ACC 2017 Appropriate Use Criteria For Coronary Revascularization

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.
-, 2017
2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jacc.2017.02.001
APPROPRIATE USE CRITERIA
ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/
STS 2017 Appropriate Use Criteria for
Coronary Revascularization in Patients
With Stable Ischemic Heart Disease
A Report of the American College of Cardiology Appropriate Use Criteria Task Force,
American Association for Thoracic Surgery, American Heart Association,
American Society of Echocardiography, American Society of Nuclear Cardiology,
Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography,
and Society of Thoracic Surgeons
Coronary Manesh R. Patel, MD, FACC, FAHA, FSCAI, Chair David J. Maron, MD, FACC, FAHA
Revascularization Peter K. Smith, MD, FACCy
Writing Group John H. Calhoon, MD
Gregory J. Dehmer, MD, MACC, MSCAI, FAHA*
*Society for Cardiovascular Angiography and Interventions
James Aaron Grantham, MD, FACC
Representative. ySociety of Thoracic Surgeons Representative.
Thomas M. Maddox, MD, MSC, FACC, FAHA
Rating Panel Michael J. Wolk, MD, MACC, Moderator Peter L. Duffy, MD, FACC, FSCAI*
Manesh R. Patel, MD, FACC, FAHA, FSCAI, T. Bruce Ferguson, JR, MD, FACCz
Writing Group Liaison Frederick L. Grover, MD, FACCz
Gregory J. Dehmer, MD, MACC, FSCAI, FAHA, Robert A. Guyton, MD, FACCk
Writing Group Liaison* Mark A. Hlatky, MD, FACCz
Peter K. Smith, MD, FACC, Writing Group Liaison Harold L. Lazar, MD, FACC{
Vera H. Rigolin, MD, FACCz
James C. Blankenship, MD, MACC, MSCAIz Geoffrey A. Rose, MD, FACC, FASE#
Alfred A. Bove, MD, PHD, MACCz Richard J. Shemin, MD, FACCk
Steven M. Bradley, MDx Jacqueline E. Tamis-Holland, MD, FACCz
Larry S. Dean, MD, FACC, FSCAI* Carl L. Tommaso, MD, FACC, FSCAI*
This document was approved by the American College of Cardiology Clinical Policy Approval Committee on behalf of the Board of Trustees in
January 2017.
The American College of Cardiology requests that this document be cited as follows: Patel MR, Calhoon JH, Dehmer GJ, Grantham JA, Maddox TM,
Maron DJ, Smith PK. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 appropriate use criteria for coronary revascularization in patients with stable
ischemic heart disease: a report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery,
American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography
and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017;69:XXXXX.
This document has been reprinted in the Journal of Nuclear Cardiology and the Journal of Thoracic and Cardiovascular Surgery.
Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document,
please contact Elsevier Reprint Department, fax (212) 633-3820 or e-mail reprints@elsevier.com.
Permissions: Multiple copies, modication, alteration, enhancement, and/or distribution of this document are not permitted without the express
permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/about/policies/
author-agreement/obtaining-permission).
2 Patel et al. JACC VOL. -, NO. -, 2017
AUC for Coronary Revascularization in Patients With SIHD -, 2017:--
L. Samuel Wann, MD, MACC** kSociety of Thoracic Surgeons Representative. {American

Association for Thoracic Surgery Representative. #American Society
John B. Wong, MDz
of Echocardiography Representative. **American Society of Nuclear
Cardiology Representative.
zAmerican College of Cardiology Representative.

xAmerican Heart Association Representative.
Appropriate Use John U. Doherty, MD, FACC, Co-Chair Warren J. Manning, MD, FACC
Criteria Task Gregory J. Dehmer, MD, MACC, Co-Chair Manesh R. Patel, MD, FACC, FAHAxx
Force Ritu Sachdeva, MBBS, FACC
Steven R. Bailey, MD, FACC, FSCAI, FAHA L. Samuel Wann, MD, MACCyy
Nicole M. Bhave, MD, FACC David E. Winchester, MD, FACC
Alan S. Brown, MD, FACCyy Michael J. Wolk, MD, MACCyy
Stacie L. Daugherty, MD, FACC Joseph M. Allen, MA
Milind Y. Desai, MBBS, FACC
Claire S. Duvernoy, MD, FACC
yyFormer Task Force member; current member during the writing
Linda D. Gillam, MD, FACC
effort. zzFormer Task Force Co-Chair; current Co-Chair during the
Robert C. Hendel, MD, FACC, FAHAyy writing effort. xxFormer Task Force Chair; current Chair during the
Christopher M. Kramer, MD, FACC, FAHAzz writing effort.
Bruce D. Lindsay, MD, FACCyy
TABLE OF CONTENTS
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Section 1. SIHD Without Prior CABG . . . . . . . . . . . . . . . . -
Table 1.1 One-Vessel Disease . . . . . . . . . . . . . . . . . . . -
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Table 1.2 Two-Vessel Disease . . . . . . . . . . . . . . . . . . . -
Table 1.3 Three-Vessel Disease . . . . . . . . . . . . . . . . . . -

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
Table 1.4 Left Main Coronary Artery Stenosis . . . . . . -
2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Section 2. Tables 2.1 and 2.2 SIHD With Prior CABG . . . -
Indication Development . . . . . . . . . . . . . . . . . . . . . . . . . - Table 2.1 IMA to LAD Patent and Without Signicant
Stenoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
Figure 1 AUC Development Process . . . . . . . . . . . . . . . . -
Table 2.2 IMA to LAD Not Patent . . . . . . . . . . . . . . . . -
Scope of Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
Section 3. Table 3.1 SIHD Undergoing Procedures for
Which Coronary Revascularization May Be
3. ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
Considered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
General Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Table 3.1 Stable Ischemic Heart Disease Undergoing
Procedures for Which Coronary Revascularization
Assumptions for Rating Multiple Treatment Options . . -
May Be Considered . . . . . . . . . . . . . . . . . . . . . . . . . . . -
4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
7. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -
Table A. Revascularization to Improve Survival
Compared With Medical Therapy . . . . . . . . . . . . . . . . . . - APPENDIX A
Table B. Noninvasive Risk Stratication . . . . . . . . . . . . . - ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS

2017 Appropriate Use Criteria for Coronary
5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Revascularization in Patients With Stable Ischemic
Heart Disease: Participants . . . . . . . . . . . . . . . . . . . . . . . -
6. CORONARY REVASCULARIZATION IN PATIENTS

APPENDIX B
WITH STABLE ISCHEMIC HEART DISEASE:
APPROPRIATE USE CRITERIA (BY INDICATION) . . - Relationships With Industry and Other Entities . . . . . . -
JACC VOL. -, NO. -, 2017 Patel et al. 3
-, 2017:-- AUC for Coronary Revascularization in Patients With SIHD
ABSTRACT Interventions, Society of Thoracic Surgeons, American

Association for Thoracic Surgery, and other societies,
The American College of Cardiology, Society for Cardio- developed and published the rst version of the AUC for
vascular Angiography and Interventions, Society of coronary revascularization in 2009, releasing the last
Thoracic Surgeons, and American Association for Thoracic update in 2012. The AUC are an effort to assist clinicians
Surgery, along with key specialty and subspecialty soci- in the rational use of coronary revascularization in
eties, have completed a 2-part revision of the appropriate common clinical scenarios found in everyday practice.
use criteria (AUC) for coronary revascularization. In prior The new AUC for coronary revascularization were
coronary revascularization AUC documents, indications for developed as separate documents for stable ischemic
revascularization in acute coronary syndromes and stable heart disease (SIHD) and acute coronary syndromes. This
ischemic heart disease (SIHD) were combined into 1 docu- was done to address the expanding clinical indications
ment. To address the expanding clinical indications for for coronary revascularization, include new literature
coronary revascularization, and to align the subject matter published since the last update, and align the subject
with the most current American College of Cardiology/ matter with the ACC/American Heart Association guide-
American Heart Association guidelines, the new AUC for lines. An additional goal was to address several of the
coronary artery revascularization were separated into 2 shortcomings of the initial document that became
documents addressing SIHD and acute coronary syndromes evident as experience with the use of the AUC accumu-
individually. This document presents the AUC for SIHD. lated in clinical practice.
Clinical scenarios were developed to mimic patient pre- The publication of AUC reects 1 of several ongoing
sentations encountered in everyday practice. These sce- efforts by the ACC and its partners to assist clinicians who
narios included information on symptom status; risk level are caring for patients with cardiovascular diseases and to
as assessed by noninvasive testing; coronary disease support high-quality cardiovascular care. The ACC/
burden; and, in some scenarios, fractional ow reserve American Heart Association clinical practice guidelines
testing, presence or absence of diabetes, and SYNTAX score. provide a foundation for summarizing evidence-based
This update provides a reassessment of clinical scenarios cardiovascular care and, when evidence is lacking, pro-
that the writing group felt were affected by signicant vide expert consensus opinion that is approved in review
changes in the medical literature or gaps from prior criteria. by the ACC and American Heart Association. However, in
The methodology used in this update is similar to the initial many areas, variability remains in the use of cardiovas-
document but employs the recent modications in the cular procedures, raising questions of over- or underuse.
methods for developing AUC, most notably, alterations in The AUC provide a practical standard upon which to
the nomenclature for appropriate use categorization. assess and better understand variability.
A separate, independent rating panel scored the clin- We are grateful to the writing committee for the
ical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate development of the overall structure of the document and
that revascularization is considered appropriate for the clinical scenarios and to the rating panela professional
clinical scenario presented. Scores of 1 to 3 indicate that group with a wide range of skills and insightsfor their
revascularization is considered rarely appropriate for the thoughtful deliberation on the merits of coronary revas-
clinical scenario, whereas scores in the mid-range of 4 to 6 cularization for various clinical scenarios. We would also
indicate that coronary revascularization may be appro- like to thank the parent AUC Task Force and the ACC
priate for the clinical scenario. staffJoseph Allen, Leah White, and specically, Maria
As seen with the prior coronary revascularization AUC, Velasquezfor their skilled support in the generation of
revascularization in clinical scenarios with high symptom this document.
burden, high-risk features, and high coronary disease Manesh R. Patel, MD, FACC, FAHA, FSCAI
burden, as well as in patients receiving antianginal ther- Chair, Coronary Revascularization Writing Group
apy, are deemed appropriate. Additionally, scenarios Immediate Past Chair, Appropriate Use Criteria Task Force
assessing the appropriateness of revascularization before Michael J. Wolk, MD, MACC, Moderator,
kidney transplantation or transcatheter valve therapy are Appropriate Use Criteria Task Force
now rated. The primary objective of the AUC is to provide
a framework for the assessment of practice patterns that 1. INTRODUCTION
will hopefully improve physician decision making.
In a continuing effort to provide information to patients,
PREFACE physicians, and policy makers, the Appropriate Use Task
Force approved this revision of the 2012 Coronary
The American College of Cardiology (ACC), in collabora- Revascularization AUC (1). Since publication of the 2012
tion with the Society for Cardiovascular Angiography and AUC focused update, the original nomenclature used to
characterize appropriate use has changed (2). New clinical encountered in practice, it would be impossible to include
practice guidelines (CPGs) for SIHD have been released, every conceivable patient presentation and maintain a
and new clinical trials extending the knowledge and evi- workable document for clinicians. The writing group ac-
dence around coronary revascularization have been pub- knowledges that the current AUC do not evaluate all pa-
lished (3,4). These trials include studies not only on the tient variables that might affect 1 or more strategies for
use of percutaneous coronary intervention (PCI), but also the management of patients with CAD. Examples of con-
on coronary artery bypass graft surgery (CABG), medical ditions not explicitly considered within the scenarios
therapy, and diagnostic technologies such as fractional include severe chronic kidney disease, severe peripheral
ow reserve (FFR) to guide revascularization (58). vascular disease, known malignancies, poor lung func-
Additional studies, some based on data from the National tion, advanced liver disease, advanced dementia, and/or
Cardiovascular Data Registry (NCDR), have been pub- other comorbidities that might have excluded patients
lished providing insights into practice patterns and in- from the clinical trials that provide the evidence base for
formation around clinical scenarios and patient features coronary revascularization. Nevertheless, it is necessary
not previously addressed (913). for the clinician to include these conditions in the nal
Improvements in our understanding of the variables decision-making process for an individual patient, and
affecting patient outcomes before and after coronary this may result in the actual therapy deviating from the
revascularization, continued emphasis on the role of AUC rating. It is expected that all clinicians will occa-
medical therapy for coronary artery disease (CAD), and an sionally treat patients with extenuating conditions that
increasing emphasis on shared decision making and pa- are not captured in the current AUC, and this could result
tient preferences also make a revision of the coronary in a treatment rating of rarely appropriate for the cho-
revascularization AUC timely (14). This document focuses sen therapy in a specic patient. However, these situa-
on SIHD and is a companion to the AUC specically for tions should not constitute a majority of treatment
acute coronary syndromes. decisions, and it is presumed that they will affect all
practitioners equally, thereby minimizing substantial
2. METHODS biases in assessing the performance of individual clini-
cians compared with their peers. Additionally, these AUC
Indication Development were developed in parallel with efforts to update data
A multidisciplinary writing group consisting of cardio- collection within the NCDR registries to include data
vascular health outcomes researchers, interventional elds that capture some of these extenuating circum-
cardiologists, cardiothoracic surgeons, and general car- stances, thereby improving the characterization of sce-
diologists was convened to review and revise the prior narios in the AUC.
coronary revascularization AUC. The writing group was AUC documents often contain specic clinical sce-
tasked with developing clinical indications (scenarios) narios rather than the more generalized situations
that reect typical situations encountered in everyday covered in CPGs; thus, subtle differences between these
practice that were then rated by a technical panel. In this documents may exist. The treatment of patients with
document, the term indication is used interchangeably SIHD should always include therapies to modify risk
with the phrase clinical scenario. Critical data elements factors and/or reduce cardiovascular eventsso-called
and mapping of the criteria to the elements will be pro- secondary prevention. In several CPGs, the phrase
vided for end-users of the revascularization AUC so that guideline-directed medical therapy is used and,
procedure notes and chart abstraction can be more easily depending on the context, may include the use of anti-
mapped to the AUC. A key goal of this effort is to leverage anginal therapy in addition to therapies for secondary
the NCDR (National Cardiovascular Data Registry) Cath- prevention. In this AUC, it is assumed that all patients will
PCI registry to map indications to appropriateness ratings, be receiving comprehensive secondary prevention thera-
so that minimal additional data collection is needed to pies as needed. Antianginal therapy has a central role in
support quarterly feedback to sites of their performance the treatment of patients with SIHD. In some patients, it
as a foundation for improving patient selection for may be the sole therapy, whereas in others it may be
revascularization. The AUC Task Force is committed to continued, albeit in lower doses, following a revasculari-
supporting linkage of the AUC with daily workow to zation procedure. The earlier coronary revascularization
capture the data elements needed for AUC ratings. AUC included information about the intensity of anti-
The revascularization AUC are based on our current anginal therapy in several scenarios, with language such
understanding of procedure outcomes plus the potential as receiving no or minimal anti-ischemic therapy or
patient benets and risks of the revascularization strate- receiving a course of maximal anti-ischemic therapy.
gies examined. Although the AUC are developed to The new AUC adopts a different format, including options
address many of the common clinical scenarios for the initiation or escalation of antianginal therapy
patterned after recommendations made in the 2012 ACCF/ framework to evaluate overall clinical practice patterns
AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diag- and improve the quality of care.
nosis and Management of Patients With Stable Ischemic In developing these AUC for coronary revasculariza-
Heart Disease (2012 SIHD guideline) (3), using a structure tion, the rating panel was asked to rate each indication
that mimics clinical practice. However, the primary pur- using the following denition of appropriate use:
pose of these AUCs is to rate the appropriateness of
A coronary revascularization is appropriate care
revascularization with the understanding that decisions
when the potential benets, in terms of survival or
about revascularization are frequently made in the
health outcomes (symptoms, functional status, and/
context of ongoing antianginal therapy. Because recom-
or quality of life), exceed the potential negative
mendations for revascularization or the medical man-
consequences of the treatment strategy.
agement of CAD are found throughout several CPGs, the
AUC ratings herein are meant to unify related CPGs and The rating panel scored each indication on a scale from
other data sources and provide a useful tool for clinicians. 1 to 9 as follows:
These AUC were developed with the intent of assisting
Score 7 to 9: Appropriate care
patients and clinicians, but they are not intended to
diminish the acknowledged complexity or uncertainty of Score 4 to 6: May be appropriate care
clinical decision making and should not be used as a Score 1 to 3: Rarely appropriate care
substitute for sound clinical judgment. There are
acknowledged evidence gaps in many areas where clinical Appropriate Use Denition and Ratings
judgment and experience must be blended with patient In rating these criteria, the rating panel was asked to assess
preferences and the existing knowledge base dened in whether the use of revascularization for each indication is
CPGs. It is important to emphasize that a rating of appropriate care, may be appropriate care, or is
appropriate care does not mandate that a revasculariza- rarely appropriate care using the following denitions
tion procedure be performed; likewise, a rating of rarely and their associated numeric ranges. Anonymized indi-
appropriate care should not prevent a revascularization vidual scores are available in an online appendix.
procedure from being performed. It is anticipated, as
noted in the previous text, that there will be occasional Median Score 7 to 9: Appropriate Care
clinical scenarios rated rarely appropriate in which per- An appropriate option for management of patients in this
forming revascularization may still be in the best interest population, as the benets generally outweigh the risks;
of a particular patient. In situations in which the AUC an effective option for individual care plans, although not
rating is not followed, clinicians should document the always necessary depending on physician judgment and
specic patient features not captured in the clinical sce- patient-specic preferences (i.e., procedure is generally
nario or the rationale for the chosen therapy. Depending acceptable and is generally reasonable for the indication).
on the urgency of care, convening a heart team or
obtaining a second opinion may be helpful in some of Median Score 4 to 6: May Be Appropriate Care
these settings. At times an appropriate option for management of pa-
The AUC can be used in several ways. As a clinical tool, tients in this population due to variable evidence or
the AUC assist clinicians in evaluating possible therapies agreement regarding the benet to risk ratio, potential
under consideration and can help better inform patients benet based on practice experience in the absence of
about their therapeutic options. As an administrative and evidence, and/or variability in the population; effective-
research tool, the AUC provide a means of comparing ness for individual care must be determined by a patients
utilization patterns among providers to thereby derive an physician in consultation with the patient on the basis of
assessment of an individual clinicians management additional clinical variables and judgment along with
strategies compared with his/her peers. It is critical to patient preferences (i.e., procedure may be acceptable
understand that the AUC should be used to assess an and may be reasonable for the indication).
overall pattern of clinical care rather than being the nal
arbitrator of specic individual cases. The ACC and its Median Score 1 to 3: Rarely Appropriate Care
collaborators believe that an ongoing review of ones Rarely an appropriate option for management of patients
practice using these criteria will help guide more effec- in this population due to the lack of a clear benet/risk
tive, efcient, and equitable allocation of healthcare re- advantage; rarely an effective option for individual care
sources, and ultimately, better patient outcomes. plans; exceptions should have documentation of the
However, under no circumstances should the AUC be clinical reasons for proceeding with this care option (i.e.,
used to adjudicate or determine payment for individual procedure is not generally acceptable and is not generally
patients. Rather, the intent of the AUC is to provide a reasonable for the indication).
The process for development of the AUC is shown in 7. Invasive testing such as intravascular ultrasound
Figure 1 and described in detail in previous documents (IVUS) and invasive physiology such as FFR.
(1,2).
The anatomic construct for CAD is based on the pres-
After completion and tabulation of the second round of
ence or absence of ow-limiting obstructions in the cor-
ratings, it became apparent to the writing group that the
onary arteries categorized by the number of vessels
original structure of certain rating tables may have
involved (1-, 2-, and 3-vessel, and/or left main CAD).
confused some members of the rating panel, causing
Additionally, we included in the anatomic construct the
ratings that were not internally consistent. This resulted
presence or absence of proximal left anterior descending
in a re-evaluation and redesign of the rating table struc-
(LAD) disease. This specic stenosis location was identi-
ture, which then required a third round of ratings. This
ed in both the 2011 ACCF/AHA guideline for coronary
AUC document presents the end result of that process and
artery bypass graft surgery (2011 CABG guidelines) and
the results of the third round of ratings.
2012 ACC/AHA/SCAI guideline for percutaneous coronary
Scope of Indications intervention (2012 PCI guidelines) and was included in
clinical trial recruitment to guide revascularization de-
The indications for coronary revascularization in SIHD were
cisions (6,15,16). Other factors such as diabetes and the
developed considering the following common variables:
complexity of disease were included in certain clinical
1. The clinical presentation (e.g., low or high activity scenarios given their effect on cardiac risk and association
level to provoke ischemic symptoms); with more favorable outcomes from surgical revasculari-
2. Use of antianginal medications; zation. As before, noninvasive test ndings are included
3. Results of noninvasive tests to evaluate the presence in many scenarios to distinguish patients with a low risk
and severity of myocardial ischemia; for future adverse events from those with intermediate-
4. Presence of other confounding factors and comorbid- or high-risk ndings, as these terms are routinely used in
ities such as diabetes; clinical practice.
5. Extent of anatomic disease; Antianginal treatment of CAD is incorporated into the
6. Prior coronary artery bypass surgery; and structure of the tables following the pattern of
F I G U R E 1 AUC Development Process
Develop list of indications, Literature review and

Indication Development
assumptions, and definitions guideline mapping

Review Panel >30 members
provide feedback
Writing Group revises

indications
Rating Panel rates the

indications in 2 rounds
Appropriateness
Determination
1st roundno interaction
2nd roundpanel interaction
Appropriate Use Score

(79) Appropriate
(46) May Be
Appropriate Prospective clinical
(13) Rarely decision aids
Prospective comparison Appropriate
with clinical records
Validation
Increase appropriate
use
% use that is
Appropriate, May Be
Appropriate, or Rarely
Appropriate
AUC indicates appropriate use criteria.

recommendations in the SIHD guideline (see 2012 SIHD 5. A signicant coronary stenosis for the purpose of the
guidelines, Section 4.4.3.1.) but without specic drug or clinical scenarios is dened as:
dose recommendations (3,4). In general, beta blockers are n $70% luminal diameter narrowing, by visual
recommended as the initial treatment for symptom relief assessment, of an epicardial stenosis measured in
(Class I recommendation), with calcium channel blockers, the worst view angiographic projection;
long-acting nitrates, or ranolazine prescribed in combi- n $50% luminal diameter narrowing, by visual
nation with beta blockers when initial treatment with beta assessment, of a left main stenosis measured in
blockers is inadequate to control symptoms despite the worst view angiographic projection; or
appropriate dosing. Calcium channel blockers, long- n 40% to 70% luminal narrowing, by visual assess-
acting nitrates, or ranolazine should be prescribed for ment, of an epicardial stenosis measured in the
relief of symptoms when beta blockers are contra- worst view angiographic projection with an
indicated or cause unacceptable side effects. Long-acting abnormal FFR as dened in the following text.
nondihydropyridine calcium channel blockers are 6. An FFR #0.80 is abnormal and is consistent with
reasonable alternatives to beta blockers as rst-line downstream inducible ischemia.
therapy for antianginal symptoms (Class IIa, Level of 7. All patients included in these scenarios are receiving
Evidence: B). The use of FFR was incorporated to a greater needed therapies to modify existing risk factors as
extent than in the previous AUC as more data on the outlined in CPGs and other documents (1719). Despite
usefulness of this testing modality have emerged. the best efforts of the clinician, all patients may not
achieve target goals for cardiac risk factor modica-
3. ASSUMPTIONS tion. However, a continuing effort and plan of care to

address risk factors are assumed to exist.
General Assumptions 8. For patients with SIHD, the writing group recognizes
there are many choices for antianginal therapy and
Specic assumptions provided to the rating panel for their
considerable variation in the use and tolerance of
use in rating the relevant clinical scenarios are summa-
antianginal medications among patients. The use of
rized in the following text.
antianginal therapy adopted in this AUC follows the
1. When available, each clinical scenario includes the recommendations of the SIHD guideline. Assume that
patients clinical status/symptom complex, ischemic antianginal therapy is prescribed at a dose that
burden as determined by noninvasive functional adequately controls the patients symptoms or is the
testing, burden of coronary atherosclerosis as deter- maximally tolerated dose for a particular drug.
mined by angiography, and additional invasive 9. Operators performing percutaneous or surgical
testing evaluations by invasive physiology (e.g., FFR, revascularization have appropriate clinical training
instantaneous wave-free ratio) or intravascular and experience and have satisfactory outcomes as
imaging. assessed by quality assurance monitoring (15,20,21).
2. When utilized, stress testing, with or without an 10. Revascularization by either percutaneous or surgical
associated imaging procedure, was performed methods is performed in a manner consistent with
correctly and with sufcient quality to produce a established standards of care at centers with quality/
meaningful and accurate result within the limits of volume standards (15,20,21).
the test performance. Evidence of myocardial viability 11. In the clinical scenarios, no unusual extenuating cir-
is also an important nding and in some clinical sit- cumstances exist (e.g., an inability to comply with
uations may inuence the decision for revasculariza- antiplatelet agents, do-not-resuscitate status, a pa-
tion, but it was not used to further expand the number tient unwilling to consider revascularization, tech-
of indications. nical reasons rendering revascularization infeasible,
3. As the main focus of this AUC is revascularization, or comorbidities likely to markedly increase proce-
assume that coronary angiography has been per- dural risk). If any of these circumstances exist, it is
formed. The rating panel should judge the appropri- critical that the clinician provide adequate documen-
ateness of revascularization on the basis of the clinical tation in the medical record to support exclusions
scenario presented, including the coronary disease from the AUC and the alternative management de-
identied, independent of a judgment about the cisions made in the patient.
appropriateness of the coronary angiogram in the 12. Patient history and physical examination are assumed
scenario. to be comprehensive and thorough. Descriptions of
4. Assume no other signicant coronary artery stenoses the patients symptoms are assumed to accurately
are present except those specically described in the represent the current status of the patient (e.g.,
clinical scenario. asymptomatic patients are truly asymptomatic rather
than asymptomatic due to self-imposed lifestyle Appropriate, May Be Appropriate, or Rarely

limitations). Appropriate for any given clinical indication.
13. When PCI is being considered in patients with multi- 2. If more than 1 treatment falls into the same appropriate
vessel disease, it may be clinically prudent to perform use category, it is assumed that patient preference
the procedures in a sequential fashion (so-called combined with physician judgment and available local
staged procedures). If this is the initial management expertise will be used to determine the nal treatment
plan, the intent for a staged procedure should be used.
clearly outlined and the appropriateness rating should
apply to the entire revascularization procedure. Spe- 4. DEFINITIONS
cically, planned staged procedures should not be
assessed by individual arteries but rather in terms of Denitions of some key terms used throughout the sce-
the plan for the entire revascularization strategy. For narios are shown in the following text. A complete set of
data collection purposes, this will require document- denitions is found in Appendix A. These denitions were
ing how the procedure is staged (either PCI or hybrid provided to and discussed with the rating panel before
revascularization with surgery), and it is assumed that the rating process started.
all stenoses covered under the umbrella of the plan-
ned staged procedure are functionally signicant. Indication
14. Although the clinical scenarios should be rated on the A set of patient-specic conditions denes an indica-
basis of the published literature, the writing committee tion. The term clinical indication (used interchange-
acknowledges that decisions about coronary artery ably with clinical scenario) provides the context for the
revascularization in patient populations that are poorly rating of therapeutic options. However, an appropriate
represented in the literature are still required in daily rating assigned by the rating panel does not necessarily
practice. Therefore, rating panel members should as- mean the therapy is mandatory, nor does a rarely
sume that some of the clinical scenarios presented will appropriate rating mean it is prohibited.
have low levels of evidence to guide rating decisions.
Key to the application of the AUC in settings where Risk Factor Modication (Secondary Prevention) and
there are extenuating circumstances or low levels of Antianginal Medical Therapy
supporting evidence is enhanced documentation by As previously stated, the indications assume that patients
the clinician to support the clinical decisions made. are receiving all indicated treatments for the secondary
15. As with all previously published clinical policies, de- prevention of cardiovascular events. This includes life-
viations by the rating panel from prior published style and pharmacological interventions according to
documents were directed by new evidence that jus- guideline-based recommendations. Antianginal medical
ties such evolution. However, the reader is advised therapy is incorporated into the structure of the rating
to pay careful attention to the wording of an indica- tables and should follow the recommendations of the
tion in the present document when making compari- SIHD guideline, with a beta blocker as initial therapy and
sons to prior publications. the option to administer calcium channel blockers, long-
16. Indication ratings contained herein supersede the acting nitrates, and/or ranolazine if the beta blocker is
ratings of similar indications contained in previous ineffective or not tolerated (3,4).
AUC coronary revascularization documents. Specic target doses of drugs are not provided as this
must be individualized, but for beta blockers, it is
assumed the dose is sufcient to blunt the exercise heart
Assumptions for Rating Multiple Treatment Options rate without causing intolerable fatigue, bradycardia, or
1. The goal of this document is to identify revasculariza- hypotension. It is assumed that the maximally tolerated
tion treatments that are considered reasonable for a dose of beta blockers is being used before the addition of
given clinical indication. Therefore, each treatment other drugs, and when other drugs are added, the dose is
option (PCI or CABG) should be rated independently for titrated to alleviate symptoms or is also the maximally
its level of appropriateness in the specic clinical sce- tolerated dose. Using multiple drugs at less than optimal
nario, rather than being placed into a forced or articial doses is an inefcient and expensive strategy. The SIHD
rank-order comparison against each other. Identifying guideline recommends calcium channel blockers or long-
options that may or may not be reasonable for specic acting nitrates if beta blockers are contraindicated or
indications is the goal of this document, rather than cause unacceptable side effects. The SIHD guideline also
determining a single best treatment for each clinical recommends adding calcium channel blockers or long-
indication or a rank-order. Therefore, more than 1 acting nitrates to beta blockers for relief of symptoms
treatment or even all treatments may be considered when initial treatment with beta blockers is unsuccessful.
Initiating, continuing, or intensifying antianginal therapy of the LAD proximal to the rst major septal and diagonal,
is integrated into the ratings tables along with revascu- the terms 1-, 2-, and 3-vessel disease do not dene the
larization options, as this is typical of real-world practice. location (i.e., proximal, mid, or distal) of the stenosis in the
artery, which is frequently related to the amount of
Stress Testing and Risk of Findings on Noninvasive Testing myocardium at risk. Furthermore, the classication of
Stress testing is commonly used for both diagnosis and diseased vessels does not consider coronary dominance,
risk stratication of patients with CAD. Therapies to although in practical terms, most consider individuals with
improve survival in patients with SIHD are outlined in signicant disease in the LAD and a left dominant
detail in the 2012 SIHD guideline (Table A) (3). The various circumex to have 3-vessel involvement. Coronary
noninvasive ndings associated with high (>3% annual anomalies are also not considered in this construct.
death or myocardial infarction), intermediate (1% to 3% Although imperfect, the commonly used classication of
annual death or myocardial infarction) and low (<1% 1-, 2-, and 3-vessel disease and left main disease remains
annual death or myocardial infarction) risk are outlined in widely used in clinical practice. Within the context of this
Table B. It is important to note that this table includes document, the terms 1-, 2-, and 3-vessel disease should be
several noninvasive ndings apart from a stress test, such assumed to mean that each vessel involved (whether the
as resting LV function and a high coronary calcium score main vessel or a major side branch) provides ow to a
in the assessment of risk. These were not specically sufcient amount of myocardium to be clinically impor-
included in the indications of this AUC, but should be tant. The anatomic denition of 1-, 2-, or 3-vessel disease is
considered as part of the patient prole described in an now often augmented by the physiological testing of ste-
indication, especially when high and intermediate risk are nosis signicance (e.g., FFR), which can reclassify the he-
used in the indication. modynamic signicance of a stenosis. In the setting of PCI,
when FFR in an artery is >0.80, treatment is deferred and
Vessel Disease the clinical scenario considered should be reclassied to be
The construct used to characterize the extent of CAD is consistent with the number of signicant stenoses. In
based on the common clinical use of the terms 1-, 2-, and 3- other words, if the angiogram suggests 2 signicant ste-
vessel disease and left main disease, although it is recog- noses, but FFR testing indicates that only 1 is signicant,
nized that individual coronary anatomy is highly variable. the clinical scenario considered should be from the group
In general, these terms refer to a signicant stenosis in 1 of with 1-vessel CAD. Although there are considerable data to
the 3 major coronary arteries (right coronary artery, LAD, or support FFR-directed PCI treatment as an option, this
circumex) or their major branches. With the exception of concept is not well-established for surgical revasculariza-
the proximal LAD, which specically refers to the segment tion (22,23).
TABLE A Revascularization to Improve Survival Compared With Medical Therapy
Anatomic
Setting COR LOE References
UPLM or complex CAD
CABG and PCI IHeart Team approach recommended C (950952)
CABG and PCI IIaCalculation of STS and SYNTAX scores B (949,950,953957)
UPLM*
CABG I B (73,381,412,959962)
PCI IIaFor SIHD when both of the following are present: B (949,953,955,958,963980)
n Anatomic conditions associated with a low risk of PCI procedural complications and a high likelihood of
good long-term outcome (e.g., a low SYNTAX score of #22, ostial or trunk left main CAD)
n Clinical characteristics that predict a signicantly increased risk of adverse surgical outcomes
(e.g., STS-predicted risk of operative mortality $5%)
IIaFor UA/NSTEMI if not a CABG candidate B (949,968971,976979,981)
IIaFor STEMI when distal coronary ow is TIMI ow grade <3 and PCI can be performed more C (965,982,983)
rapidly and safely than CABG
IIbFor SIHD when both of the following are present: B (949,953,955,958,963980,984)

n Anatomic conditions associated with a low to intermediate risk of PCI procedural complications
and an intermediate to high likelihood of good long-term outcome (e.g., low-intermediate
SYNTAX score of <33, bifurcation left main CAD)
n Clinical characteristics that predict an increased risk of adverse surgical outcomes
(e.g., moderatesevere COPD, disability from prior stroke, or prior cardiac surgery;
STS-predicted operative mortality >2%)
III: HarmFor SIHD in patients (versus performing CABG) with unfavorable anatomy for PCI and who are B (73,381,412,949,953,955,959964)
good candidates for CABG
Continued on the next page

TABLE A Continued
Anatomic
Setting COR LOE References
3-vessel disease with or without proximal LAD artery disease*
CABG I B (353,412,959,985987)
IIaIt is reasonable to choose CABG over PCI in patients with complex 3-vessel CAD B (964,980,987989)
(e.g., SYNTAX score >22) who are good candidates for CABG.
PCI IIbOf uncertain benet B (366,959,980,985,987)
2-vessel disease with proximal LAD artery disease*
CABG I B (353,412,959,985987)
PCI IIbOf uncertain benet B (366,959,985,987)
2-vessel disease without proximal LAD artery disease*
CABG IIaWith extensive ischemia B (327,990992)
IIbOf uncertain benet without extensive ischemia C (987)
1-vessel proximal LAD artery disease
CABG IIaWith LIMA for long-term benet B (412 987,993,994)
1-vessel disease without proximal LAD artery involvement
CABG III: Harm B (306,327,412,985,990,995998)
PCI III: Harm B (306,327,412,985,990,995998)
LV dysfunction
CABG IIaEF 35% to 50% B (365,412,9991002)
CABG IIbEF <35% without signicant left main CAD B (355,365,410,412,9991002)
PCI Insufcient data N/A
Survivors of sudden cardiac death with presumed ischemia-mediated VT
CABG I B (350,1003,1004)
PCI I C (1003)
No anatomic or physiological criteria for revascularization
CABG III: Harm B (306,327,412,985,990,995998)
PCI III: Harm B (306,327,412,985,990,995998)
*In patients with multivessel disease who also have diabetes mellitus, it is reasonable to choose CABG (with LIMA) over PCI (30,991,10051011) (Class IIa; LOE: B).
Reproduced from Fihn et al. (3).
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; COR, class of recommendation; EF, ejection fraction; LAD, left anterior
descending; LIMA, left internal mammary artery; LOE, level of evidence; LV, left ventricular; N/A, not available; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease;
STEMI, ST-elevation myocardial infarction; STS, Society of Thoracic Surgeons; SYNTAX, Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery; TIMI, Thrombolysis
In Myocardial Infarction; UA/NSTEMI, unstable angina/nonST-elevation myocardial infarction; UPLM, unprotected left main disease; and VT, ventricular tachycardia.
TABLE B Noninvasive Risk Stratication
High risk (>3% annual death or MI)

1. Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes
2. Resting perfusion abnormalities $10% of the myocardium in patients without prior history or evidence of MI
3. Stress ECG ndings including $2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or
exercise-induced VT/VF
4. Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress $10%)
5. Stress-induced perfusion abnormalities encumbering $10% myocardium or stress segmental scores indicating multiple vascular territories with
abnormalities
6. Stress-induced LV dilation
7. Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)
8. Wall motion abnormality developing at low dose of dobutamine (#10 mg/kg/min) or at a low heart rate (<120 beats/min)
9. CAC score >400 Agatston units
10. Multivessel obstructive CAD ($70% stenosis) or left main stenosis ($50% stenosis) on CCTA
Intermediate risk (1% to 3% annual death or MI)

1. Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes
2. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI
3. $1 mm of ST-segment depression occurring with exertional symptoms
4. Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular
territory with abnormalities but without LV dilation
5. Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed
6. CAC score 100 to 399 Agatston units
7. One vessel CAD with $70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in $2 arteries on CCTA
Low risk (<1% annual death or MI)

1. Low-risk treadmill score (score $5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise
2. Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium*
3. Normal stress or no change of limited resting wall motion abnormalities during stress
4. CAC score <100 Agaston units
5. No coronary stenosis >50% on CCTA
*Although the published data are limited; patients with these ndings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting LV
dysfunction (LVEF <35%).
Reproduced from Fihn et al. (3).
CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomography angiography; LV, left ventricular; LVEF, left ventricular ejection fraction;
and MI, myocardial infarction.
Ischemic Symptoms variability in the assessment of symptom severity, the

Angina pectoris is usually described as a discomfort (not writing group chose not to use the Canadian Cardiovascular
necessarily pain) in the chest or adjacent areas. It is Society classication system in this document (24,25).
variably described as tightness, heaviness, pressure, Symptom status of the patient was broadly classied into
squeezing, or a smothering sensation. In some patients, asymptomatic or simply ischemic symptoms, emphasizing
the symptom may be a more vague discomfort, a the use of more objective measures of ischemia within each
numbness, or a burning sensation. Alternatively, so- indication to stratify patients into low-risk or intermediate-/
called anginal equivalents such as dyspnea, faintness, high-risk ndings.
or fatigue may occur. The location is usually substernal
and radiation may occur to the neck, jaw, arms, back, or Invasive Methods of Determining Hemodynamic Signicance
epigastrium. Isolated epigastric discomfort or pain in the The writing group recognizes that not all patients referred
lower mandible may rarely be a symptom of myocardial for revascularization will have previous noninvasive
ischemia. The typical episode of angina pectoris begins testing. In fact, there are several situations in which pa-
gradually and reaches its maximum intensity over a tients may be appropriately referred for coronary angi-
period of minutes. Typical angina pectoris is precipi- ography on the basis of symptom and ECG presentation
tated by exertion or emotional stress and is relieved and a high pretest probability of CAD. In these settings,
within minutes by rest or nitroglycerin. Because of the there may be situations where angiography shows a cor-
variation in symptoms that may represent myocardial onary narrowing of questionable hemodynamic impor-
ischemia, the clinical scenarios are presented using the tance in a patient with symptoms that can be related to
broad term ischemic symptoms to capture this myocardial ischemia. In such patients, the use of addi-
concept. tional invasive measurements (such as FFR or intravas-
This AUC document is specic for patients with SIHD. cular ultrasound) at the time of diagnostic angiography
Therefore, by denition, there are no Canadian Cardiovas- may be very helpful in further dening the need for
cular Society Class 4 patients. Because of the variety of revascularization and may substitute for stress test nd-
symptoms that may indicate myocardial ischemia, individual ings. Accordingly, many of the indications now include
patient variation in how they are described and observer FFR test results.
The Role of Patient Preference in the AUC BB beta-blockers

Patients often make decisions about medical treatments CABG coronary artery bypass graft
without a complete understanding of their options. Pa- CAD coronary artery disease
tient participation or shared decision making (SDM) de-
FFR fractional ow reserve
scribes a collaborative approach whereby patients are
provided with evidence-based information on treatment IMA internal mammary artery
choices and encouraged to use the information in an LAD left anterior descending coronary artery
informed dialogue with their provider to make decisions LVEF left ventricular ejection fraction
that not only use the scientic evidence, but also align
PCI percutaneous coronary intervention
with their values, preferences, and lifestyle (2628). The
alternative decision paradigm, often referred to as medi- SIHD stable ischemic heart disease
cal paternalism, places decision authority with physicians
and assigns the patient a more passive role (29). SDM re-
6. CORONARY REVASCULARIZATION IN
spects both the providers knowledge and the patients
PATIENTS WITH STABLE ISCHEMIC HEART
right to be fully informed of all care options with their
DISEASE: APPROPRIATE USE CRITERIA (BY
associated risks and benets. SDM often uses decision
INDICATION)
aids such as written materials, online modules, or videos
to present information about treatment options that help
Section 1. SIHD Without Prior CABG
the patient evaluate the risks and benets of a particular
treatment. The most effective decision aids to help pa- The format for tables in Section 1 is similar, with separate
tients make truly informed decisions provide relevant tables for 1-, 2-, and 3-vessel disease and left main dis-
facts and videos of real patient perspectives regarding the ease. The columns in each table are stratied into 2 cat-
particular treatment (30). Many professional organiza- egories. There is a single column combining patients who
tions now endorse SDM in practice (31,32). are asymptomatic and not receiving antianginal therapy
More than 1 treatment option often exists with no clear with patients who are asymptomatic and receiving anti-
evidence identifying the best option. This is compounded anginal therapy. The remaining columns are devoted to
when there is variation in experts recommendations patients with ischemic symptoms, with 3 separate cate-
about the best treatment under different circumstances gories: ischemic symptoms and receiving no antianginal
(33). A challenging situation exists when scientic data therapy, ischemic symptoms and receiving 1 antianginal
suggest 1 treatment is likely to have better outcomes, yet drug (beta blocker preferred), and ischemic symptoms
the patient prefers an alternative treatment. Within the receiving 2 or more antianginal drugs. As outlined in the
context of the AUC, this would be manifest as the patient SIHD guideline, in the absence of contraindications,
requesting a therapy with a lower AUC rating (e.g., initial therapy should be a beta blocker prescribed at a
wanting a therapy rated as rarely appropriate when a dose that reduces heart rate without excessive resting
therapy rated appropriate exists). Informed consent is bradycardia, hypotension, or fatigue. Other antianginal
fundamental to SDM (34). Without understanding the pros drugs are then added to beta blockers depending on the
and cons of all treatment options, patients cannot properly individual needs of the patient until symptoms are sup-
engage in SDM and blend their personal desires with the pressed to the satisfaction of the patient or higher doses
scientic data. Without question, it is important that cannot be used because of side effects. In each of the
blending AUC ratings into clinical decision making provide subordinate columns, the panel was asked to rate the
a pathway for including patient preference and SDM. options for revascularization, specically PCI or CABG. As
However, the mechanism for that process is beyond the noted earlier, the rating panel was asked to rate each
scope of this AUC document. The purpose of this docu- revascularization option independent of the other, with
ment is to develop clinical scenarios and provide ratings of the intent to rate each therapy on its own merits rather
those scenarios by an expert panel. A complete discussion than in comparison to the other option. In this construct,
about treatment options with SDM can only be nalized both revascularization options could be assigned identical
once the category of appropriate use is determined. ratings.
In this and subsequent tables, clinical scenarios often
contain the phrase noninvasive testing. In this docu-
5. ABBREVIATIONS
ment, that phrase includes all forms of stress testing using
either dynamic or pharmacological stress that may be
AA antianginal
coupled with various imaging tests. It also could include
ACS acute coronary syndrome other imaging, such as coronary computed tomography
AUC appropriate use criteria angiography or magnetic resonance imaging, to assess
myocardial viability. Some would favor the term func- the equivalent of 2-vessel disease (i.e., right coronary
tional testing, but the writing committee did not view artery and circumex disease). Following this construct,
this as inclusive of computed tomography or magnetic the combination of proximal LAD disease and proximal
resonance imaging and thus favored the term noninva- left dominant circumex disease would be considered as
sive testing. FFR is considered as part of an invasive 3-vessel disease and rated using the 3-vessel disease table
evaluation and is cited separately in some scenarios. An (Table 1.3.). In the absence of exercise data, invasive
emerging technology, computed tomography-derived physiological testing of both involved vessels is included
FFR is a combination technique that is noninvasive like in several of the indications. To remain in this table of
computed tomography but provides FFR, which has 2-vessel disease, such testing must be abnormal in both
traditionally only been an invasive test. vessels. If this testing shows only 1 vessel to be abnormal,
the patient would no longer be rated using this table, but
Table 1.1. One-Vessel Disease rather would be rated in the table for 1-vessel CAD.
Similar to the 2011 CABG and 2012 SIHD guidelines, this Finally, because of the increasing body of literature that
document uses proximal LAD disease as an additional has identied diabetes as an important factor to consider
anatomic discriminator for 1-vessel CAD. Although data when recommending revascularization, scenarios indi-
are minimal, the writing committee felt that proximal cating the presence of diabetes are provided.
disease of a dominant circumex should be considered as
high-risk anatomy with similar implications as proximal Table 1.3. Three-Vessel Disease
LAD disease, and thus, it was considered in a separate Similar to Table 1.2., because of the increasing body of
section along with proximal LAD disease. literature that has identied diabetes as an important
factor to consider when recommending revascularization,
Table 1.2. Two-Vessel Disease categories indicating the presence or absence of diabetes
The format of this table is similar to that for 1-vessel are provided among the individual indications. Stenosis
disease. Similar to the 2011 CABG and 2012 SIHD guide- complexity is also an important factor to consider in any
lines, this document makes a distinction regarding the revascularization procedure, probably more so for PCI
presence or absence of proximal LAD disease. The writing than for CABG. The SYNTAX (Synergy between Percuta-
group did not add proximal left dominant circumex neous Coronary Intervention with TAXUS and Cardiac
disease as an additional discriminator, because most Surgery) trial provided a comprehensive comparison of
would consider an isolated stenosis in this location to be PCI and CABG and a structure that may be helpful in
TABLE 1.1 One-Vessel Disease
Appropriate Use Score (1-9)

One-Vessel Disease
Asymptomatic Ischemic Symptoms
Not on AA
Therapy or With Not on AA On 1 AA Drug
AA Therapy Therapy (BB Preferred) On $2 AA Drugs
Indication PCI CABG PCI CABG PCI CABG PCI CABG
No Proximal LAD or Proximal Left Dominant LCX Involvement
1. n Low-risk ndings on noninvasive testing R (2) R (1) R (3) R (2) M (4) R (3) A (7) M (5)
2. n Intermediate- or high-risk ndings on M (4) R (3) M (5) M (4) M (6) M (4) A (8) M (6)
noninvasive testing
3. n No stress test performed or, if performed, M (4) R (2) M (5) R (3) M (6) M (4) A (8) M (6)
results are indeterminate
n FFR #0.80*
Proximal LAD or Proximal Left Dominant LCX Involvement Present
4. n Low-risk ndings on noninvasive testing M (4) R (3) M (4) M (4) M (5) M (5) A (7) A (7)
5. n Intermediate- or high-risk ndings on M (5) M (5) M (6) M (6) A (7) A (7) A (8) A (8)
noninvasive testing
6. n No stress test performed or, if performed, M (5) M (5) M (6) M (6) M (6) M (6) A (8) A (7)
n FFR #0.80
The number in parentheses next to the rating reects the median score for that indication. *iFR measurements with appropriate normal ranges may be substituted for FFR.
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional ow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary
artery; LCX, left circumex artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate.
TABLE 1.2 Two-Vessel Disease
Appropriate Use Score (19)

Two-Vessel Disease
Not on AA
No Proximal LAD Involvement
7. n Low-risk ndings on noninvasive testing R (3) R (2) M (4) R (3) M (5) M (4) A (7) M (6)
8. n Intermediate- or high-risk ndings on M (5) M (4) M (6) M (5) A (7) M (6) A (8) A (7)
noninvasive testing
9. n No stress test performed or, if performed, M (5) M (4) M (6) M (4) A (7) M (5) A (8) A (7)
n FFR #0.80* in both vessels
Proximal LAD Involvement and No Diabetes Present
10. n Low-risk ndings on noninvasive testing M (4) M (4) M (5) M (5) M (6) M (6) A (7) A (7)
11. n Intermediate- or high-risk ndings on M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
noninvasive testing
12. n No stress test performed or, if performed, M (6) M (6) M (6) M (6) A (7) A (7) A (8) A (8)
n FFR #0.80 in both vessels
Proximal LAD Involvement With Diabetes Present
13. n Low-risk ndings on noninvasive testing M (4) M (5) M (4) M (6) M (6) A (7) A (7) A (8)
14. n Intermediate- or high-risk ndings on M (5) A (7) M (6) A (7) A (7) A (8) A (8) A (9)
noninvasive testing
15. n No stress test performed or, if performed, M (5) M (6) M (6) A (7) A (7) A (8) A (7) A (8)
n FFR #0.80 in both vessels*
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional ow reserve; iFR, instant wave-free ratio; LAD, left anterior descending coronary
artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate.
formulating revascularization recommendations (35). procedures and, more recently, comparisons with PCI in
Factors such as vessel occlusion, bifurcation or trifurca- some anatomic situations. There are data suggesting that
tion at branch points, ostial stenosis location, length stenting of the left main ostium or trunk is more
>20 mm, tortuosity, calcication, and thrombus all add to straightforward than treating distal bifurcation or trifur-
the complexity of PCI. The presence of multiple complex cation stenoses and is associated with a lower rate of
features (SYNTAX score >22) is associated with more restenosis. In comparison, left main lesion location has a
favorable outcomes with CABG. Although limitations of negligible inuence on the success and long-term results
the SYNTAX score for certain revascularization recom- of CABG. Accordingly, there are separate rating options
mendations are recognized and it may be impractical to for ostial and mid-shaft left main disease and distal or
apply this scoring system to all patients with multivessel bifurcation left main disease. The denition of a signi-
disease, it is a reasonable surrogate for the extent and cant left main stenosis used herein is $50% narrowing by
complexity of CAD and provides important information angiography. However, the angiographic assessment of
that can be helpful when making revascularization the severity of left main disease has several shortcomings,
decisions. and other assessments such as IVUS or FFR may be
Accordingly, in this table specically for patients with needed. For left main coronary artery stenoses, a mini-
3-vessel disease, the rating panel was asked to consider mum lumen diameter of <2.8 mm or a minimum lumen
the indications in patients with low complexity compared area of <6 mm 2 suggests a physiologically signicant
with those with intermediate and high complexity. lesion. It has been suggested that a minimum lumen area
>7.5 mm 2 suggests revascularization may be safely de-
Table 1.4. Left Main Coronary Artery Stenosis ferred. A minimum lumen area between 6 and 7.5 mm 2
Literature on the treatment of signicant left main dis- requires further physiological assessment, such as mea-
ease is dominated by surgical revascularization surement of FFR. Alternatively, FFR may be used as the
TABLE 1.3 Three-Vessel Disease

Three-Vessel Disease
Not on AA
Low Disease Complexity (e.g., Focal Stenoses, SYNTAX #22)
n No diabetes
17. n Intermediate- or high-risk ndings on M (6) A (7) A (7) A (7) A (7) A (8) A (8) A (8)
noninvasive testing
n No diabetes
18. n Low-risk ndings on noninvasive testing M (4) M (6) M (5) M (6) M (6) A (7) A (7) A (8)
n Diabetes present
19. n Intermediate- or high-risk ndings on M (6) A (7) M (6) A (8) A (7) A (8) A (7) A (9)
noninvasive testing
n Diabetes present
Intermediate or High Disease Complexity (e.g. Multiple Features of Complexity as Noted Previously, SYNTAX >22)
20. n Low-risk ndings on noninvasive testing M (4) M (6) M (4) A (7) M (5) A (7) M (6) A (8)
n No diabetes
21. n Intermediate- or high-risk ndings on M (5) A (7) M (6) A (7) M (6) A (8) M (6) A (9)
noninvasive testing
n No diabetes
22. n Low-risk ndings on noninvasive testing M (4) A (7) M (4) A (7) M (5) A (8) M (6) A (9)
n Diabetes present
23. n Intermediate- or high-risk ndings on M (4) A (8) M (5) A (8) M (5) A (8) M (6) A (9)
noninvasive testing
n Diabetes present
The number in parentheses next to the rating reects the median score for that indication.
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; M, may be appropriate; PCI, percutaneous coronary intervention; and SYNTAX, Synergy between
PCI with Taxus and Cardiac Surgery trial.
rst modality to assess ambiguous left main severity, and be particularly challenging because of the usual marked
the criteria for a signicant stenosis are the same as for size difference between the SVG and native artery.
nonleft main stenosis (21,36,37). Although FFR measurements are well-validated in
native vessels, data on the use of FFR in vein grafts are
Section 2. Tables 2.1 and 2.2 SIHD With Prior CABG limited (38). After CABG surgery, the bypass conduit
Patients with prior CABG surgery can present with a wide should act in a similar fashion to the native, low-
spectrum of disease progression. This includes the resistance epicardial vessel. However, the assessment
development of new obstructive disease in coronary ar- of ischemia due to a stenosis in a vein graft is compli-
teries not bypassed in the rst operation, new stenoses in cated by several features, which include: 1) the poten-
existing bypass grafts, and territory previously bypassed tial for competing ow (and pressure) from both the
but jeopardized again because of graft occlusion. Devel- native and conduit vessels; 2) the presence of collaterals
oping indications inclusive of all of these anatomic pos- from longstanding native coronary occlusion; and 3) the
sibilities would be impractical. Accordingly, the writing potential for microvascular abnormalities due to
committee adopted a more compact construct based on ischemic brosis and scarring, pre-existing or bypass
the presence of a signicant stenosis in a bypass graft or surgeryrelated myocardial infarction, or chronic low-
native coronary artery supplying 1, 2, or 3 distinct ow ischemia. Despite these complicating features, the
vascular territories roughly corresponding to the terri- theory of FFR should apply equally to both a lesion in
tories of the 3 main coronary arteries. As in patients an SVG to the right coronary artery feeding a normal
without prior CABG, the indications included an assess- myocardial bed and a lesion in the native right coro-
ment of risk based on noninvasive testing (low versus nary. However, if the native and collateral supply
intermediate or high risk). are sufciently large, the FFR across an SVG stenosis
Evaluation of the severity and physiological signi- could be normal. FFR measurements may be most
cance of a stenosis in saphenous vein grafts (SVG) can useful in the setting of an occluded bypass graft to a
TABLE 1.4 Left Main Coronary Artery Stenosis

Left Main Disease
Not on AA
24. n Isolated LMCA disease M (6) A (8) A (7) A (8) A (7) A (9) A (7) A (9)
n Ostial or midshaft stenosis
25. n Isolated LMCA disease M (5) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
n Bifurcation involvement
26. n LMCA disease M (6) A (8) M (6) A (9) A (7) A (9) A (7) A (9)
n Ostial or midshaft stenosis
n Concurrent multivessel disease
n Low disease burden (e.g., 12 additional focal
stenoses, SYNTAX score #22)
27. n Ostial or midshaft stenosis M (4) A (9) M (4) A (9) M (4) A (9) M (4) A (9)
n Concurrent multivessel disease
n Intermediate or high disease burden (e.g., 12
additional bifurcation stenosis, long stenoses,
SYNTAX score >22)
28. n LMCA disease M (4) A (8) M (5) A (8) M (5) A (9) M (6) A (9)
n Low disease burden in other vessels (e.g., 12
additional focal stenosis, SYNTAX score #22)
29. n LMCA disease R (3) A (8) R (3) A (9) R (3) A (9) R (3) A (9)
n Intermediate or high disease burden in other
vessels (e.g., 12 additional bifurcation ste-
nosis, long stenoses, SYNTAX score >22)
A indicates appropriate; AA, antianginal; BB, beta blockers; CABG, coronary artery bypass graft; LMCA, left main coronary artery; M, may be appropriate; PCI, percutaneous coronary
intervention; R, rarely appropriate; and SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial.
native artery with an intermediate-severity stenosis. in the presence of a patent and fully functional IMA graft,
FFR measurements in bypass grafts are less well- especially to the LAD. The path of the IMA, particularly if
validated and should thus be interpreted with caution. it courses medially or is adherent to the back of the ster-
Two tables are presented for the rating of patients with num, may be at greater risk during sternal re-entry, with
prior CABG depending on the patency of an existing in- adverse consequences even if the IMA-grafted vessel is
ternal mammary artery (IMA) graft. IMAs have a greater regrafted. For Table 2.1., it is assumed that the LAD was
long-term patency rate than SVGstypically >90% after signicantly diseased at the time of the original opera-
10 years (39,40). Accordingly, use of the IMA as a conduit tion. Therefore, if the IMA to the LAD is no longer patent
in CABG surgery has steadily increased. Current use is or is severely diseased, it is assumed that the native LAD
98%, as reported in the Society of Thoracic Surgeons na- is also severely diseased or occluded.
tional database, and use of the IMA as a conduit is 1 of the
quality metrics in their composite score. Because of the Section 3. Table 3.1 SIHD Undergoing Procedures for Which
current high use of the IMA, the writing committee felt Coronary Revascularization May Be Considered
there were too few patients to consider a separate cate- In an effort to capture common clinical scenarios that are
gory consisting of patients who only had SVGs used in not well-represented in guidelines, the writing group
their rst operation, although a few such patients may developed indications for preoperative revascularization
exist. Moreover, the writing committee did not develop in patients being evaluated for renal transplantation or
any scenarios where the initial operation consisted of structural heart procedures. The writing committee
only bypass grafts to the circumex and right coronary recognized that pre-operative revascularization is some-
artery in the absence of LAD disease. The patency and times requested before transplantation of other organs,
longevity of the IMA as a bypass graft was felt by the but there is insufcient experience or data from
writing committee to be an important decision point in controlled studies upon which to develop meaningful
the indication development, as many cardiovascular sur- scenarios. These scenarios do not capture all possible
geons are hesitant to perform a second bypass operation clinical situations, but were felt to capture the majority of
TABLE 2.1 IMA to LAD Patent and Without Signicant Stenoses

Not on AA
Stenosis Supplying 1 Territory Disease (Bypass Graft or Native Artery) to Territory Other Than Anterior
30. n Low-risk ndings on noninvasive testing R (3) R (1) R (3) R (2) M (6) R (3) A (7) M (4)
31. n Intermediate- or high-risk ndings on M (5) R (3) M (5) R (3) A (7) M (4) A (8) M (5)
noninvasive testing
32. n No stress test performed or, if performed, the M (4) R (3) M (4) R (3) M (6) M (4) A (8) M (5)
n FFR of stenosis #0.80*
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) Not Including Anterior
Territory
33. n Low-risk ndings on noninvasive testing R (3) R (2) M (4) R (3) M (6) R (3) A (7) M (5)
34. n Intermediate- or high-risk ndings on M (5) R (3) M (5) M (4) A (7) M (5) A (8) M (6)
noninvasive testing
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional ow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left
anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate.
common clinical situations. If patients have an acute 5 cardiac surgeons, 5 interventional cardiologists, 6 cardi-
coronary syndrome, the writing group felt they should ologists not directly involved with performing revascu-
be rated according to the AUC for acute coronary syn- larization, and 1 outcomes researcher. Third, the new
drome. For many of these patients, symptoms may be criteria stratify symptoms into 2 general group-
difcult to attribute to myocardial ischemia; thus, the sasymptomatic and ischemic symptomsto be inclusive
indications used in this table provide only anatomic and of the spectrum of complaints that may occur from
noninvasive test ndings for review. Note that for pa- myocardial ischemia. Furthermore, because of the variety
tients being evaluated before a percutaneous valve pro- of symptoms that may indicate myocardial ischemia, in-
cedure, the option for CABG surgery is blocked out, as it is dividual patient variation in how they are described, and
assumed such patients have clinical factors making their observer variability in the assessment of symptom
risk of surgery prohibitively high. severity, the writing group chose to abandon the Canadian
Cardiac Society classication. However, the current
7. DISCUSSION criteria continue to emphasize the use of more objective
measures of ischemia within indications to stratify pa-
The AUC are intended to inform clinicians, patients, and tients into low-risk or intermediate-/high-risk ndings, as
health policy makers about the reasonable use of tech- described in the SIHD guideline. Fourth, the scenarios
nologies to help improve patient symptoms and health expand the use of intracoronary physiological testing,
outcomes. Since 2005, the American College of Cardiol- mainly with FFR. Fifth, the structure of the AUC tables
ogy, along with its professional partners, has worked to concerning the use of antianginal therapy has changed to
provide criteria for both invasive and noninvasive testing reect typical practice patterns rating patients on the basis
and selected treatments, with the intention of further of no antianginal therapy, use of 1 antianginal drug, or use
expanding the AUC portfolio. of 2 or more antianginal drugs. As in earlier documents, it is
The 2017 Appropriate Use Criteria for Revascularization assumed that all patients are being treated with guideline-
in Patients With Stable Ischemic Heart Disease is the directed medical therapies to reduce risk. Finally, in an
culmination of approximately 2 years of review and revi- effort to capture patients who have not previously been
sion to the existing AUC. In response to comments from categorized, the current AUC also rate coronary revascu-
multiple stakeholders, the current AUC has several larization in patients being considered for renal trans-
important changes (41). First, this document will use the plantation and percutaneous valve procedures.
new terms appropriate care, may be appropriate care, Review of the ratings demonstrate some themes
and rarely appropriate care, which were described in the around revascularization of patients with SIHD that are
updated AUC methodology paper (2). Second, the compo- consistent with existing clinical practice guidelines. In
sition of the rating panel was changed slightly to include general, in patients with a low burden of coronary disease
TABLE 2.2 IMA to LAD Not Patent

Not on AA
Stenosis Supplying 1-Territory Disease (Bypass Graft or Native Artery)Anterior (LAD) Territory
35. n Low-risk ndings on noninvasive testing M (4) R (3) M (5) R (3) M (6) M (4) A (7) M (5)
36. n Intermediate- or high-risk ndings on M (6) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
noninvasive testing
37. n No stress test performed or, if performed, the M (5) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
n FFR of stenosis #0.80*
Stenoses Supplying 2 Territories (Bypass Graft or Native Artery, Either 2 Separate Vessels or Sequential Graft Supplying 2 Territories) LAD Plus Other Territory
38. n Low-risk ndings on noninvasive testing M (5) M (4) M (6) M (4) A (7) M (5) A (7) M (6)
39. n Intermediate- or high-risk ndings on M (6) M (5) A (7) M (6) A (7) A (7) A (8) A (8)
noninvasive testing
Stenoses Supplying 3 Territories (Bypass Graft or Native Arteries, Separate Vessels, Sequential Grafts, or Combination Thereof) LAD Plus 2 Other Territories
41. n Intermediate- or high-risk ndings on A (7) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
noninvasive testing
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; FFR, fractional ow reserve; iFR, instant wave-free ratio; IMA, internal mammary artery; LAD, left
anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention; and R, rarely appropriate.
(e.g., single-vessel disease), low-risk ndings on nonin- the majority of patients being evaluated before a percu-
vasive testing, and/or no antianginal therapy, revascu- taneous valve procedure.
larization by PCI or CABG surgery for care is felt to be
rarely appropriate as the initial step. As disease burden Application of Criteria
progresses through 2-vessel to 3-vessel and left main There are many potential applications for AUC, including
disease, revascularization by PCI or CABG frequently be- their adoption by Centers for Medicare & Medicaid Ser-
comes rated as may be appropriate care or appropriate vices regulators as a means of evaluating care. Clinicians
care, with CABG surgery consistently rated as appro- can use the ratings for decision support or as an educa-
priate care for intermediate or high disease complexity tional tool when considering the need for revasculariza-
(SYNTAX $22) even in patients with ischemic symptoms tion. Moreover, these criteria can be used to facilitate
who are not on antianginal therapy. Of note, CABG sur- discussions with patients and/or referring physicians
gery was consistently rated as appropriate care and PCI about the need for revascularization. The original intent
as rarely appropriate care for left main bifurcation dis- of the AUC was to provide a tool to identify patterns of
ease with intermediate or high disease burden in other care, including both the overuse and underuse of various
vessels. services. In fact, some of the initial publications related to
Repeat CABG surgery was felt to be rarely appropriate AUC identied underuse and the consequences of
in patients with a functional patent IMA to the LAD in all underuse rather than overuse of services (42,43). Facil-
but 1 indication, with both PCI and CABG being rated as ities have used these criteria to design protocols to facil-
either may be appropriate care or appropriate care in itate the appropriate care of patients. Some payers have
the other indications, reecting the complex and indi- adopted the AUC for use in the preauthorization of pro-
vidualized decision making required in these patients. cedures or retrospectively for quality reports. Although
With the exception of a few specic scenarios in asymp- the AUC were never intended to determine payment in
tomatic patients with a low disease burden, revasculari- individual patients, some payers have adopted the AUC
zation options were considered as may be appropriate for this purpose. The desire of payers to control costs is
care or appropriate care options. Although not directly understood, but it should be in the context of developing
rated, the use of fractional ow reserve for evaluation of rational payment management strategies to ensure their
renal transplant patients may be considered and will be members receive necessary, benecial, and cost-effective
addressed in future revascularization documents. Revas- cardiovascular care, rather than for other purposes. It is
cularization by PCI was considered appropriate care for expected that services performed for appropriate or
-, 2017:--
JACC VOL.
TABLE 3.1 Stable Ischemic Heart Disease Undergoing Procedures for Which Coronary Revascularization May Be Considered

-, NO. -, 2017
Not on AA Therapy
or With AA On 1 AA Drug
Therapy Not on AA Therapy (BB Preferred) On $2 AA Drugs
Patients Undergoing Renal Transplantation, No Diabetes
42. n One- or two-vessel CAD, no proximal LAD involvement, with low-risk noninvasive R (3) R (2) M (4) R (3) M (6) M (4) A (7) M (5)
ndings
43. n One- or two-vessel CAD, no proximal LAD involvement, with intermediate- or high-risk M (5) M (4) M (6) M (4) A (7) M (5) A (8) M (6)
noninvasive ndings
44. n One- or two-vessel CAD, including proximal LAD, with low-risk noninvasive ndings M (5) M (4) M (6) M (5) M (6) M (6) A (8) A (7)
45. n One- or two-vessel CAD, including proximal LAD, with intermediate- or high-risk M (6) M (6) A (7) A (7) A (7) A (7) A (8) A (8)
noninvasive ndings
46. n Left main and/or three-vessel disease, with intermediate- or high-risk noninvasive M (6) A (7) A (7) A (7) A (7) A (7) A (8) A (8)
ndings (e.g., SYNTAX #22)
47. n Left main and/or three-vessel disease, with intermediate- or high-risk noninvasive M (5) A (7) M (6) A (8) M (6) A (8) M (6) A (9)
ndings (e.g., SYNTAX >22)
Patients Undergoing Renal Transplantation, Diabetes Present
48. n One- or two-vessel CAD, no proximal LAD involvement, with low-risk noninvasive R (3) R (3) M (4) R (3) M (5) M (4) A (7) M (6)
ndings
49. n One- or two-vessel CAD, no proximal LAD involvement, with intermediate- or high-risk M (5) M (4) M (5) M (4) M (6) M (5) A (7) A (7)
noninvasive ndings
50. n One- or two-vessel CAD, including proximal LAD, with low-risk noninvasive ndings M (5) M (5) M (5) M (6) M (5) A (7) A (7) A (7)
51. n One- or two-vessel CAD, including proximal LAD, with intermediate- or high-risk M (6) M (6) M (6) A (7) M (6) A (7) A (7) A (8)
noninvasive ndings
52. n Left main and/or three-vessel disease, with intermediate- or high-risk noninvasive M (6) A (8) M (6) A (8) M (6) A (8) A (7) A (9)
AUC for Coronary Revascularization in Patients With SIHD

53. n Left main and/or three-vessel disease, with intermediate- or high-risk noninvasive M (5) A (8) M (5) A (8) M (5) A (9) M (5) A (9)
Patient Who Will Undergo a Percutaneous Valve Procedure (TAVR, MitraClip, Others)
54. n One- or two-vessel CAD, no proximal LAD involvement, with low-risk noninvasive M (4) M (4) M (6) A (8)
ndings
55. n One- or two-vessel CAD, no proximal LAD involvement, with intermediate- or high-risk A (7) A (7) A (7) A (8)
noninvasive ndings
56. n One- or two-vessel CAD, including proximal LAD, with low-risk noninvasive ndings M (6) M (6) A (7) A (8)
57. n One- or two-vessel CAD, including proximal LAD, with intermediate- or high-risk A (7) A (7) A (8) A (9)
noninvasive ndings
58. n Left main and/or three-vessel disease, with intermediate- or high-risk noninvasive A (8) A (8) A (8) A (9)
Patel et al.
59. n Left main and/or three-vessel disease, with intermediate- or high-risk noninvasive A (7) A (7) A (8) A (8)
A indicates appropriate; AA, Antianginal; BB, beta blockers; CABG, coronary artery bypass graft; CAD, coronary artery disease; LAD, left anterior descending coronary artery; M, may be appropriate; PCI, percutaneous coronary intervention;
19
R, rarely appropriate; SYNTAX, Synergy between PCI with Taxus and Cardiac Surgery trial; and TAVR, transcatheter aortic valve replacement.
may be appropriate indications will receive reim- transparent for all providers to review and implement
bursement. In contrast, services performed for rarely local systems of care.
appropriate indications should be justied by additional In conclusion, this document represents the current
documentation to justify payment because of the unique understanding of the clinical benet of coronary revascu-
circumstances or the clinical prole that must exist in larization with respect to health outcomes and survival.
such a patient. It is critical to emphasize that the writing These criteria have been developed through the AUC pro-
group, technical panel, Appropriate Use Criteria Task cess and alignment with the evidence and recommenda-
Force, and clinical community do not believe a rating of tions from clinical practice guidelines. This is intended to
may be appropriate is justication to deny reimburse- provide a practical guide to clinicians and patients when
ment for revascularization. Rather, may be appropriate considering revascularization. As with all AUC, some of
ratings are those in which the available data vary and these ratings will require research and further evaluation
many other factors exist that may affect the decision to to provide the greatest information and benet to clinical
perform or not perform revascularization. The opinions of decision making. We anticipate that the utility and ability
the technical panel often varied for these indications, of these criteria to improve the quality of care will be
reecting that additional research is needed. measured by the overall use and adoption of the criteria.
The writing group recognizes the need to align the With each update, the AUC for coronary revascularization
collection of clinical data required for the determination in SIHD have become more rened and specic, while areas
of appropriate use with appropriate methods to reduce for continued focus and research have been identied.
the burden of data collection. To this end, the NCDR
CathPCI Registry group has been engaged in a parallel ACC PRESIDENT AND STAFF
process to ensure that needed data elements are incor-
porated into the Registry. The criteria will also be eval- Richard A. Chazal, MD, FACC, President
uated for collection by the Society for Thoracic Surgeons Shalom Jacobovitz, Chief Executive Ofcer
registry. Incorporating elds to identify patients who are William J. Oetgen, MD, FACC, Executive Vice President,
not felt to be candidates for PCI or CABG surgery has Science, Education and Quality
been suggested to ensure proper mapping of the AUC in Joseph M. Allen, MA, Director, Team Leader, Clinical
the course of medical decision making. The writing Policy and Pathways
committee believes the key step to ensuring that the Leah White, MPH, CCRP, Team Leader, Appropriate Use
AUC are iterated and continually improved is the use of Criteria
a feedback cycle of data between current clinical practice Mara Velsquez, Senior Research Specialist, Appropriate
and the Registry. The writing group also believes that Use Criteria
the mapping of the data elements on the NCDR CathPCI Amelia Scholtz, PhD, Publications Manager, Clinical Pol-
Registry data collection from the AUC should be icy and Pathways
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25. Arnold SV, Grodzinsky A, Gosch KL, et al. Predictors Houghtaling PL, Cosgrove DM. Comparison of
AHA/SCAI Guideline for Percutaneous Coronary Inter-
of physician under-recognition of angina in outpatients saphenous vein and internal thoracic artery graft
vention and the 2013 ACCF/AHA Guideline for the
with stable coronary artery disease. Circ Cardiovasc patency by coronary system. Ann Thorac Surg. 2005;
Management of ST-Elevation Myocardial Infarction: a
Qual Outcomes. 2016;9:5549. 79:54451.
report of the American College of Cardiology/American
Heart Association Task Force on Clinical Practice 26. Chewning B, Bylund CL, Shah B, Arora NK, 41. Marso SP, Teirstein PS, Kereiakes DJ, Moses J,
Guidelines and the Society for Cardiovascular Angiog- Gueguen JA, Makoul G. Patient preferences for shared Lasala J, Grantham JA. Percutaneous coronary inter-
raphy and Interventions. J Am Coll Cardiol. 2016;67: decisions: a systematic review. Patient Educ Couns. vention use in the United States: dening measures of
123550. 2012;86:918. appropriateness. J Am Coll Cardiol Intv. 2012;5:229
17. Adult Treatment Panel III. Third Report of the Na- 27. Lin GA, Fagerlin A. Shared decision making: state of 35.
tional Cholesterol Education Program (NCEP) Expert the science. Circ Cardiovasc Qual Outcomes. 2014;7:
42. Hemingway H, Crook AM, Feder G, et al. Underuse
Panel on Detection, Evaluation, and Treatment of High 32834.
of coronary revascularization procedures in patients
Blood Cholesterol in Adults (Adult Treatment Panel III)
28. Ting HH, Brito JP, Montori VM. Shared decision considered appropriate candidates for revasculariza-
Final Report. Circulation. 2002;106:3143421.
making: science and action. Circ Cardiovasc Qual Out- tion. N Engl J Med. 2001;344:64554.
18. Chobanian AV, Bakris GL, Black HR, et al. Seventh comes. 2014;7:3237. 43. Laouri M, Kravitz RL, French WJ, et al. Underuse of
report of the Joint National Committee on Prevention,
29. Buchanan A. Medical paternalism. Philos Public Aff. coronary revascularization procedures: application of a
Detection, Evaluation, and Treatment of High Blood
1978;7:37090. clinical method. J Am Coll Cardiol. 1997;29:8917.
Pressure. Hypertension. 2003;42:120652.
30. Stacey D, Bennett CL, Barry MJ, et al. Decision aids
19. Smith SC Jr., Benjamin EJ, Bonow RO, et al. AHA/
for people facing health treatment or screening de-
ACCF secondary prevention and risk reduction therapy KEY WORDS ACC Appropriate Use Criteria,
cisions. Cochrane Database Syst Rev. 2011:CD001431.
for patients with coronary and other atherosclerotic coronary artery bypass graft, coronary
vascular disease: 2011 update: a guideline from the 31. Coley C, Barry M, Mulley A. Screening for prostate revascularization, percutaneous coronary
American Heart Association and American College of cancer. Ann Intern Med. 1977;126:4804. intervention, stable ischemic heart disease
APPENDIX A. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 APPROPRIATE USE CRITERIA FOR

CORONARY REVASCULARIZATION IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE:
PARTICIPANTS
Writing Group A&M Health Science Center College of Medicine; Vice-

Manesh R. Patel, MD, FACC, FAHA, FSCAIAssociate President and Medical Director, Cardiovascular Services,
Professor of Medicine Director of Interventional Cardi- Central Texas Division, Baylor Scott & White-Temple
ology and Catheterization Labs, Duke University Memorial, Temple, TX
Health System, Duke Clinical Research Institute, Peter K. Smith, MD, FACC, Writing Committee Liaison
Durham, NC Professor of Surgery, Division Chief, Cardiovascular and
John H. Calhoon, MDProfessor and Chair, Presidents Thoracic Surgery, Duke University, Durham, NC
Council Chair for Excellence in Surgery, Department of James C. Blankenship, MD, MACC, FSCAIStaff Physi-
Cardiothoracic Surgery; Director, University of Texas cian, Director, Cardiac Catheterization Laboratory, Divi-
Health Science Center at San Antonio, Heart and Vascular sion of Cardiology, Geisinger Medical Center, Danville, PA
Institute, San Antonio, TX Alfred A. Bove, MD, PhD, MACC Past President,
Gregory J. Dehmer, MD, MACC, MSCAI, FAHAClinical American College of Cardiology; Professor Emeritus,
Professor of Medicine, Texas A&M Health Science Center Lewis Katz School of Medicine, Heart and Vascular,
College of Medicine; Vice-President and Medical Director, Temple University, Philadelphia, PA
Cardiovascular Services, Central Texas Division, Baylor Steven M. Bradley, MDStaff Cardiologist, VA Eastern
Scott & White-Temple Memorial, Temple, TX Colorado Health Care System; Assistant Professor of
James Aaron Grantham, MD, FACCAssociate Clinical Medicine, Division of Cardiology at the University of
Professor, University of Missouri-Kansas City School of Colorado, Denver, CO
Medicine; Director, Cardiovascular Disease Fellowship Larry S. Dean, MD, FACC, FSCAIProfessor of Medicine
Program, University of Missouri-Kansas City School of and Surgery, University of Washington School of Medi-
Medicine; Director, Cardiovascular Medical Education, cine; Director, University of Washington, Medicine
Saint Lukes Hospital, Kansas City, MO Regional Heart Center, Seattle, WA
Thomas M. Maddox, MD, MSc, FACC, FAHANational Peter L. Duffy, MD, FACC, FSCAIDirector of Quality
Director, VA CART Program Cardiology, VA Eastern Col- for the Cardiovascular Service Line, First Health of the
orado Health Care System; Associate Professor, Depart- Carolinas, Reid Heart Institute/Moore Regional Hospital,
ment of Medicine, Cardiology, University of Colorado, Pinehurst North Carolina
Colorado Cardiovascular Outcomes Research Consortium, T. Bruce Ferguson, Jr., MD, FACCProfessor of
Denver, CO Thoracic Surgery, Department of Cardiovascular Sciences,
David J. Maron, MD, FACC, FAHAClinical Professor of Cardiothoracic Surgery, East Carolina Heart Institute, East
Medicine, Cardiovascular; Director, Preventive Cardiol- Carolina University, Greenville, NC
ogy, Stanford University School of Medicine, Stanford, CA Frederick L. Grover, MD, FACCProfessor of Cardio-
Peter K. Smith, MD, FACC Professor of Surgery, Divi- thoracic Surgery, Department of Cardiothoracic Surgery,
sion Chief, Cardiovascular and Thoracic Surgery, Duke University of Colorado, Denver, CO
University, Durham, NC Robert A. Guyton, MD, FACCChief of Cardiothoracic
Surgery, Professor of Surgery, Division of Cardiothoracic
Surgery, Department of Surgery; Director, Thoracic Sur-
Rating Panel gery Residency Program, Emory University School of
Manesh R. Patel, MD, FACC, FAHA, FSCAI, Writing Com- Medicine, Atlanta, GA
mittee LiaisonAssociate Professor of Medicine, Director Mark A. Hlatky, MD, FACCProfessor of Heath
Interventional Cardiology and Catheterization Labs, Duke Research and Policy, Health Services Research; Professor
University Health System, Duke Clinical Research Insti- of Medicine, Cardiovascular Medicine, Stanford Univer-
tute, Durham, NC sity School of Medicine, Stanford, CA
Michael J. Wolk, MD, MACC, ModeratorPast Presi- Harold L. Lazar, MD, FACCDirector, Cardiothoracic
dent, American College of Cardiology; Clinical Professor Research Program; Professor of Cardiothoracic Surgery,
of Medicine, Weill Medical College of Cornell University, Boston University School of Medicine, Boston, MA
New York Cardiology Associates, New York, NY Vera H. Rigolin, MD, FACCProfessor, Cardiology,
Gregory J. Dehmer, MD, MACC, MSCAI, FAHA, Writing Northwestern University Feinberg School of Medicine,
Committee LiaisonClinical Professor of Medicine, Texas Chicago, IL
Geoffrey A. Rose, MD, FACC, FASEChief, Division of Robert N. Piana, MD, FACCProfessor of Medicine, Car-
Cardiology, Sanger Heart and Vascular Institute, Char- diology, Vanderbilt University Medical Center, Nashville, TN
lotte, NC John A. Spertus, M.D, MPH, FACCAdjunct Professor of
Richard J. Shemin, MD, FACCRobert and Kelly Day Medicine, Washington University School of Medicine,
Professor, Chief of Cardiothoracic Surgery, Executive Vice Saint Louis, MO
Chair of Surgery, Co-Director of the Cardiovascular Cen- Raymond F. Stainback, MD, FACC Medical Director,
ter, Director of Cardiac Quality at the Ronald Reagan Non-Invasive Cardiology Texas Heart Institute at Baylor
UCLA Medical Center, Los Angeles, CA St. Lukes Medical Center, Houston, TX
Jacqueline E. Tamis-Holland, MD, FACCDirector, Robert C. Stoler, MD, FACCDirector of Cardiac Cath-
Interventional Cardiology Fellowship, Mount Sinai; Saint eterization Laboratory, Cardiology Consultants of Texas,
Lukes Hospital Director, Womens Heart NY Assistant Dallas, TX
Professor of Medicine, Icahn School of Medicine at Mount Todd C. Villines, MD, FACCCo-Director of Cardiovas-
Sinai Hospital, New York, NY cular Computed Tomography and Assistant Chief, Cardi-
Carl L. Tommaso, MD, FACC, FSCAIDirector, Cardiac ology Service at Walter Reed Army Medical Center,
Catheterization Laboratory, Skokie Illinois Hospital, part Rockville, MD
of the Northshore University Health System; Associate David H. Wiener, MD, FACCProfessor of Medicine,
Professor of Medicine, Rush Medical College, Chicago, IL Jefferson Medical College, Jefferson Heart Institute,
L. Samuel Wann, MD, MACCPast President, American Philadelphia, PA
College of Cardiology; Clinical Cardiologist, Columbia St.
Marys Healthcare; Medical Director, Heart Failure Pro- ACC Appropriate Use Criteria Task Force
gram, Milwaukee, WI Steven R. Bailey, MD, FACC, FSCAI, FAHAChair, Divi-
John B. Wong, MDChief, Division of Clinical Decision sion of Cardiology; Professor of Medicine and Radiology,
Making, Primary Care Physician, Principal Investigator, Janey Briscoe Distinguished Chair, University of Texas
Institute for Clinical Research and Health Policy Studies; Health Sciences Center, San Antonio, TX
Professor, Tufts University School of Medicine, Boston, MA Nicole Bhave, MD, FACCClinical Assistant Professor,
Department of Internal Medicine, Division of Cardiovas-
Reviewers cular Medicine, University of Michigan Cardiovascular
Jeffrey L. Anderson, MD, FACCAssociate Chief of Center, Ann Arbor, MI
Cardiology, Intermountain Medical Center, Murray, UT Alan S. Brown, MD, FACCMedical Director, Midwest
James C. Blankenship, MD, MACC, MSCAIStaff Heart Disease Prevention Center, Advocate Lutheran
Physician, Director, Cardiac Catheterization Laboratory, General Hospital; Director, Division of Cardiology, Park
Geisinger Medical Center, Division of Cardiology, Ridge, IL
Danville, PA Stacie L. Daugherty, MD, FACCAssociate Professor,
Jeffrey A. Brinker, MD, FACCProfessor of Medicine, Division of Cardiology, Department of Medicine, Univer-
Johns Hopkins Hospital, Baltimore, MD sity of Colorado School of Medicine, Denver, CO
Alexandru I. Costea, MDAssociate Professor, Univer- Gregory J. Dehmer, MD, MACC, MSCAI, FAHA
sity of Cincinnati Medical Center, Cincinnati, OH Co-Chair, AUC Task Force, Clinical Professor of Medicine,
Ali E. Denktas, MD, FACCAssistant Professor, Baylor Texas A&M Health Science Center College of Medicine;
College of Medicine, Houston, TX Vice President and Medical Director, Cardiovascular
Lloyd W. Klein, MD, FACCProfessor of Medicine, Services, Central Texas Division, Baylor Scott and White-
Melrose Park, IL Temple Memorial, Temple, TX
Frederick G. Kushner, MD, FACCClinical Professor, Milind Y. Desai, MBBS, FACCAssociate Director,
Tulane University Medical Center; Medical Director, Heart Clinical Investigations Heart and Vascular Institute,
Clinic of Louisiana, Marrero, LA Cleveland Clinic, Cleveland, OH
Glenn N. Levine, MD, FACCProfessor, Baylor College John U. Doherty, MD, FACC, FAHACo-Chair, AUC Task
of Medicine, Cardiology, Pearland, TX Force, Professor of Medicine, Jefferson Medical College of
David Joel Maron, MD, FACCProfessor of Medicine Thomas Jefferson University, Philadelphia, PA
and Emergency Medicine, Stanford University School of Claire Duvernoy, MD, FACCCardiology Section Chief,
Medicine, Stanford, CA Division of Cardiology, University of Michigan Health
James B. McClurken, MD, FACCDirector of System, Ann Arbor, MI
Thoracic Surgery, Professor of Surgery Emeritus, Temple Linda D. Gillam, MD, FACCChair, Department of Car-
University, School of Medicine, Richard A Reif Heart diovascular Medicine, Morristown Medical Center, Mor-
Institute, Doylestown Hospital, Doylestown, PA ristown, NJ
Robert C. Hendel, MD, FACC, FAHA, FASNCDirector David E. Winchester, MD, FACCAssistant Professor of
of Cardiac Imaging and Outpatient Services, Division Medicine, University of Florida, Division of Cardiology,
of Cardiology, Miami University School of Medicine, Gainesville, FL
Miami, FL Joseph M. Allen, MATeam Leader, Clinical Policy and
Christopher M. Kramer, MD, FACC, FAHAFormer Co- Pathways, American College of Cardiology, Washington, DC
Chair, AUC Task Force, Ruth C. Heede Professor of Car-
diology & Radiology; Director, Cardiovascular Imaging
APPENDIX B. RELATIONSHIPS WITH INDUSTRY
Center, University of Virginia Health System, Charlottes-
AND OTHER ENTITIES
ville, VA
Bruce D. Lindsay, MD, FACCProfessor of Cardiology, The College and its partnering organizations rigorously
Cleveland Clinic Foundation of Cardiovascular Medicine, avoid any actual, perceived, or potential conicts of in-
Cleveland, OH terest that might arise as a result of an outside relationship
Warren J. Manning, MD, FACCProfessor of Medicine or personal interest of a member of the rating panel. Spe-
and Radiology, Beth Israel Deaconess Medical Center, cically, all panelists are asked to provide disclosure
Division of Cardiology, Boston, MA statements of all relationships that might be perceived as
Manesh R. Patel, MD, FACC Former Chair, AUC Task real or potential conicts of interest. These statements
Force; Assistant Professor of Medicine, Division of Car- were reviewed by the Appropriate Use Criteria Task Force,
diology, Duke University Medical Center, Durham, NC discussed with all members of the rating panel at the face-
Ritu Sachdeva, MD, FACCAssociate Professor, Division to-face meeting, and updated and reviewed as necessary.
of Pediatric Cardiology, Department of Pediatrics, Emory The following is a table of relevant disclosures by the rating
University School of Medicine, Childrens Health Care of panel and oversight working group members. In addition,
Atlanta, Sibley Heart Center Cardiology, Atlanta, GA to ensure complete transparency, a full list of disclosure
L. Samuel Wann, MD, MACCStaff Cardiologist, informationincluding relationships not pertinent to this
Columbia St. Marys Healthcare, Milwaukee, WI documentis available in the Online Appendix.
APPROPRIATE USE CRITERIA FOR CORONARY REVASCULARIZATION IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE:
-, 2017:--
JACC VOL.
MEMBERS OF THE WRITING GROUP, RATING PANEL, INDICATION REVIEWERS, AND AUC TASK FORCE
RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT)
-, NO. -, 2017
Institutional,
Ownership/ Organizational,
Speakers Partnership/ or Other Financial Expert
Participant Employment Consultant Bureau Principal Personal Research Benet Witness
Manesh R. Patel Duke University Health System, Duke None None None None None None
(Chair) Clinical Research InstituteAssociate
Professor of Medicine, Director,
Interventional Cardiology and
Catheterization Labs
John H. Calhoon University of Texas Health Science Center None None None None None None
at San Antonio, Department of
Cardiothoracic Surgery, Heart and Vascular
InstituteDirector, Professor, and Chair,
Presidents Council Chair for Excellence in
Surgery
Gregory J. Dehmer Baylor Scott & White-Temple Memorial, None None None None None None
Texas A&M Health Science Center College
of Medicine, Central Texas DivisionClinical
Professor of Medicine, Medical Director,
Cardiovascular Services, Director,
Cardiology Division
James Aaron Saint Lukes HospitalAssociate Clinical n Abbott Vascular* None None n Abbott Vascular* None None
Grantham Professor, University of MissouriKansas n Asahi-Intecc* n Asahi-Intecc*
City School of MedicineDirector, n Boston Scientic* n Boston Scientic*
Cardiovascular Disease Fellowship n Bridgepoint Medical n Bridgepoint Medical
Program, Director, Cardiovascular Medical Systems* Systems*
Education n Medtronic* n Medtronic*
Thomas M. Maddox VA Eastern Colorado Health Care System None None None None None None
National Director, Associate Professor,

Department of Medicine, Cardiology,
University of Colorado, Colorado
Cardiovascular Outcomes Research
Consortium
David J. Maron Stanford University School of Medicine None None None None None None
Clinical Professor of Medicine,
Cardiovascular, Director, Preventive
Cardiology
Peter K. Smith Cardiovascular and Thoracic Surgery, Duke None None None None None None
UniversityProfessor of Surgery, Division
Chief
Patel et al.
25
26
APPENDIX B. CONTINUED

Patel et al.
Institutional,
Rating Panel
James C. Blankenship Geisinger Medical Center, Division of None None None n Abbott Vascular None None
CardiologyStaff Physician, Director, n AstraZeneca
Cardiac Catheterization Laboratory n Boston Scientic
n GlaxoSmithKline
n Hamilton Health
Services
n Medinal LTD*
n Orexigen Therapeu-
tics/Takeda
n Stentys, Inc.
n Takeda
Pharmaceuticals
Alfred A. Bove Temple University, Lewis Katz School of None None None n Merck Schering- None None
Medicine, Heart and VascularProfessor Plough
Emeritus
Steven M. Bradley VA Eastern Colorado Health Care System, None None None None None None
Division of Cardiology at the University of
ColoradoStaff Cardiologist, Assistant
Professor of Medicine
Larry S. Dean Medicine Regional Heart Center University n Philips Medical* None None n Edwards None None
of Washington School of Medicine Lifesciences*
Professor of Medicine and Surgery, Director
Peter L. Duffy First Health of the Carolinas, Reid Heart None n Volcano Corp* None None None None
Institute/Moore Regional Hospital
Director of Quality for the Cardiovascular
Service Line
T. Bruce Ferguson, Jr. East Carolina Heart Institute, East Carolina None None n RFPi n Novadaq None None
University, Department of Cardiovascular Technologies*
Sciences, Cardiothoracic SurgeryProfessor
of Thoracic Surgery
Frederick L. Grover University of Colorado, Department of n Somalution None None None None None
Cardiothoracic SurgeryProfessor of
Cardiothoracic Surgery
Robert A. Guyton Emory University School of Medicine, n Medtronic* None None None None None
Division of Cardiothoracic Surgery,
JACC VOL.
Department of Surgery, Thoracic Surgery
Residency ProgramChief of
Cardiothoracic Surgery, Professor of
Surgery Director
-, NO. -, 2017
n
-, 2017:--
Mark A. Hlatky Stanford University School of Medicine, None None None None Sano-Aventis None
Cardiovascular Medicine, Health Services
ResearchProfessor of Heath Research and
Policy, Professor of Medicine

-, 2017:--
JACC VOL.
Institutional,
-, NO. -, 2017
Harold L. Lazar Boston University School of Medicine, None None None None None None
Cardiothoracic Research ProgramDirector
Professor of Cardiothoracic Surgery
Vera H. Rigolin Northwestern University Feinberg School None None None None n Pzer* None
of Medicine, CardiologyProfessor
Geoffrey A. Rose Division of Cardiology, Sanger Heart and None None None None n Medtronic None
Vascular InstituteChief
Richard J. Shemin Ronald Reagan UCLA Medical Center, n Edwards Lifesciences None None None None None
Cardiovascular CenterDirector of Cardiac n Sorin Group
Quality, Robert and Kelly Day Professor,
Chief of Cardiothoracic Surgery, Executive
Vice Chair of Surgery
Jacqueline E. Saint Lukes Hospital, Icahn School of None None None None None None
Tamis-Holland Medicine at Mount Sinai Hospital Mount
SinaiDirector, Womens Heart NY,
Assistant Professor of Medicine, Director,
Interventional Cardiology Fellowship
Carl L. Tommaso Rush Medical College in Chicago, Skokie None None None None None None
Illinois Hospital, part of the Northshore
University Health SystemDirector of the
Cardiac Catheterization Laboratory,
Associate Professor of Medicine
L. Samuel Wann Columbia St. Marys HealthcareClinical n United Healthcare None None None None None
Cardiologist, Medical Director, Heart
Failure Program
John B. Wong Tufts University School of MedicineChief, None None None None None None
Division of Clinical Decision Making,

Primary Care Physician, Principal
Investigator, Institute for Clinical Research
and Health Policy Studies, Professor
Reviewers
Jeffrey L. Anderson Intermountain Medical CenterAssociate n Medicines Company None None None None None
Chief of Cardiology n Sano-Aventis
Jeffrey A. Brinker Johns Hopkins HospitalProfessor of None None None None None None
Medicine
Alexandru I. Costea University of Cincinnati Medical Center None None None None n Boston None
Associate Professor Scientic
Ali E. Denktas Baylor College of MedicineAssistant None None None n AstraZeneca None None
Professor n Edwards Lifesciences
Patel et al.
27
28

Patel et al.
Institutional,
Lloyd W. Klein Melrose ParkProfessor of Medicine None None None None None None
Frederick G. Kushner Tulane University Medical Center, Heart None None None None None None
Clinic of LouisianaClinical Professor,
Medical Director
Glenn N. Levine Baylor College of Medicine, Cardiology None None None None None None
Professor
David J. Maron Stanford University School of Medicine None None None None None None
Professor of Medicine and Emergency
Medicine
James B. McClurken Temple University, School of Medicine, None None None None None None
Richard A Reif Heart Institute, Doylestown
HospitalDirector of Thoracic Surgery,
Professor of Surgery Emeritus
Robert N. Piana Vanderbilt University Medical Center n Axio Research None None None None None
Professor of Medicine, Cardiology n Harvard Clinical
Research Institute
n W.L. Gore & Associ-
ates, Inc.
John A. Spertus Washington University School of n Amgen None n Health Outcomes None None None
MedicineAdjunct Professor of Medicine n Bayer Healthcare Sciences
Pharmaceuticals
n Janssen
n Novartis
n Regeneron
Raymond F. Texas Heart Institute at Baylor St. Lukes None None None None None None
Stainback Medical Center, Non-Invasive Cardiology
Medical Director
Robert C. Stoler Cardiology Consultants of TexasDirector n Boston Scientic None None None None None
of Cardiac Catheterization Laboratory n Medtronic
Todd C. Villines Cardiology Service at Walter Reed Army n Boehringer None None None None None
Medical CenterCo-Director of Ingelheim
Cardiovascular Computed Tomography and Pharmaceutical*
Assistant Chief
David H. Wiener Jefferson Medical College, Jefferson Heart None None None None None None
JACC VOL.
InstituteProfessor of Medicine
Appropriate Use Criteria Task Force

Steven R. Bailey University of Texas Health Sciences None None None None None None
CenterChair, Division of Cardiology,
-, NO. -, 2017
-, 2017:--
Professor of Medicine and Radiology, Janey
Briscoe Distinguished Chair

-, 2017:--
JACC VOL.
Institutional,
-, NO. -, 2017
Nicole Bhave University of Michigan Cardiovascular None None None None None None
Center, Department of Internal Medicine,
Division of Cardiovascular Medicine
Clinical Assistant Professor
Alan S. Brown Midwest Heart Disease Prevention Center, None None None None None None
Advocate Lutheran General Hospital
Director, Division of CardiologyMedical
Director
Stacie L. Daugherty University of Colorado School of Medicine, None None None None None None
Division of Cardiology, Department of
MedicineAssociate Professor
Gregory J. Dehmer Baylor Scott & White, Central Texas None None None None None None
Division, Cardiovascular Services Health
Medical Director
Milind Y. Desai Cleveland Clinic, Clinical Investigations, None None None None None None
Heart and Vascular InstituteAssociate
Director
John U. Doherty Thomas Jefferson University, Jefferson None None None None None None
Medical CollegeProfessor of Medicine
Claire Duvernoy University of Michigan Health System, None None None None None None
Division of CardiologyCardiology Section
Chief
Linda D. Gillam Morristown Medical Center, Department of n Edwards None None None None None
Cardiovascular MedicineChair Lifesciences*
n Medtronic
Robert C. Hendel Miami University School of Medicine, None None None None None None

Division of CardiologyDirector of Cardiac
Imaging and Outpatient Services
Christopher M. University of Virginia Health SystemRuth None None None None None None
Kramer C. Heede Professor of Cardiology &
Radiology, Director, Cardiovascular
Imaging Center
Bruce D. Lindsay Cleveland Clinic Foundation of None None None None None None
Cardiovascular MedicineProfessor of
Cardiology
Warren J. Manning Beth Israel Deaconess Medical Center, n Merck None None n Philips Medical None None
Division of CardiologyProfessor of Systems*
Medicine and Radiology
Manesh R. Patel Duke University Medical Center, Division of None None None None None None
CardiologyAssistant Professor of
Patel et al.
Medicine
29
30

Patel et al.
Institutional,
Ritu Sachdeva Emory University School of Medicine, None None None None None None
Childrens Health Care of Atlanta, Sibley
Heart Center Cardiology, Division of
Pediatric Cardiology, Department of
PediatricsAssociate Professor
L. Samuel Wann Columbia St. Marys HealthcareStaff None None None None None None
Cardiologist
David Winchester University of Florida, Division of None None None None None None
CardiologyAssistant Professor of
Medicine
Joseph M. Allen American College of CardiologyTeam None None None None None None
Leader, Clinical Policy and Pathways
Note: A standard exemption to the ACC relationship with industry policy is extended to AUC writing groups, because they do not make recommendations but rather prepare background materials and typical clinical scenarios/indications that are rated
independently by a separate panel of experts. This table represents relevant relationships of participants with industry and other entities that were reported by reviewers at the time this document was under development. The table does not necessarily
reect relationships with industry at the time of publication. A person is deemed to have a signicant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$5,000 of the fair
market value of the business entity; or if funds received by the person from the business entity exceed 5% of the persons gross income for the previous year. Relationships that exist with no nancial benet are also included for the purpose of
transparency. Relationships in this table are modest unless otherwise noted. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for denitions of disclosure categories or additional
information about the ACC Disclosure Policy for Writing Committees.
*Signicant relationship.
No nancial benet.
ACC indicates American College of Cardiology; and AUC, appropriate use criteria.
JACC VOL.
-, NO. -, 2017
-, 2017:--

ACC 2017 Appropriate Use Criteria For Coronary Revascularization

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ACC 2017 Appropriate Use Criteria For Coronary Revascularization

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. -, NO.

APPROPRIATE USE CRITERIA

L. Samuel Wann, MD, MACC** kSociety of Thoracic Surgeons Representative. {American

zAmerican College of Cardiology Representative.

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

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

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

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

Table B. Noninvasive Risk Stratication . . . . . . . . . . . . . - ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS

6. CORONARY REVASCULARIZATION IN PATIENTS

ABSTRACT Interventions, Society of Thoracic Surgeons, American

F I G U R E 1 AUC Development Process

Develop list of indications, Literature review and

assumptions, and definitions guideline mapping

Writing Group revises

Rating Panel rates the

1st roundno interaction

2nd roundpanel interaction

Appropriate Use Score

AUC indicates appropriate use criteria.

3. ASSUMPTIONS tion. However, a continuing effort and plan of care to

than asymptomatic due to self-imposed lifestyle Appropriate, May Be Appropriate, or Rarely

TABLE A Revascularization to Improve Survival Compared With Medical Therapy

UPLM or complex CAD

CABG and PCI IHeart Team approach recommended C (950952)

CABG and PCI IIaCalculation of STS and SYNTAX scores B (949,950,953957)

IIaFor UA/NSTEMI if not a CABG candidate B (949,968971,976979,981)

IIbFor SIHD when both of the following are present: B (949,953,955,958,963980,984)

Continued on the next page

3-vessel disease with or without proximal LAD artery disease*

PCI IIbOf uncertain benet B (366,959,980,985,987)

2-vessel disease with proximal LAD artery disease*

PCI IIbOf uncertain benet B (366,959,985,987)

2-vessel disease without proximal LAD artery disease*

CABG IIaWith extensive ischemia B (327,990992)

IIbOf uncertain benet without extensive ischemia C (987)

PCI IIbOf uncertain benet B (366,959,985,987)

1-vessel proximal LAD artery disease

CABG IIaWith LIMA for long-term benet B (412 987,993,994)

PCI IIbOf uncertain benet B (366,959,985,987)

1-vessel disease without proximal LAD artery involvement

CABG III: Harm B (306,327,412,985,990,995998)

PCI III: Harm B (306,327,412,985,990,995998)

CABG IIaEF 35% to 50% B (365,412,9991002)

CABG IIbEF <35% without signicant left main CAD B (355,365,410,412,9991002)

PCI Insufcient data N/A

Survivors of sudden cardiac death with presumed ischemia-mediated VT

No anatomic or physiological criteria for revascularization

CABG III: Harm B (306,327,412,985,990,995998)

PCI III: Harm B (306,327,412,985,990,995998)

TABLE B Noninvasive Risk Stratication

High risk (>3% annual death or MI)

Intermediate risk (1% to 3% annual death or MI)

Low risk (<1% annual death or MI)

Ischemic Symptoms variability in the assessment of symptom severity, the

The Role of Patient Preference in the AUC BB beta-blockers

TABLE 1.1 One-Vessel Disease

Appropriate Use Score (1-9)

Proximal LAD or Proximal Left Dominant LCX Involvement Present

TABLE 1.2 Two-Vessel Disease

Appropriate Use Score (19)

Proximal LAD Involvement and No Diabetes Present

Proximal LAD Involvement With Diabetes Present