Latest Appropriate Use Criteria for Coronary Revascularization Indicate Patients Who Would Benefit from CABG or PCI

December 16, 2015

The latest update of the appropriate use criteria (AUC) for coronary revascularization by Patel et al. entitled “ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria For Coronary Revascularization Focused Update” was published in the Journal of the American College of Cardiology in 2012 [vol 59, pages 857-881]. The authors defined coronary revascularization as “appropriate when the expected benefits in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure.”

How to Identify Patients for Revascularization by CABG or PCIBecause recent improvements in surgical and percutaneous coronary intervention (PCI) techniques for revascularization have changed significantly since the initial report in 2009, Patel et al (2012) addressed the appropriateness of revascularization by coronary artery bypass graft surgery (CABG) and PCI. The authors reported when to use PCI and CABG in patients, as indicated below [adapted from Figures 4 and 5, Patel et al. 2012]:

PCI is appropriate in patients with:

  • 2-vessel coronary artery disease (CAD) with involvement of the proximal left anterior descending artery.
  • 3-vessel disease with low SYNTAX score, 3 focal stenosis, and no left main involvement.
  • Prior bypass surgery with native 3-vessel disease and failure of multiple bypass grafts, depressed left ventricular ejection fraction and left internal mammary artery is patent to a native coronary artery.

CABG is appropriate in patients with:

  • 2-vessel CAD with proximal left anterior descending artery stenosis
  • 3-vessel CAD with low SYNTAX score and 3 focal stenosis
  • 3-vessel CAD with multiple diffuse lesions, presence of chronic total occlusion, or high SYNTAX score
  • Isolated left main stenosis
  • Left main stenosis and additional CAD with low SYNTAX score and the involvement of 1 to 2 more vessels
  • Left main stenosis and additional CAD with 3 vessel involvement, presence of chronic total occlusion, or high SYNTAX score
  • Prior bypass surgery with 3-vessel disease and failure of multiple bypass grafts and depressed left ventricular ejection fraction and a nonfunctional left internal mammary artery.

Note: Table 4 in Patel et al (2012) was corrected and the citation for the corrected table is J Am Coll Cardiol. 2012 Apr 3;59(14):1336.

How were the AUC developed?

The AUC criteria were developed by a writing group and technical panel that included practicing interventional and noninterventional cardiologists, cardiovascular and cardiothoracic surgeons, doctors treating patients with cardiovascular disease, health outcome researchers, and a medical officer from a health plan. Members of the ACCF/AHA/PCI and CABG revascularization guideline committees and all relevant professional societies also participated in this process.

This group revisited each of the 180 original clinical cases, rated them from 1 to 9, and categorized them as below:

  • 7 to 9: Appropriate—coronary revascularization is appropriate and likely to improve health outcome or survival.
  • 4 to 6: Uncertain—coronary revascularization was uncertain to improve health or survival.
  • 1 to 3: Inappropriate—revascularization was not appropriate and unlikely to improve health outcome or survival.

Patel et al (2012) noted the “rating of uncertain should not be viewed as excluding the use of revascularization for such patients.” They emphasized this category means that under the conditions assessed, the technical panel could not determine or agree if revascularization was warranted. However, the panel realizes that patients could present with additional factors that may make it appropriate to perform revascularization.

What does this mean clinically?

The goal of the AUC is to serve as a guide to physicians as they consider the best way to treat their patients in need of coronary revascularization. The authors indicate these criteria were developed based on current knowledge and abilities to conduct these procedures. The authors emphasize the large number of possible cases that could be included in such a report and noted the most common scenarios were included. For this reason, physicians should use the AUC as guidelines to make the best decision possible in the treatment of their patients.

Next Steps:

  1. Read the updated AUC paper by Patel et al (2012)
  2. Read the original AUC paper by Patel et al (2009)
  3. Learn more about identifying patients for Protected PCI
  4. Learn more about the use of Impella 2.5 for PCI

About Impella

The Impella 2.5 system is a temporary (<6 hours) ventricular support device indicated for use during high risk percutaneous coronary interventions (PCI) performed in elective or urgent, hemodynamically stable patients with severe coronary artery disease and depressed left ventricular ejection fraction, when a heart team, including a cardiac surgeon, has determined high risk PCI is the appropriate therapeutic option. Use of the Impella 2.5 in these patients may prevent hemodynamic instability which can result from repeat episodes of reversible myocardial ischemia that occur during planned temporary coronary occlusions and may reduce peri- and post-procedural adverse events.

Protected PCI and use of the Impella 2.5 is not right for every patient. Patients may not be able to be treated with Impella if they have certain pre-existing conditions, which a cardiologist can determine, such as: severe narrowing of the heart valve, severe peripheral artery disease, clots in blood vessels, or a replacement heart valve or certain heart valve deficiencies. Additionally, use of Impella has been associated with risks, including, but not limited to valvular and vascular injury, bleeding, and limb ischemia in certain patients. Learn more about the Impella devices’ approved indications for use, as well as important safety and risk information at