Definitions

From the 2012 Diagnostic Catheterization AUC

An appropriate diagnostic cardiac catheterization (left heart, right heart, ventriculography, and/or coronary angiography) is one in which the expected incremental information combined with clinical judgment exceeds the negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.

Median Score 7 to 9:

Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).

Median Score 4 to 6

Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.

Median Score 1 to 3

Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).

Additional Notes

Clinical Classification of Chest Pain:

  • Typical Angina (Definite): defined as 1) substernal chest pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin (12).
  • Atypical Angina (Probable): chest pain or discomfort that lacks 1 of the characteristics of definite or typical angina.
  • Nonanginal Chest Pain: chest pain or discomfort that meets 1 or none of the typical angina characteristics.

Grading of Angina Pectoris by the Canadian Cardiovascular Society Classification System:

Class 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.

Class II: slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and in normal condition.

Class III: marked limitations of ordinary physical activity. Angina occurs on walking 1 or 2 blocks on the level and climbing 1 flight of stairs in normal conditions and at a normal pace.

Class IV: inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.

Pretest Probability of Coronary Artery Disease: Symptomatic (Ischemic Equivalent) Patients:

  • Very low pretest probability: <5% pretest probability of CAD
  • Low pretest probability: between 5% and 10% pretest probability of CAD
  • Intermediate pretest probability: between 10% and 90% pretest probability of CAD
  • High pretest probability: >90% pretest probability of CAD

Global CAD Risk:

  • Low global CAD risk: Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk <6%.
  • Intermediate global CAD risk: Defined by the age-specific risk level that is average. In general, moderate risk will correlate with a 10-year absolute CAD risk range of 10% to 20. Among women and younger men, an expanded intermediate risk range of 6% to 20% may be appropriate.
  • High global CAD risk: Defined by the age-specific risk level that is above average. In general, high risk will correlate with a 10-year absolute CAD risk of >20%. CAD equivalents (e.g., diabetes mellitus, peripheral arterial disease) can also define high risk.

Duke Treadmill Score:

The equation for calculating the Duke treadmill score (DTS) is DTS = exercise time in minutes – (5 X ST-segment deviation) – (4 X exercise angina), with 0 = none, 1 = nonlimiting, and 2 = exercise-limiting. The score typically ranges from –25 to +15. These values correspond to low-risk (with a score of ≥+5), moderate-risk (with scores ranging from –10 to +4), and high-risk (with a score of ≤–11) categories.

From the 2016 ACS and 2017 SIHD Coronary Revascularization AUC

A coronary revascularization is appropriate care when the potential benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life), exceed the potential negative consequences of the treatment strategy.

Median Score 7 to 9: Appropriate Care

An appropriate option for management of patients in this population, as the benefits generally outweigh the risks; an effective option for individual care plans, although not always necessary depending on physician judgment and patient-specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication).

Median Score 4 to 6: May Be Appropriate Care

At times an appropriate option for management of patients in this population due to variable evidence or agreement regarding the benefit to risk ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient on the basis of additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).

Median Score 1 to 3: Rarely Appropriate Care

Rarely an appropriate option for management of patients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).

Table B, Noninvasive Risk Stratification

High risk (>3% annual death or MI)

  1. Severe resting LV dysfunction (LVEF <35%) not readily explained by noncoronary causes
  2. Resting perfusion abnormalities ≥10% of the myocardium in patients without prior history or evidence of MI
  3. Stress ECG findings including ≥2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF
  4. Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)
  5. Stress-induced perfusion abnormalities encumbering ≥10% myocardium or stress segmental scores indicating multiple vascular territories with abnormalities
  6. Stress-induced LV dilation
  7. Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)
  8. Wall motion abnormality developing at low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)
  9. CAC score >400 Agatston units
  10. Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA

Intermediate risk (1% to 3% annual death or MI)

  1. Mild/moderate resting LV dysfunction (LVEF 35% to 49%) not readily explained by noncoronary causes
  2. Resting perfusion abnormalities in 5% to 9.9% of the myocardium in patients without a history or prior evidence of MI
  3. ≥1 mm of ST-segment depression occurring with exertional symptoms
  4. Stress-induced perfusion abnormalities encumbering 5% to 9.9% of the myocardium or stress segmental scores (in multiple segments) indicating 1 vascular territory with abnormalities but without LV dilation
  5. Small wall motion abnormality involving 1 to 2 segments and only 1 coronary bed
  6. CAC score 100 to 399 Agatston units
  7. One vessel CAD with ≥70% stenosis or moderate CAD stenosis (50% to 69% stenosis) in ≥2 arteries on CCTA

Low risk (<1% annual death or MI)

  1. Low-risk treadmill score (score ≥5) or no new ST segment changes or exercise-induced chest pain symptoms; when achieving maximal levels of exercise
  2. Normal or small myocardial perfusion defect at rest or with stress encumbering <5% of the myocardium
  3. Normal stress or no change of limited resting wall motion abnormalities during stress
  4. CAC score <100 Agaston units
  5. No coronary stenosis >50% on CCTA