Journal of Invasive Cardiology

From Advocate Illinois Masonic Medical Center, Chicago, Illinois.
The author reports no conflicts of interest regarding the content herein.
Address for correspondence: Lloyd W. Klein MD, Advocate Illinois Masonic Medical Center, Professional Office Building Suite #625, 3000 North Halsted Avenue, Chicago, IL 60614. E-mail: lloydklein@comcast.net

“Science is the father of knowledge, but opinion breeds ignorance.” — HIPPOCRATES

Whether it is most appropriate to treat coronary artery disease (CAD) patients with medical therapy alone, or to prescribe medical therapy and also perform revascularization — either by percutaneous coronary intervention (PCI) or bypass surgery (CABG) — depends on a myriad of clinical, angiographic and physiologic factors that vary widely from patient to patient. In some cases the best decision is readily apparent based on objective evidence from clinical trials; but often, the best course to take is more nuanced and dependent on one’s interpretation of that individual’s clinical and angiographic findings, then placed in the context of existing clinical trial data.

Concept of appropriateness. It seems intuitive that if one could create a matrix of a large number of relevant factors and submit each scenario to a panel of thoughtful, impartial practitioners from the various fields of cardiology, that their dispassionate consensus opinion would provide a practical tool for weighing each of those factors to arrive at the principles leading to the right treatment decision. This is the concept behind the development of the ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization.¹

Appropriateness Criteria for Coronary Revascularization.¹ A technical panel consisting of cardiologists, surgeons, and numerous other stakeholders developed a ranked score of 1–9 for each of 180 clinical scenarios, scoring each according to whether revascularization was appropriate, inappropriate or uncertain. These Appropriateness Criteria were not intended to diminish the importance of clinical judgment in evaluating individual patients, nor was it possible to include every possible variable or influential fact which might correctly sway a clinical decision. The reasons for the development of these criteria include an initial attempt at objective measurement of what constitutes quality practice, to provide a framework for evaluating patterns of care and to help reduce the large variation in rates of revascularization that has been observed.