI was rated appro-riate only in patients with 2-vessel CAD with involvementf the proximal LAD and uncertain in patients with 3-vesselisease. For patients with left main stenosis and/or left maintenosis and multivessel CAD, CABG was deemed to beppropriate and likely to improve the patients’ healthutcomes or survival. PCI for this patient group was deemedot to be a reasonable approach and unlikely to improve theatients’ health outcomes or survival.

pplication of Criteria

here are many potential applications for appropriatenessriteria. Clinicians could use the ratings for decision supportr as an educational tool when considering the need forevascularization. Moreover, these criteria could be used toacilitate discussion with patients and or referring physiciansbout the need for revascularization. Facilities and payersay choose to use these criteria either prospectively in the

esign of protocols or pre-authorization procedures, oretrospectively for quality reports. It is hoped that payersould use these criteria as the basis for the development of

ational payment management strategies to ensure that theirembers receive necessary, beneficial, and cost-effective

ardiovascular care, rather than for other purposes.It is expected that services performed for appropriate

ndications will receive reimbursement. In contrast, serviceserformed for inappropriate indications will likely requiredditional documentation to justify payment because of thenique circumstances or the clinical profile that must existn such a patient. It is critical to emphasize that the writingroup, technical panel, Appropriateness Task Force, andlinical community do not believe an uncertain rating isrounds to deny reimbursement for revascularization.ather, uncertain ratings are those in which the availableata vary and many other factors exist that may affect theecision to perform or not perform revascularization. Thepinions of the technical panel often varied for these

igure 5. Method of Revascularization of Advanced Coronary Arter

ABG indicates coronary artery bypass grafting; LAD, left anterior descending artery;

ndications, reflecting that additional research is needed. p

ndications with high clinical volume that are rated asncertain identify important areas for further research.When evaluating physician or facility performance, ap-

ropriateness criteria should be used in conjunction withfforts that lead to quality improvement. Prospective pre-uthorization procedures, if put in place, are most effectivence a retrospective review has identified a pattern ofotential inappropriate use. Because these criteria are basedn current scientific evidence and the deliberations of theechnical panel, they should be used prospectively to gen-rate future discussions about reimbursement, but shouldot be applied retrospectively to cases completed before

ssuance of this report or documentation of centers/roviders performing an unexpectedly high proportion ofnappropriate cases as compared with their peers.

The writing group recognizes that these criteria will bevaluated during routine clinical care. To that end, specificata fields such as symptom status, presence or absence ofcute coronary syndrome, history of bypass surgery, extentf ischemia on noninvasive imaging, CAD burden, andegree of antianginal therapy are anticipated to provideufficient detail to determine individual appropriatenessatings. Since a reasonable and tolerated dose of antianginalherapy may vary significantly among different patients, theriting group recommends the presence of 2 classes of

ntianginal therapies as a minimum standard for medicalherapy.

The primary objective of this report is to provide guid-nce regarding the suitability of coronary revascularizationor diverse clinical scenarios. As with previous appropriate-ess criteria documents, consensus among the raters wasesirable, but an attempt to achieve complete agreementithin this diverse panel would have been artificial and wasot the goal of the process. Two rounds of ratings withubstantial discussion among the technical panel membersetween the ratings did lead to some consensus amonganelists. However, further attempts to drive consensusould have diluted true differences in opinion among

ease

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anelists and, therefore, was not undertaken.

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Future research analyzing patient outcomes for indica-ions rated as appropriate would help ensure the equitablend efficient allocation of resources for coronary revascu-arization. Review of appropriateness patterns may alsomprove understanding of regional variations in the usef revascularization as highlighted in the Dartmouthtlas Project (17). Further exploration of the indications

ated as “uncertain” will help generate the informationequired to further define the appropriateness of coronaryevascularization. Additionally, the criteria will need toe updated with the publication of ongoing trials inoronary revascularization and new clinical practice guidelines.

In conclusion, this document represents the currentnderstanding of the clinical benefit of coronary revas-ularization with respect to health outcomes and survival.t is intended to provide a practical guide to cliniciansnd patients when considering revascularization. As withther appropriateness criteria, some of these ratings willequire research and further evaluation to provide thereatest information and benefit to clinical decisionaking. Finally, it will be necessary to periodically assess

nd update the indications and criteria as technologyvolves and new data and field experience becomes available.

ppendix A: Additional Coronaryevascularization Definitions

ngina/Chest Pain Classification

ngina is a syndrome typically noted to include discomfortn the chest, jaw, shoulder, back, or arm that is aggravatedy exertion or emotional stress and relieved by nitroglycerin.he quality of the discomfort, provoking factors, and

elieving factors are used to define typical, atypical, andoncardiac chest pain. Atypical angina is generally definedy 2 of the above 3 characteristics, and noncardiac chestain is generally defined as chest pain that meets 1 or nonef the above criteria. These definitions are represented inable A1 presented below.

The writing group assumes that noninvasive assessmentsf coronary anatomy (i.e., cardiac computed tomography,ardiac magnetic resonance angiography) provide anatomicnformation that is potentially similar to X-ray angiography.

able A1. Clinical Classification of Chest Pain

ypical angina (definite)

1) Substernal chest discomfort with a characteristic quality and duration thatis 2) provoked by exertion or emotional stress and 3) relieved by rest or NTG.

typical angina (probable)

Meets 2 of the above characteristics.

oncardiac chest pain

Meets one or none of the typical anginal characteristics.

odified from Diamond GA. A clinically relevant classification of chest discomfort. J Am Collardiol. 1983;1:574–5 (18).

owever, these modalities do not currently provide infor- i

ation on ischemic burden and are not assumed to beresent in the clinical scenarios.

nvasive Methods of Determiningemodynamic Significance

he writing group recognizes that not all patients referredor coronary angiography and revascularization will haverevious noninvasive testing. In fact, there are severalituations in which patients may be appropriately referredor coronary angiography based on symptom presentationnd a high pre-test probability of CAD. In these settings,here may be situations where angiography shows a coronaryarrowing of questionable hemodynamic importance in aatient with symptoms that could be related to myocardialschemia. In such patients, the use of additional invasive

easurements (such as fractional flow reserve or intravas-ular ultrasound) at the time of diagnostic angiography maye very helpful in further defining the need for revascular-zation and substituted for stress test findings (Table A2).

ppendix B: Additional Methods

ee the earlier Methods section of the report for a descrip-ion of panel selection, indication development, scope of

able A2. Noninvasive Risk Stratification

igh-Risk (greater than 3% annual mortality rate)

1. Severe resting left ventricular dysfunction (LVEF less than 35%)

2. High-risk treadmill score (score less than or equal to �11)

3. Severe exercise left ventricular dysfunction (exercise LVEF less than 35%)

4. Stress-induced large perfusion defect (particularly if anterior)

5. Stress-induced multiple perfusion defects of moderate size

6. Large, fixed perfusion defect with LV dilation or increased lung uptake(thallium-201)

7. Stress-induced moderate perfusion defect with LV dilation or increasedlung uptake (thallium-201)

8. Echocardiographic wall motion abnormality (involving greater than twosegments) developing at low dose of dobutamine (less than or equal to10 mg/kg/min) or at a low heart rate (less than 120 beats/min)

9. Stress echocardiographic evidence of extensive ischemia

ntermediate-Risk (1% to 3% annual mortality rate)

1. Mild/moderate resting left ventricular dysfunction (LVEF equal to 35% to49%)

2. Intermediate-risk treadmill score (�11 less than score less than 5)

3. Stress-induced moderate perfusion defect without LV dilation or increasedlung intake (thallium-201)

4. Limited stress echocardiographic ischemia with a wall motion abnormalityonly at higher doses of dobutamine involving less than or equal to twosegments

ow-Risk (less than 1% annual mortality rate)

1. Low-risk treadmill score (score greater than or equal to 5)

2. Normal or small myocardial perfusion defect at rest or with stress*

3. Normal stress echocardiographic wall motion or no change of limitedresting wall motion abnormalities during stress*

Although the published data are limited, patients with these findings will probably not be at lowisk in the presence of either a high-risk treadmill score or severe resting left ventricularysfunction (LVEF � 35%).

ndications, and rating process.

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elationships With Industry

he College and its partnering organizations rigorouslyvoid any actual, perceived, or potential conflicts of interesthat might arise as a result of an outside relationship orersonal interest of a member of the technical panel.pecifically, all panelists are asked to provide disclosuretatements of all relationships that might be perceived aseal or potential conflicts of interest. These statements wereeviewed by the Appropriateness Criteria Working Group,iscussed with all members of the technical panel at theace-to-face meeting, and updated and reviewed as neces-ary. A table of disclosures by the technical panel and oversightorking group members can be found in Appendix D.

iterature Review

he technical panel members were asked to refer to theelevant guidelines for a summary of the relevant literature,uideline recommendation tables, and reference lists pro-ided for each indication table when completing theiratings (Online Appendix).

ppendix C: ACCF/SCAI/STS/AATS/AHA/SNC 2009 Appropriateness Criteria fororonary Revascularization Participants

oronary Revascularization Writing Group

anesh R. Patel, MD—Chair, Appropriateness Criteriaor Coronary Revascularization Writing Group—Assistantrofessor of Medicine, Division of Cardiology, Assistantirector, Cardiac Catheterization Lab, Duke Universityedical Center, Durham, NCGregory J. Dehmer, MD, FACC, FACP, FSCAI,

AHA—Past President, Society for Cardiovascular An-iography and Interventions; Professor of Medicine, Texas&M School of Medicine; and Director, Cardiology Divi-

ion, Scott & White Clinic, Temple, TXJohn W. Hirshfeld, MD, FACC—Professor of Medi-

ine, Hospital of The University of Pennsylvania, Depart-ent of Medicine, Cardiovascular Medicine Division, Phil-

delphia, PAPeter K. Smith, MD, FACC—Professor and Chief,

horacic Surgery, Duke University, Durham, NCJohn A. Spertus, MD, MPH, FACC—Professor,

MKC School of Medicine, Director of CV Education andutcomes Research, MidAmerica Heart Institute of St.uke’s Hospital, Kansas City, MO

oronary Revascularization Technical Panel

rederick A. Masoudi, MD, MSPH, FACC—Moderatoror the Technical Panel—Associate Professor of Medicine,enver Health Medical Center & University of Colorado atenver and Health Sciences Center, Denver, CORalph G. Brindis, MD, MPH, FACC, FSCAI—ethodology Liaison for the Technical Panel—Regional

enior Advisor for Cardiovascular Disease, Northern Cali- D

ornia Kaiser Permanente; Clinical Professor of Medicine,niversity of California at San Francisco; Chief Medicalfficer and Chairman, NCDR Management Board, Amer-

can College of Cardiology Foundation, Washington, DCGregory J. Dehmer, MD, FACC, FACP, FSCAI,

AHA—Writing Group Liaison for the Technical Panel—ast President, Society for Cardiovascular Angiography andnterventions, Professor of Medicine, Texas A&M Schoolf Medicine; and Director, Cardiology Division, Scott &

hite Clinic, Temple, TXManesh R. Patel, MD—Writing Group Liaison for the

echnical Panel—Assistant Professor of Medicine, Divi-ion of Cardiology, Duke University Medical Center,urham, NCPeter K. Smith, MD, FACC—Writing Group Liaison

or the Technical Panel—Professor and Chief, Thoracicurgery, Duke University, Durham, NCKaren J. Beckman, MD, FACC—Professor of Medicine,

niversity of Oklahoma Health Science Center, Cardiacrrhythmia Research Institute, Oklahoma City, OKCharles E. Chambers, MD, FACC, FSCAI, FAHA—

rofessor of Medicine and Radiology, Penn State Heart andascular Institute, Hershey, PAT. Bruce Ferguson, Jr., MD, FACC, FAHA—Professor

f Surgery and Physiology and Associate Director of Car-iothoracic and Vascular Surgery, East Carolina Brodychool of Medicine, Division of CT and Vascular Surgery,reenville, NCMario J. Garcia, MD, FACC—Professor of Medicine

nd Director of Non-Invasive Cardiology, Cardiovascularnstitute, Mount Sinai Hospital, Mount Sinai Medicalchool, New York, NYFrederick L. Grover, MD, FACC—Professor and De-

artment Chair, Department of Surgery and Director, Lungransplantation, University of Colorado Health Sciencesenter, Denver, CODavid R. Holmes, Jr., MD, FACC, FSCAI—Professor

f Medicine, Mayo Clinic, Rochester, MNLloyd W. Klein, MD, FACC, FSCAI, FAHA—irector, Clinical Cardiology Associates, Gottlieb Memo-

ial Hospital, Melrose Park, ILMarian Limacher, MD, FACC—Professor of Medicine,

niversity of Florida Division of Cardiovascular Medicine,ainesville, FLMichael J. Mack, MD—Director, Cardiopulmonary Re-

earch Science Technology Institute, Baylor Healthcareystem, Dallas, TXDavid J. Malenka, MD, FACC—Professor of Medicine,artmouth Hitchcock Medical Center, Lebanon, NHMyung H. Park, MD, FACC—Assistant Professor ofedicine and Director, Pulmonary Vascular Diseases Pro-

ram, Lutherville, MDMichael Ragosta, III, MD, FACC, FSCAI—Associate

rofessor of Internal Medicine, Department of Medicine,
ivision of Cardiovascular Medicine, Charlottesville, VA

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James L. Ritchie, MD, FACC, FAHA—Clinical Pro-essor of Medicine, University of Washington, Seattle

ashington; and Bend Memorial Clinic, Bend, ORGeoffrey A. Rose, MD, FACC, FASE—Director, Car-

iac Ultrasound Laboratory, Sanger Clinic/Carolinas Heartnstitute, Charlotte, NC

Alan B. Rosenberg, MD—Vice President & Medicalirector, WellPoint Health Networks, Chicago, ILRichard J. Shemin, MD, FACC, FAHA—Professor of

urgery, UCLA David Geffen School of Medicine, Chief,ivision of Cardiothoracic Surgery; Executive Vice Chair,epartment of Surgery; and Co-Director, Cardiovascularenter, Ronald Reagan UCLA Medical Center, Los An-

eles, CAWilliam S. Weintraub, MD, FACC, FAHA—Professor

f Medicine; John H. Ammon Chair of Cardiology; andirector, Christiana Center for Outcomes Research, New-

rk, DE

xternal Reviewers of the Appropriatenessriteria Indications

tephan Achenbach, MD, FACC, FESC—Professor ofedicine, Department of Cardiology, University of Erlan-

en, GermanyJoseph S. Alpert, MD, FAHA, FACC, MACP—

rofessor of Medicine, Special Assistant to the Dean,niversity of Arizona College of Medicine, Tucson, AZ;ditor-in-Chief, American Journal of MedicineH. Vernon Anderson, MD, FACC, FAHA—Professor

f Medicine, Cardiology Division, University of Texasealth Science Center, Houston, TXElliott M. Antman, MD, FACC, FAHA—Professor ofedicine, Harvard Medical School, and Director, Samuel. Levine Cardiac Unit, Cardiovascular Division, BrighamWomen’s Hospital, Boston, MALee M. Arcement, MD, MPH, FACC, FCCP—Chief

f Cardiology, Chabert Medical Center, Houma, LA;ivision Director of Heart Failure Disease Management,ouisiana State University Health Care Services, Batonouge, LAR. Morton Bolman, III, MD—Professor of Surgery,arvard Medical School, and Chief, Division of Cardiac

urgery, Brigham & Women’s Hospital, Boston, MAJaved Butler, MBBS, MPH, FACC, FAHA—Associate

rofessor of Medicine and Director, Heart Failure Re-earch, Emory University, Atlanta, GA

Jun R. Chiong, MD, MPH, FACC, FCCP—Associaterofessor of Medicine Medical Director, Advanced Heartailure Program Loma Linda University Medical Centeroma Linda, CAG. William Dec, MD, FACC, FAHA—Professor ofedicine, Harvard Medical School and Chief, Cardiologyivision, Massachusetts General Hospital, Boston, MADavid P. Faxon, MD, FACC—Chief of Cardiology,

oston VA Health System, West Roxbury, MA, and o

irector of Strategic Planning, Department of Medicine,righam and Women’s Hospital, Boston, MARaymond J. Gibbons, MD—Professor of Medicine,ayo Clinic, Rochester, MNRobert A. Guyton, MD, FACC—Professor of Surgery

nd Chief of Cardiothoracic Surgery, Emory Universitychool of Medicine, Atlanta, GAAlice K. Jacobs, MD, FACC—Professor of Medicine,

oston University School of Medicine; Director, Cardiacatheterization Laboratories & Interventional Cardiology,oston Medical Center, Boston, MAJohn A. Kern, MD, FACS—Associate Professor of

urgery, Co-Director Heart and Vascular Center, Univer-ity of Virginia Health System, Charlottesville, VA

Lloyd W. Klein, MD, FACC, FSCAI, FAHA—rofessor of Medicine, Rush University Medical Center,hicago, ILMichael J. Mack, MD—Director, Cardiopulmonary Re-

earch Science Technology Institute, Baylor Healthcareystem, Dallas, TXL. Brent Mitchell, MD, FRCPC, FACC—Professor andead, Department of Cardiac Sciences, Calgary Healthegion and University of Calgary; Director, Libin Cardio-

ascular Institute of Alberta, Calgary, AB, CanadaMarc R. Moon, MD—Professor of Surgery, Barnes-

ewish Hospital/Washington University, St. Louis, MODouglass A. Morrison, MD, PhD, FACC, FSCAI—

rofessor of Medicine, Director, Cardiac Catheterizationab, Yakima Heart Center, Yakima, WAReid T. Muller, MD, FACC, FACP—Director, Non-

nvasive Vascular Lab, SJH Cardiology Associates, Syra-use, NY

Sherif F. Nagueh, MD, FACC—Professor of Medicine,ethodist DeBakey Heart and Vascular Center, Houston, TXNavin C. Nanda, MD, FACC—Professor of Medicine

nd Director, Heart Station/Echocardiography Laborato-ies, University of Alabama at Birmingham, Birmingham, AL

William C. Nugent, MD—Professor and Chief, Cardio-horacic Surgery, Dartmouth-Hitchcock Medical Center,ebanon, NHMyung H. Park, MD, FACC—Assistant Professor ofedicine and Director, Pulmonary Vascular Diseases Pro-

ram, Division of Cardiology, University of Marylandchool of Medicine, Baltimore, MDMichael Poon, MD—Associate Clinical Professor ofedicine, New York, NYJohn D. Puskas, MD—Professor of Surgery (Cardiotho-

acic) and Associate Chief of Cardiothoracic Surgery,mory University; Chief of Cardiac Surgery, Emory Craw-

ord Long Hospital, Atlanta, GAJ. Scott Rankin, MD—Associate Clinical Professor,

anderbilt University, Nashville, TNRita F. Redberg, MD, MSc, FACC, FAHA—Professor

f Medicine, University of California at San Francisco School
f Medicine, Division of Cardiology, San Francisco, CA

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Michael W. Rich, MD, FSGC, FACC—Professor ofedicine, Cardiovascular Division, Washington University

chool of Medicine, St. Louis, MOCraig R. Smith, MD—Calvin F. Barber Professor of

urgery, College of Physicians & Surgeons of Columbianiversity, New York, NY; and Interim Chairman, Depart-ent of Surgery and Chief, Division of Cardiothoracic

urgery, New York Presbyterian Hospital, New York, NYBarry F. Uretsky, MD, FACC, FSCAI, FAHA—

rofessor of Medicine, University of Texas Medical Branch,alveston, TX; and Director of Cardiology and Cardiovas-

ular Services Sparks Health System, Fort Smith, AKEdward D. Verrier, MD, FACS, FACC, FAHA—

rofessor and Chief, Division of Cardiothoracic Surgery,niversity of Washington, Seattle, WASusan J. Zieman, MD, PhD, FACC—Assistant Profes-

or of Medicine, Division of Cardiology, Johns Hopkinsniversity School of Medicine, Baltimore, MD

CCF Appropriateness Criteria Task Force

ichael J. Wolk, MD, MACC—Chair, Working Group—ast President, American College of Cardiology Founda-

ion and Clinical Professor of Medicine, Weill-Cornell
edical School, New York, NY F
Ralph G. Brindis, MD, MPH, FACC, FSCAI—egional Senior Advisor for Cardiovascular Disease, North-

rn California Kaiser Permanente, Oakland, CA; Clinicalrofessor of Medicine, University of California at Sanrancisco, San Francisco, CA; Chief Medical Officer &hairman, NCDR Management Board, American Collegef Cardiology Foundation, Washington, DCPamela S. Douglas, MD, MACC, FAHA, FASE—Past

resident, American College of Cardiology Foundation;ast President, American Society of Echocardiography; andrsula Geller Professor of Research in Cardiovasculariseases and Chief, Cardiovascular Disease, Duke Univer-

ity Medical Center, Durham, NCRobert C. Hendel, MD, FACC, FAHA—Midwesteart Specialists, Fox River Grove, ILManesh R. Patel, MD—Assistant Professor of Medicine,ivision of Cardiology, Duke University Medical Center,urham, NCEric D. Peterson, MD, MPH, FACC, FAHA—

rofessor of Medicine and Director, Cardiovascular Re-earch, Duke Clinical Research Institute, Duke University

edical Center, Durham, NCJoseph M. Allen, MA—Director, TRIP (Translating

esearch into Practice), American College of Cardiology
oundation, Washington, DC
PPENDIX D. ACCF/SCAI/STS/AATS/AHA/ASNC 2009 CORONARY REVASCULARIZATION APPROPRIATENESSRITERIA WRITING GROUP, TECHNICAL PANEL, TASK FORCE, AND INDICATION REVIEWERS—RELATIONSHIPSITH INDUSTRY (IN ALPHABETICAL ORDER)

Committee Member Research Grant

Speakers’ Bureau/Honoraria/

Expert Witness Stock OwnershipBoard ofDirectors

Consultant/Scientific Advisory Board/

Steering Committee

Coronary Revascularization Appropriateness Criteria Writing Group

r. Gregory J. Dehmer None None None None None

r. John W. Hirshfeld None None None None None

r. Manesh R. Patel ● Datascope● Daiichi Sankyo/Lilly

None None None ● Genzyme● Novartis

r. Peter K. Smith None None None None None

r. John A. Spertus ● Amgen● Bristol-Myers Squibb/Sanofi-Aventis Partnership

● Lilly

● St. Jude Medical ● Copyright forSeattle AnginaQuestionnaire,Kansas CityCardiomyopathyQuestionnaire, andPeripheral ArterialQuestionnaire

● PRISM Technology

Coronary Revascularization Appropriateness Criteria Technical Panel

r. Karen J. Beckman ● Bio-Sense Webster● Cardio-Focus● Pro-Rhythm● Reliant● Stereo-taxis

None None None None

r. Charles E. Chambers None ● GE Medical None None None

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Steering Committee

r. T. Bruce Ferguson, Jr. None None None None None

r. Mario J. Garcia ● Philips Medical Systems ● Philips Medical Systems● Vital Images

None None ● BG Medicine● Philips Medical Systems

r. Frederick L. Grover None None None None None

r. David R. Holmes, Jr. None None None None None

r. Lloyd W. Klein None None None None Pfizer

r. Marian Limacher ● Boehringer Ingelheim● Orexigen Therapeutics, Inc

None None None None

r. Michael J. Mack None None None None None

r. David J. Malenka None None None None None

r. Frederick A. Masoudi Amgen ● Amgen● Takeda● United HealthCare

None None None

r. Myung H. Park None ● Actelion Pharmaceuticals● Gilead Sciences● United Therapeutics

None None ● Actelion Pharmaceuticals● Gilead Sciences● United Therapeutics

r. Michael Ragosta, III None None None None None

r. James L. Ritchie None None None None None

r. Geoffrey A. Rose None None None None None

r. Alan B. Rosenberg None None ● WellPoint None None

r. Richard J. Shemin None ● Edwards Life Sciences● St. Jude Medical

None None None

r. William S. Weintraub None None None None None

ACCF Appropriateness Criteria Task Force

oseph M. Allen None None None None None

r. Ralph G. Brindis None None None None None

r. Pamela S. Douglas ● Atritech● BG Medicine● Edwards Life Sciences● Lab Corp● Reata● United HealthCare

● BG Medicine● Expression Analysis● Genentech● GlaxoSmithKlineFoundation

● Northpoint Domain● Ortho Diagnostics● Pappas Ventures● Visen Medicad● Xceed Molecular

● CardioDX● Millennium● NorthpointDomain

None None

r. Robert C. Hendel None None None None None

r. Eric D. Peterson ● Bristol-Myers Squibb/Sanofi-Aventis

● Merck● Schering-Plough● St. Jude Medical

None None None None

r. Michael J. Wolk None None None None None

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Steering Committee

Coronary Revascularization Appropriateness Criteria Indication Reviewers

r. Stephan Achenbach ● Schering● Siemens Medical Solutions

None None None ● Bracco

r. Joseph S. Alpert None None None None None

r. H. Vernon Anderson None ● Bristol-Myers SquibbPharmaceuticals

● PDL Biopharma● Sanofi-AventisPharmaceuticals

None None None

r. Elliott M. Antman ● Accumetrics, Inc.● Amgen, Inc● AstraZeneca PharmaceuticalsLP

● Bayer Healthcare LLC● Beckman Coulter, Inc.● Biosite Incorporated● Bristol-Myers SquibbPharmaceutical ResearchInstitute

● CV Therapeutics● Eli Lilly and Company● GlaxoSmithKline● Inotek PharmaceuticalsCorporation

● Integrated TherapeuticsCorporation

● Merck & Co● Millennium Pharmaceuticals● Novartis Pharmaceuticals● Nuvelo, Inc.● Ortho-Clinical Diagnostics, Inc.● Pfizer, Inc.● Roche DiagnosticsCorporation

● Roche Diagnostics GmbH● Sanofi-Aventis● Sanofi-Synthelabo Recherche● Schering-Plough ResearchInstitute

None None None ● Eli Lilly● Sanofi-Aventis

r. Lee M. Arcement None ● GlaxoSmithKline● Nitromed

None None None

r. R. Morton Bolman None None None None None

r. Javed Butler None ● Boehringer Ingelheim● GlaxoSmithKlinePharmaceutical

● Novartis Pharmaceuticals

None None None

r. Jun R. Chiong None None None None None

r. G. William Dec None None None None None

r. David P. Faxon None None None None None

r. Raymond J. Gibbons ● KAI Pharmaceuticals● King Pharmaceuticals● Radiant Medical TargeGen● Ther Ox

None None None ● Cardiovascular ClinicalStudies (WOMEN Study)

● Consumers Union TIMI37A

r. Robert A. Guyton None None None None ● Guidant, Inc● Medtronic, Inc

r. Alice K. Jacobs None None None None None

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Steering Committee

r. John A. Kern None None None None None

r. L. Brent Mitchell ● Guidant Canada● Medtronic Canada

● Medtronic Canada None None ● Boehringer-Ingelheim● CardiomePharmaceuticals

● Medtronic, Inc

r. Marc R. Moon None ● Edwards Life Sciences None None None

r. Douglass A. Morrison None None None None None

r. Reid T. Muller None None None None None

r. Sherif F. Nagueh None ● Medtronic None None ● GE Healthcare● St. Jude Medical

r. Navin C. Nanda None None None None ● Philips

r. William C. Nugent None None None None None

r. Michael Poon None None None None None

r. John D. Puskas ● Maquet● Medtronic Scanlan (royaltyincome)

None None None ● Maquet● Medtronic, Inc

r. J. Scott Rankin None None None None None

r. Rita F. Redberg ● Blue Shield of CaliforniaFoundation

None None None None

r. Michael W. Rich None None None None None

r. Craig R. Smith None None None None None

r. Barry F Uretsky None None None None None

r. Edward D. Verrier None None None None None

r. Susan J. Zieman None None None None None

taff

merican College of Cardiology Foundationohn C. Lewin, MD, Chief Executive Officerhomas E. Arend, Jr., Esq., Chief Operating Officer

oseph M. Allen, MA, Director, TRIP (Translating Re-earch Into Practice)aren Cowdery Caruth, MBA, Senior Specialist, Appro-riateness Criteriaennedy Elliott, Specialist, Appropriateness Criteriaindsey Law, MA, Senior Specialist, Appropriateness Criteriarin A. Barrett, Senior Specialist, Science and Clinicalolicy

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2. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLAAppropriateness Method User’s Manual. Arlington, VA: RAND,2001.

3. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline
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6. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention ofcardiovascular diseases in people with diabetes mellitus: a scientificstatement from the American Heart Association and the AmericanDiabetes Association. Circulation. 2007;115:114–26.

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0. King, SB, Aversano, T, Ballard WL, et al. ACCF/AHA/SCAI 2007update of the clinical competence statement on cardiac interventionalprocedures: a report of the American College of Cardiology Founda-tion/American Heart Association/American College of PhysiciansTask Force on Clinical Competence and Training. J Am Coll Cardiol.2007;50:82–108.

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2. Smith SC Jr., Feldman TE, Hirshfeld JW Jr. ACC/AHA/SCAI 2005guideline update for percutaneous coronary intervention—summaryarticle: a report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines forPercutaneous Coronary Intervention). J Am Coll Cardiol. 2006;47:216–35.

3. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guidelineupdate for the management of patients with chronic stable angina: areport of the American College of Cardiology/American Heart Asso-ciation Task Force on Practice Guidelines (Committee to Update the
1999 Guidelines for the Management of Patients with Chronic Stable S
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APPENDIX

upplementary materials cited in this article are available online.

http://www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf

http://www.acc.org/qualityandscience/clinical/guidelines/stable/stable_clean.pdf

http://www.dartmouthatlas.org/

http://www.dartmouthatlas.org/

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