Welcome to the CAHP PCI Registry June 2022 case scenario where we will discuss appropriate use criteria for acute coronary syndrome. A 56-year-old male presents to the emergency department complaining of chest pain with minimal activity that progressively worsened throughout the week. The patient has a medical history significant for hypertension, former smoker, prediabetes, and Crohn's disease. The vital signs are as follows, heart rate of 56, blood pressure 168 over 92, respirations 18, and O2 saturation 97% on room air. Patient's ECG shows sinus bradycardia with a first-degree AV block. Serial troponins are drawn and are elevated, troponin I of 0.73, then 0.85, and 0.81. The patient is diagnosed with NSTEMI. His chest pain is relieved when sublingual nitroglycerin times two is administered. The following morning, the patient has a diagnostic catheterization that shows a 95% distal RCA lesion, as well as mild luminal irregularities in the LAD and circumflex. PCI with a drug-eluting stent to the distal RCA is performed. In the details of this scenario, our question is, what is the AUC evaluation and score for this PCI procedure? And if you need any help in arriving at an answer, the registry advises having the applicable AUC manuscript at your disposal. For this particular scenario, that would be the 2016 AUC for coronary revascularization of ACS manuscript, available at cath PCI registry, resources, documents. We recommend having the AUC manuscripts available for reference when evaluating performance in the AUC metrics. Again, here's the documentation and question for your review. And the answer is number three, may be appropriate with a score of five. This procedure was assigned to metric 32, proportion of PCI procedures that were evaluated as may be appropriate for PCI patients with ACS by the AUC. We are going to need the dashboard to get a more complete understanding of why. And so by selecting the patient detail for metric 32, we can drill down into some of the particulars of this case. First thing we want to do is identify the indication number and score, shown here as indication number 17, with a score of five. We take that indication and score number and utilizing the 2016 appropriate use criteria for coronary revasc in patients with ACS manuscript. We locate table 1.4, which is specific to ACS procedures for treatment of end-stemi unstable angina, and where indication number 17 is positioned. The basic answers to our question of why this patient is classified as may be appropriate are located here. The patient is stabilized after presentation. The patient has low risk features for clinical events. And the procedure involved revascularization of one or more coronary arteries. On closer examination, the notable difference between indication number 17 may be appropriate and indication number 16 appropriate is the second bullet point. With respect to table 1.4, end-stemi unstable angina, the difference between an indication of 16 with a score of 7, falling into metric 31 appropriate, and an indication of 17 with a score of 5, falling into metric 32 may be appropriate, is whether or not the patient is exhibiting intermediate or high risk features for clinical events or low risk features for clinical events. And it's worth noting that for purposes of the AUC, intermediate and high risk features for clinical events are treated as one in the same. So how are these high risk features differentiated from low risk features by the AUC? Per the AUC companion guide, a patient is considered high risk if they exhibit any one of the characteristics listed in this table. These characteristics cover a broad range, starting with age greater than 75, ECG abnormalities, including ST deviation greater than or equal to 0.5 millimeters, or new left bundle branch block, or second degree AV block type 2, or symptomatic bradyarrhythmia, pre-procedure troponin I greater than 1.0, or T greater than 0.5. And finally, cardiovascular instability types, persistent ischemic symptoms, ventricular arrhythmias, acute heart failure symptoms, or hemodynamic instability. Taking a closer look at our patient, if you recall, his age at the time of the procedure was 56. So the age criteria for high risk is not met. His ECG showed first degree AV block and bradycardia, but that did not meet the ECG abnormality criteria. Additionally, his pre-procedure troponin value did not meet the minimum as listed. And lastly, this patient was not exhibiting any cardiovascular instabilities upon presenting for his procedure, and therefore, this last variable is not met either. Consequently, the absence of any of these conditions position the patient as having low risk features and placing the procedure in indication number 17. The 2016 AUC for coronary revasc in patients with ACS has the following to say about patients that present for PCI with NSTEMI or unstable angina. For patients with NSTEMI or unstable angina and consistent with existing guidelines and the available evidence, revascularization was rated as appropriate care in the setting of cardiogenic shock or in a patient with intermediate or high risk features. For stable patients with low risk features, revascularization was rated as maybe appropriate. Decisions around the timing of revascularization, management of multivessel disease, and concomitant pharmacotherapy should all be on the basis of evidence from the relevant practice guidelines. The position of the AUC is that without evidence of significant ischemia, the benefits of revascularization are not clear. It is recognized that some patients may be viewed as rarely appropriate or maybe appropriate by the AUC that proceed to PCI for good clinical reasons, and therefore, it is not the intent to have 100% of procedures viewed as appropriate or 0% of procedures viewed as rarely appropriate. It is critical to understand that the AUC should be used to assess an overall pattern of clinical care rather than being the final arbiter of specific individual cases. The intent of the AUC is to provide a framework to evaluate overall clinical practice patterns and improve the quality of care. Thank you for viewing the CAF PCI Registry Monthly Case Scenario for June of 2022, the appropriate use criteria for acute coronary syndrome. Thank you for viewing the CAF PCI Registry Monthly Case Scenario for June of 2022, the appropriate use criteria for acute coronary syndrome.

chest pain

56-year-old male

NSTEMI

PCI

AUC evaluation