I/we have no real or apparent conflicts of interest to report.

The Alphabet Soup of Appropriate Use Criteria in the Cath Lab Tools for the Trade. By Steven Simms, RN BSN

IVUS + FFR + OCT + AUC = CCL Making Sense of the Alphabet Soup Called Appropriateness

Is using the Naked Eye still good enough?

Overview 21st century CV care in the USA What are Appropriateness of Use Criteria? (AUC) Why and how were the AUC developed? How are the AUC different from Guidelines? Why is the AUC getting so much attention? What is the role of FFR/ IVUS/ OCT in this context?

Revascularization-PCI in the USA in the 21st century Improvement in quality of life with severe Symptoms Improvement in mortality in certain groups Quality of life Quantity of Life Quantity of Life

PCI Regional Variability Seen Across the US 2007 rates per 1,000 Medicare Enrollees

Over the past few years all of our programs had to make major changes to show that the decision made about a lesion was correct. Is it a Committee to review random films? Making FFR, IVUS a must for a lesion that has that looks uncertain with the naked eyes? Who or What do our patients listen to and trust a lot?

50% of stents are not necessary! The Media!!! 50% of stents are not necessary! TV shows like DR. OZ, Doctors all have the publics ear. They will come to you and tell you I heard …….

Ron WInslow and John Carreyrou, Heart Treatment Overused , WSJ, July 6, 2011

What is Appropriate Use Criteria An ACC-led effort to address the rising costs of care The rising costs of medical care are unsustainable Payers – through the Medical Directors’ Institute – have called for guidance in understanding the need for tests An opportunity to insert clinical rationality over uninformed cuts Imaging tests were the initial focus Difficult to create, given that outcomes are downstream New effort on coronary revascularization First Released January 2009 Updated in 2012

ACC Definition of Appropriateness: “Coronary revascularization is appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life) exceed the expected negative consequences of the procedure.”

Goals of the AUC 2009 -17 experts from ACCF, AHA ,SCAI, AATS, STS Met: MDs and researchers and an insurance health officer chose 180 distinct clinical indications. To improve quality of care Filling of the “guideline void” Framework for Physician decision-making Clinician education on practice habits and comparisons to peers To increase cost effectiveness: Addressing the rising+ unsustainable costs of care Payers – through the Medical Directors’ Institute – have called for guidance in understanding the need for tests An opportunity to insert clinical rationality over uninformed cuts

Appropriate Use Criteria Is Updated and Expanded in 2012

What Is the Framework for Appropriateness? Clinical Presentation Severity of Angina Extent of ischemia on noninvasive testing and the presence or absence of other prognostic factors Extent of medical therapy Extent of anatomic disease 3 Classes: Appropriate, Uncertain, and Inappropriate

ACC Cath PCI Registry ACC Documentations asks IF 40-70%, did you IVUS If 40-70% did you FFR, if so what’s the ratio? Add portion about if you did not use the tools needed to treat the lesion that you get dinged by the registries.

Degree of Symptoms + Meds What does AUC look like? Non Invasive testing Degree of Symptoms + Meds Burden of Disease

Demystifying the Rubric Low Risk Intermediate Risk High Risk Inappropriate Uncertain Appropriate

Intravascular Ultrasound (IVUS) Old Faithful? Pre use right size vessel length and Diameter for the Appropriate size stent. Post dilatation for stent to wall adherence New technologies can show plaque burden, calcium, thrombus in colored views.

Hot Potatoe Question ! I have a patient with chest pain, a negative stress test, and an ambiguous / intermediate Left Main on angio. I was told that I should just send for surgery and not worry about IVUS. Should I? So it would be appropriate to do an IVUS run to see what vessel diameter looks like to see if appropriate to go to surgery or treat medically.

Fractional Flow Reserve (FFR)

How FFR Fits in AUC on Intermediate Findings: Changing Uncertainty1 So let’s take a look at how FFR fits into the AUC and in particular with those “Uncertain” cases. (This slide has some animations – the arrows move) Here is the intermediate risk findings chart again. (Click once and the yellow arrow on the left floats down) Remember we look at the symptoms and meds, then we look at disease burden. We see many yellow boxes here. Dr Kern used this slide at a recent talk and shared it with us. He feels that the use of FFR can convert these “Uncertain” scenarios into a more clearly defined status. (Click again a several FFR boxes will pop-up covering the yellow cells) So in his opinion, these are instances when FFR would be helpful. Ask the audience if this makes sense to them.

So we are taking a look at a patient with Class 1-2 1 vessel disease So we are taking a look at a patient with Class 1-2 1 vessel disease. Prior to FFR shows an Uncertanty. After FFR and PCI this is now an appropriate vessel to have treated. So it is beneficial for us to IVUS or FFR to changes those Uncertain vessel to Appropriate or even in appropriate. But now at least we have the documentation to show why or why we did not treat that vessel.

How FFR Fits Into the Diagnostic Cath “Appropriateness Criteria”

Hot Potatoe Question! I have a patient with chest pain, a confirmatory noninvasive test, and a ambiguous / intermediate angio. I was told I can not do an FFR because I have a stress test that supports the symptoms. Can I ?

Angiography FFR IVUS 4.3% reduction in Death & MI1 3.8% reduction

Aside from AUC…. FFR can be invaluable in evaluating borderline lesions in pts with chest pain especially if no stress or discordant non-invasive findings LAD severity frequently underestimated and this can be the deciding factor re: PCI or CABG vs medical therapy. SYNTAX score: risk stratify: CABG vs PCI FAME :FFR to achieve “complete functional revascularization” IVUS to optimize PCI especially in LM, prox LAD, in-stent restenosis, SVG PCI, CTOs, diffuse disease

The End

References Claesson BE, Mehran R, et al, Impact of Intravascular Imaging on Early and Late Clinical Outcome Following PCI with Drug-Eluting Stents. J. Am. Coll. Cardiol. Intv. 2011;4;974-981 De Bruyne B., et al, Fractional Flow Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease, New England Journal of Medicine, August 28, 2012, (10.1056/NEJMoa1205361) Morton J. Kern, MD, Addressing Uncertainty during PCI: Appropriate Lesion Selection with FFR, Presented at Scripps Conference 10/10/12 Patel M., et al, ACCF/SCAI/STS/AATS/ AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update, J. AM. Coll Cardiol. Jan 30, 2012 Patel MR, Bailey SR, et al ACCF/SCAI/AATS/AHA/ASE/ ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: J Am Coll Cardiol Vol. 59, No. 22, 2012 Tonino P, De Bruyne B, et al (2009). Fractional Flow Reserve Versus Angiography for Guiding Percutaneous Coronary Intervention. New England Journal of Medicine. Volume 360, Number 3:213-224. Volcano Therapeutics