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The latest appropriate use criteria (AUC) for coronary revascularization in patients with stable ischemic heart disease cut down on the number of percutaneous coronary interventions (PCIs) deemed "inappropriate," researchers found in analysis of a mandatory population-based registry.

Of the PCIs done in 2014 in the New York State PCI registry, 9.8% were labeled "inappropriate" under the 2012 AUC compared with only 1.8% under the equivalent 2017 AUC terminology of "rarely appropriate."

"All the patients rated as 'inappropriate' in the 2012 AUC who were not rated as 'rarely appropriate' in the 2017 AUC were rated as either 'may be appropriate' or were not rated," researchers led by Edward Hannan, MD, of the State University of New York at Albany, reported in the March 12 issue of .

Notably, the difference between the two criteria was almost entirely accounted for by stable, asymptomatic, one- to two-vessel disease not involving the proximal left anterior descending artery and either no noninvasive testing or low- to intermediate-risk findings.

The researchers suggested these were low-risk patients for whom "the relative benefits of optimal medical therapy with and without PCI are unknown." They called for randomized controlled trials and observational studies to compare strategies for these patients.

"The finding that applying the 2017 AUC to a large PCI registry resulted in <2% of patients' undergoing 'rarely appropriate' PCI is important and surprising given the consistent criticism from non-interventional cardiologists that PCI overuse (or any use!) is an important issue," commented Eric Bates, MD, of University of Michigan in Ann Arbor, in an , suggesting this points to a mismatch between guidelines and the new AUC.

"Indeed, the fact that there are no 'rarely appropriate' PCI designations in patients with proximal left anterior descending coronary artery or 3-vessel disease in the 2017 AUC is the point I would emphasize when attempting to evaluate the new AUC," Bates wrote.

"The benefit associated with PCI is relief of ischemic chest pain and myocardial ischemia, not reduction in death or MI rates. The guidelines clearly state that PCI is indicated for unacceptable angina despite GDMT [guideline-directed medical therapy] or in patients in whom GDMT cannot be implemented because of medication contraindications, adverse effects, or patient preferences," he continued.

However, he posed the question: "How can an asymptomatic patient on or off antianginal medication and with low risk on noninvasive testing be considered a 'sometimes appropriate' PCI patient when clinical trials and clinical practice guidelines, with a few exceptions ... have stated that anatomy alone is not an indication for PCI in SIHD [stable ischemic heart disease]?"

He ultimately recommended clinicians reserve elective PCI and cardiac catheterization exclusively for patients with SIHD with continued unacceptable symptoms or ischemia burden on GDMT, calling this "the current standard of care."

"The good news is that appropriate patients with SIHD can weigh the risks of PCI versus the inconvenience, possible side effects, and cost of taking 1 to 4 antianginal medications daily, knowing that initially choosing either treatment option does not put them at increased risk for death or MI and that PCI can safely be deferred if they wish to try medical therapy first. That is how to use PCI appropriately in SIHD," he emphasized.

"It appears that some 2017 AUC determinations are not concordant with the SIHD PCI guideline recommendations," the editorialist concluded.

The was by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.

Hannan's study included PCI recipients without prior coronary artery bypass grafting (n=9,261). The researchers acknowledged that they could not distinguish between "may be appropriate" and "not rated" cases for some patients due to the incomplete fractional flow reserve data available.