Updated AUC Address Coronary Revascularization in SIHD Patients Updated appropriate use criteria (AUC), developed by the ACC, the Society for Cardiovascular Angiography and Interventions, The Society of Thoracic Surgeons and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, address coronary revascularization in patients with stable ischemic heart disease (SIHD). The new criteria contain several important changes from the original version published in 2012. Among the biggest changes, the new criteria now use the new terms “appropriate care,” “may be appropriate care,” and “rarely appropriate care” to rate the clinical scenarios, bringing them in line with AUC developed after 2013. In response to comments from stakeholders, the composition of the rating panel was also changed slightly to include five cardiac surgeons, five interventional cardiologists, six cardiologists not directly involved with performing revascularization and one outcomes researcher. Other changes include replacing prior recommendations mandating two antianginal drugs for medical therapy with a step-wise use of antianginals – an approach more applicable to real-world treatment patterns, according to Gregory J. Dehmer, MD, MACC, writing group member and co-chair of ACC’s AUC Task Force. The use of the Canadian Cardiovascular Society Classification of angina was also replaced with a simplified pattern that groups patients based on whether they have or don’t have ischemic symptoms. Expanded use of fractional flow reserve for lesion assessment is incorporated into the update AUC as well. Lastly, a new table was added to evaluate revascularization in patients being considered for kidney transplantation or percutaneous valve therapies. In general, the writing group rated revascularization by PCI or CABG surgery as rarely appropriate as a first step in patients with a low burden of coronary disease (e.g., singlevessel disease), low-risk findings on noninvasive testing, and/or no antianginal therapy. However, in patients with two-vessel to three-vessel and left main disease, revascularization by PCI or CABG was rated as may be appropriate care or appropriate care, with CABG consistently rated as appropriate care for intermediate or high disease complexity (SYNTAX =22) even in patients with ischemic symptoms who are not on antianginal therapy. The writing group noted that “CABG surgery was consistently rated as appropriate care and PCI as rarely appropriate care for left main bifurcation disease with intermediate or high disease burden in other vessels.” Repeat CABG surgery was also felt to be rarely appropriate in patients with a functional patent internal mammary artery to the left anterior descending in all but one indication, with both PCI and CABG being rated as either may be appropriate or appropriate in the other indications. “These new AUC are an important advance in the efforts of the partnering societies to improve the quality of cardiovascular care and deliver the right care to the right patients,” said Writing Committee Chair Manesh R. Patel, MD, FACC. “The document provides a framework for how patients and providers can think about revascularization in the stable setting and will help health systems and medical societies judge quality of care.” An important advance in the efforts of the partnering societies to improve the quality of cardiovascular care and deliver the right care to the right patients. The document provides a framework for how patients and providers can think about revascularization in the stable setting and will help health systems and medical societies judge quality of care. Manesh R. Patel, MD, FACC AUC for SIHD are a culmination of a twopart revision of the original AUC for coronary revascularization. The first part, AUC addressing revascularization in patients with acute coronary syndrome, was published in December 2016. The new criteria will be integrated soon into ACC’s CathPCI Registry. First-Ever Guideline Addresses Evaluation, Management of Syncope The ACC, with the American Heart Association and the Heart Rhythm Society, released the first guideline for the evaluation and management of patients with syncope. The guideline, published March 9 in the Journal of the American College of Cardiology, aims to provide “contemporary, accessible, and succinct guidance on the management of adult and pediatric patients with suspected syncope.” Specifically, the guideline includes recommendations on initial evaluation, as well as additional evaluation and diagnosis; management of cardiovascular conditions (i.e., structural, arrhythmic and inheritable conditions); uncommon conditions associated with syncope; and syncope in special populations. Additionally, the guideline addresses quality of life and health care costs of syncope and looks at emerging technologies, evidence gaps and future directions Of note, the guideline recommends that if a patient faints, a physician should perform a detailed history and physical examination during the initial evaluation. Using an electrocardiogram during this time may be useful to determine the cause of fainting. People with serious medical conditions that could be related to their fainting should be evaluated and/or treated at a hospital after the initial assessment. The guideline also explains that certain tests such as routine laboratory testing and routine cardiac imaging may not be useful in evaluating these patients unless the patient has a suspected cardiac issue. Carotid artery or head imaging may not be useful unless there is a specific reason why the patient needs to be evaluated further. Depending on the reason for fainting, treatment options may include implantable cardioverter-defibrillators, beta-blockers or pacemakers. According to the guideline, patients who faint and who also have certain types of heart issues should restrict their exercise, and athletes who experience fainting should have a heart assessment done by an experienced health care provider or specialist before returning to competitive sports. Heart rhythm monitoring can be a good choice for patients with unexplained fainting who may have intermittent heart rhythm issues that cause fainting. “Studies show that in the U.S., about one-third to half the population faints at some point in their lifetime,” said Win-Kuang Shen, MD, FACC, chair of the writing group. “Therefore, having these guidelines is not only good for the clinicians using them – but for everyone. Now that we have these guidelines, physicians and clinicians will be able to make better-informed decisions and this will contribute to improved patient outcomes.” Training Statement Focuses on Competencies for HF and Transplant Specialists A new training statement from the ACC and numerous partnering societies addresses the competencies required of sub-subspecialists in Advanced Heart Failure and Transplant Cardiology (AHFTC). The training statement complements the ACC’s Core Cardiovascular Training Statement (COCATS), and outlines the knowledge, skills and experiences that should result from a 12-month training program in AHFTC and defines the competencies required of these trainees. It also includes detailed recommendations for procedural numbers which trainees, in general, should perform during their fellowship, recognizing that true competency to perform each procedure may exceed or be below this recommendation for any individual trainee. “The document will serve as a foundation upon which the training of cardiologists entering the field of AHFTC can be based, so that patients with advanced heart failure will be optimally treated by skilled and knowledgeable physicians,” said Mariell Jessup, MD, FACC, chair of the writing committee.
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