The following is the summary of “Comparing the Classification of Percutaneous Coronary Interventions Using the 2012 and 2017 Appropriate Use Criteria: Insights From 245,196 Patients in the NCDR CathPCI Registry” published in the January 2023 issue of Heart Journal by Nelson, et al.

In an effort to get doctors to utilizepercutaneous coronary intervention (PCI) more wisely, experts devised appropriate use criteria (AUC) to use as a baseline for comparing facilities. Although the 2012 AUC were revised in 2017 to take into account new data, it is still being determined whether or not the revised advice reclassifies PCI suitability. The National Cardiovascular Data Registry(NCDR) CathPCI database was mined for information on elective PCI procedures performed between March 1, 2018, and June 30, 2021. According to the 2012 AUC, PCI cases were labeled as “appropriate,” “uncertain,” or “inappropriate,” but the 2017 AUC reclassified them as “appropriate,” “may be acceptable,” or “rarely appropriate.” In addition, cases with missing data pieces were labeled as “not mappable.” 

There was a descriptive comparison made between the groups that “remained appropriate” (appropriate in both 2012 and 2017), “became non-appropriate” (appropriate in 2012 but “may be appropriate” or “rarely appropriate” in 2017), and “became appropriate” (appropriate in 2017 but “uncertain” or “inappropriate” in 2012). Cohen’s Kappa was utilized to determine the level of agreement. An estimated 245,196 individuals in need of PCI were treated at 1669 facilities. By the end of the 2012 AUC, 44% were deemed to be within the ‘acceptable’ range. Compared to the 2017 AUC, where 34% were deemed “suitable,” 56% may be “appropriate,” and 4% were deemed “rarely appropriate,” 2018 AUC respondents were 28% unsure and 16% improper. Kappa Was 0.40 (95% CI=0.396, 0.403), which indicates moderate agreement. PCIs that “become non-suitable” in 2017 were more likely to be asymptomatic, less likely to be on anti-anginals, and less likely to have complicated lesions than PCIs that “remained appropriate” under the 2017 AUC. 

In contrast to PCI that “become non-suitable,” PCI that “became appropriate” was associated with a higher prevalence of atypical and non-anginal symptoms and a lower likelihood of positive functional tests. The results of the procedures themselves were uniform across the board. The percentage of unmappable PCI increased from 12.0% in 2012 AUC to 6.6% in 2017 AUC, from 29,429 to 16,077. Only moderate agreement was found between the 2012 and revised 2017 AUC in this recent study of PCI patients in the US. The fact that so many were deemed “maybe okay” or “becoming non-appropriate” despite the updated guidance’s best intentions speaks to the challenges of recording and implementing modern AUC recommendations.

Source: sciencedirect.com/science/article/abs/pii/S0002870322001995