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

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

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

5. Is using the Naked Eye still good enough?

6. 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?

7. 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

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

9. 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?

10. 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 …….

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

12. 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

13. 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.”

14. Goals of the AUC
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

15. Appropriate Use Criteria Is Updated and Expanded in 2012

16. 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

17. 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.

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

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

20. 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.

22. 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.

23. Fractional Flow Reserve (FFR)

24. 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.

25. 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 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.

26. How FFR Fits Into the Diagnostic Cath “Appropriateness Criteria”

27. 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 ?

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

29. 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

30. The End

31. 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;
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, ( /NEJMoa )
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:
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