TRIP

PCI Upgraded in 'Appropriate Use' Updates (CME/CE)

MedPageToday, 2012

and a few other trials caused the writing committee and technical committee to reevaluate high-risk findings in complex coronary disease," Gregory J.
Dehmer, MD, who represented the Society for Cardiovascular Angiography and Interventions (SCAI) on the writing group, told MedPage Today .
In the SYNTAX trial, PCI was compared with surgery in patients with complex coronary artery disease.
"Results indicated that PCI was a viable option in patients with low-burden complex disease," said Dehmer, a professor of medicine at Texas A&M College of Medicine in Temple, Texas.
It's important to realize, Dehmer said, that the classification of "uncertain" merely means that more research and patient information is needed to classify the indication definitively.
In fact, the document points out that "the writing group, technical panel, AUC Task Force, and clinical community do not believe an uncertain rating justifies denial of reimbursement for revascularization."
Another important change to reflect emerging data and also be consistent with guidelines is an update to the cutpoint for fractional flow reserve (FFR) from 0.75 to 0.80.
This change was evident in the indication for one- or two-vessel coronary artery disease (CAD) with borderline stenosis (50% to 60%) in patients without prior bypass surgery who either have had equivocal test results or no noninvasive testing (indication #22 on a table explaining the criteria) .
The appropriateness use criteria were developed with five core variables considered: The clinical presentation, or the stability of the patient The symptom class (very mild or class 4 symptoms at rest) Extent of ischemia on noninvasive testing and the presence or absence of other prognostic factors, such as congestive heart failure, depressed left ventricular function, or diabetes Extent of medical therapy Extent of anatomic disease
Although there are a multitude of other variables that inform medical decision-making, such as age, gender, and comorbidities, "it would be impractical for us to create a classification for the myriad potential patient scenarios," Dehmer said.
Most of the ratings in the document are listed by indication (i.e., ST-segment elevation myocardial infarction [STEMI], non-STEMI, one-vessel CAD involving the proximal left anterior descending artery [LAD]) and they are not intended to distinguish between different methods of revascularization.