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AUC Definitions

 

Appropriate

 

Inappropriate

 

Uncertain

Clinical Judgement

Appropriateness criteria are designed to examine the use of diagnostic and therapeutic procedures to support efficient use of medical resources during the pursuit of quality medical care. The primary objective of the appropriate use criteria (AUC) for coronary revascularization is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research. The 2012 AUC represent a practical standard upon which to assess and better understand variability in the use of cardiovascular procedures. Appropriate use criteria are intended to assist patients and clinicians, but are not intended to diminish the acknowledged difficulty or uncertainty of clinical decision making and cannot act as substitutes for sound clinical judgment and practice experience.

Section 3 - Details On Ischemic Symptoms

Canadian Cardiovascular Society Angina Classificatin System

CCS I - Ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.

CCS II - Slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal condition.

CCS III - Marked limitations of ordinary physical activity. Angina occurs on walking one or two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace.

CCS IV - Inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.

Section 4 - Details On Non-invasive Test Results

Non-invasive Risk Stratification

Low-risk stress findings (associated with a cardiac mortality of less that 1% per year):
1) Low-risk treadmill score (score ≥5)
2) Normal or small myocardial perfusion defect at rest or with stress*
3) Normal stress echocardiographic wall motion or no change of limited resting wall motion abnormalities during stress*

* Although the published data are limited, patients with these findings will probably not be at low risk in the presence of either a high-risk treadmill score or severe resting left ventricular dysfunction (LVEF <35%)

Intermediate-risk stress findings (associated with a 1% to 3% per year cardiac mortality):
1) Mild/moderate resting left ventricular dysfunction (LVEF = 35% to 49%)
2) Intermediate-risk treadmill score (-11 < score <5)
3) Stress-induced moderate perfusion defect without LV dilation or increased lung intake (thallium-201)
4) Limited stress echocardiographic ischemia with a wall motion abnormality only at higher doses of dobutamine involving less than or equal to two segments
High-risk stress findings (associated with a greater than 3% per year cardiac mortality):
1) Severe resting left ventricular dysfunction (LVEF <35%)
2) High-risk treadmill score (score ≤ -11)
3) Severe exercise left ventricular dysfunction (exercise LVEF <35%)
4) Stress-induced large perfusion defect (particularly if anterior)
5) Stress-induced multiple perfusion defects of moderate size
6) Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201)
7) Stress-induced moderate perfusion defect with LV dilation or increased lung uptake (thallium-201)
8) Echocardiographic wall motion abnormality (involving greater than two segments) developing at low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)
9) Stress echocardiographic evidence of extensive ischemia

What are Indications?

The term indication is used interchangeably with clinical scenario in the document for brevity and does not imply that a procedure should necessarily be performed. Some patients seen in clinical practice are not represented in these appropriate use criteria or have additional extenuating features that would alter the appropriateness of treatment as compared with the clinical scenarios presented.