The Medicare Appropriate Use Criteria Program: A Review of Recommendations for Testing in Coronary Artery Disease.

BACKGROUND: Congress established the Appropriate Use Criteria (AUC) Program to reduce unnecessary advanced imaging studies. Organizations that wish to develop AUC can apply to the Centers for Medicare & Medicaid Services (CMS) to qualify as provider-led entities (PLEs) under this program. Variable methods, content, and formatting of PLE-generated AUC could lead to clinician uncertainty about whether an advanced imaging test is appropriate or not. PURPOSE: To review AUC published by CMS-qualified PLEs focused on advanced imaging tests for coronary artery disease (CAD), a "priority clinical area" identified by CMS. DATA SOURCES: Publicly available data from the worldwide web searched on 29 August 2022. STUDY SELECTION: Approved AUC with recommendations related to testing for CAD. DATA EXTRACTION: Manual review of published AUC by all authors. DATA SYNTHESIS: Among the 17 CMS-qualified PLEs, only 7 had published AUC related to CAD. Substantial variation in the methods and formatting of these AUCs was observed. The number of clinical scenarios covered ranged from 6 to 210, and the number of advanced imaging methods covered ranged from 1 to 25. When specifically applied to clinical scenarios, many AUC offered no guidance on appropriateness; those that did conflicted with respect to appropriateness. LIMITATION: Other CMS-identified priority clinical areas were not evaluated. CONCLUSION: CMS-qualified AUC for imaging of CAD are heterogeneous and sometimes discrepant, creating substantial potential for uncertainty among clinicians seeking to provide their patients with appropriate imaging tests. PRIMARY FUNDING SOURCE: No funding was received for this study.

Systematic Review of Literature Citing the ISCHEMIA Trial.

PURPOSE OF REVIEW: Optimal therapy for patients with chronic coronary artery disease (CCD) has long been a topic under investigation and a subject of debate. Seeking to clarify appropriate management, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial compared medical management versus coronary angiography for patients with stable ischemic heart disease. Its reception in the medical community has been met with both acclaim and criticism. In light of such disparate views of this trial, a systematic review of the literature citing the ISCHEMIA trial was performed. RECENT FINDINGS: All articles citing the ISCHEMIA trial on PubMed as of July 21, 2023, were compiled and underwent qualitative analysis. A total of 430 articles were evaluated; 109 (25.3%) did not offer substantial commentary on ISCHEMIA and cite it as background evidence for further study. Of the commentary articles, the majority (224, 52.1%) gave balanced, honest appraisals of the ISCHEMIA trial. A total of 46 (10.7%) strongly praised the trial while another 39 (9.1%) were strongly critical of the results. Almost three-quarters of the literature citing the ISCHEMIA trial was commentary in nature, with roughly equal distribution across the spectrum of praise and criticism. Despite being one of the largest studies on CCD and coronary revascularization ever conducted, the impact of ISCHEMIA on the cardiology community appears to be mixed.

ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease.

The American College of Cardiology (ACC) Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD), formerly referred to as stable ischemic heart disease (SIHD). This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging, stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. As with the prior version of this document, rating of test modalities is provided side-by-side for a given clinical scenario. These ratings are explicitly not considered competitive rankings due to the limited availability of comparative evidence, patient variability, and the range of capabilities available in any given local setting1-4.This version of the AUC for CCD is a focused update of the prior version of the AUC for SIHD4. Key changes beyond the updated ratings based on new evidence include the following: 1. Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document under development. 2. Some clinical scenarios and tables were removed in an effort to simplify the selection of clinical scenarios. Additionally, the flowchart of tables has been reorganized, and all clinical scenario tables can now be reached by answering a limited number of clinical questions about the patient, starting with the patient's symptom status. 3. Several clinical scenarios have been revised to incorporate changes in other documents such as pretest probability assessment, atherosclerotic cardiovascular disease (ASCVD) risk assessment, syncope, and others. ASCVD risk factors that are not accounted for in contemporary risk calculators have been added as modifiers to certain clinical scenarios. The 64 clinical scenarios rated in this document are limited to the detection and risk assessment of CCD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines.5 These clinical scenarios do not specifically address patients having acute chest pain episodes. They may, however, be applicable in the inpatient setting if the patient is not having an acute coronary syndrome and warrants evaluation for CCD.Using standardized methodology, clinical scenarios were developed to describe common patient encounters in clinical practice focused on common applications and anticipated uses of testing for CCD. Where appropriate, the scenarios were developed on the basis of the most current ACC/American Heart Association guidelines. A separate, independent rating panel scored the clinical scenarios in this document on a scale of 1 to 9, following a modified Delphi process consistent with the recently updated AUC development methodology. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented, midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is rarely appropriate.

The New Role of Telehealth in Contemporary Medicine.

PURPOSE OF REVIEW: Understand the current uses for telehealth as well as future directions as it relates to the COVID-19 pandemic and cardiovascular medicine. RECENT FINDINGS: Telehealth interventions in various forms have proven to be efficacious in the management of obesity, hypertension, glycemic control in diabetes, hyperlipidemia, medication adherence, and ICU length of stay and mortality. The use and study of such interventions have been greatly expanded during the pandemic partly due to the expanded coverage by payers. However, heterogenous interventions and a relative lack of cost analyses are barriers to more widespread adoption. Telehealth has proven efficacy for modifying risk factors for cardiovascular disease. To date, this has not been shown to translate to a reduction in hard cardiovascular endpoints such as mortality. With ongoing research and expanded funding, the role of telehealth is likely to evolve as the COVID pandemic continues.

Discrepancy between patient-reported and clinician-documented symptoms for myocardial perfusion imaging: initial findings from a prospective registry.

BACKGROUND: Occasionally, the symptoms reported by patients disagree with those documented in the medical record. We designed the Patient Centered Assessment of Symptoms (PCAS) registry to measure discrepancies between patient-reported and clinician-documented symptoms. OBJECTIVE: Use patient-derived symptoms data to measure discrepancies with clinical documentation. METHODS: The PCAS registry captured data from a prospective cohort of patients undergoing myocardial perfusion imaging (MPI) and includes free response and structured questions to gauge symptoms. Clinician-documented symptoms were extracted from the patients' medical records. The appropriateness of testing was determined twice: once using the patient-reported symptoms and once using the clinician-documented symptoms. RESULTS: A total of 90 subjects were enrolled, among whom diabetes (36.7%), prior coronary disease (28.9%), hypertension (80.0%) and hyperlipidemia (85.6%) were common. Percentage of patient-reported symptoms compared to clinician-documented symptoms and agreement were as follows: chest pain (patient 29.0%, clinician 36.6%, moderate [kappa = 0.54]), chest pressure (patient 18.3%, clinician 10.8%, fair [kappa = 0.27]), dyspnea (patient 41.0%, clinician 36.6%, fair [kappa = 0.28]), onset with exertion (patient 61.7%, clinician 59.6%, slight [kappa = 0.17]), symptoms same as prior coronary artery disease (patient 46.2%, clinician 15.3%, slight [kappa = 0.01]). As a result of these inconsistencies, appropriateness ratings were different for 13.3% (n = 12) subjects. CONCLUSION: In this prospective registry of patients undergoing MPI, we observed substantial disagreements between patient-reported and clinician-documented symptoms. Disagreement resulted in a considerable proportion of MPI appropriateness ratings also being incongruous.

Comparing two methods for determining appropriateness of myocardial perfusion imaging: Criteria from the American College of Cardiology Foundation and the American College of Radiology.

BACKGROUND: Appropriate use criteria (AUC) developed by the American College of Cardiology Foundation and the appropriateness criteria (AC) developed by the American College of Radiology (ACR) are two existing methods of rating appropriateness of myocardial perfusion imaging (MPI). One study found poor agreement of ratings between the two methods. However, using the most contemporary AUC from 2013, it is unknown if poor agreement still exists. METHODS: Retrospective cohort investigation comparing patients undergoing nuclear MPI between June 2011 and September 2014. The appropriateness category was determined based on the 2013 AUC (Appropriate, may be appropriate, rarely appropriate) and the 2010 ACR AC (usually appropriate, maybe appropriate, usually not appropriate). The primary outcome was the degree of the agreement between the two methods. RESULTS: The kappa coefficient between ACR AC and AUC was 0.32, P < 0.0001, indicating poor agreement; 40 (8%) patients were classified by the AUC but could not be classified by the ACR AC. CONCLUSION: The two methods for rating the appropriateness of MPI have poor agreement; a potential for disagreement between providers and payers if only one method is used.

Use of Cardiac Troponin Testing in the Outpatient Setting.

OBJECTIVES: Cardiac troponin (cTn) measurement is useful for diagnosing myocardial infarction (MI), particularly in the inpatient setting. A growing body of literature suggests that cTn may be useful for evaluating chronic conditions in the outpatient environment; however, little is known regarding cTn ordering patterns in this setting. We sought to investigate patterns of care and outcomes for patients evaluated with cTn in the outpatient setting. We hypothesized that a majority of outpatient cTn orders would be for the purpose of diagnosing possible MI. METHODS: We analyzed 228 patients who had outpatient orders for standard-sensitivity troponin T assays placed at our institution between January 1, 2013 and December 18, 2015. Data were divided into two cohorts based on the intended utility of cTn measurement: orders placed to evaluate for possible MI versus orders placed for some other purpose. RESULTS: Of the 228 patients, 161 were evaluated for possible MI and 67 for other reasons. Risk factors (hypertension P = 0.32, diabetes mellitus P = 0.41, coronary disease P = 0.38, heart failure P = 0.098, and chronic kidney disease P = 0.70) were similar between the cohorts. In the suspected MI cohort, an electrocardiogram was obtained in only 77% of patients, and only 13.1% were sent to the emergency department (ED) for further evaluation. Within the suspected MI cohort, 10.5% (n = 17) had elevated cTn and the majority of these patients (n = 10) were not sent to the ED. CONCLUSIONS: The majority of outpatient cTn orders were intended to evaluate for MI, although electrocardiograms were frequently not ordered and few patients were sent for further ED evaluation. Providers should be encouraged to use cTn testing in a manner that minimizes the potential risk to patients with possible MI.

The elusive role of myocardial perfusion imaging in stable ischemic heart disease: Is ISCHEMIA the answer?

The assessment of ischemia through myocardial perfusion imaging (MPI) is widely accepted as an index step in the diagnostic evaluation of stable ischemic heart disease (SIHD). Numerous observational studies have characterized the prognostic significance of ischemia extent and severity. However, the role of ischemia in directing downstream SIHD care including coronary revascularization has remained elusive as reductions in ischemic burden have not translated to improved clinical outcomes in randomized trials. Importantly, selection bias leading to the inclusion of many low risk patients with minimal ischemia have narrowed the generalizability of prior studies along with other limitations. Accordingly, an ongoing randomized controlled trial entitled ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) will compare an invasive coronary revascularization strategy vs a conservative medical therapy approach among stable patients with moderate to severe ischemia. The results of ISCHEMIA may have a substantial impact on the management of SIHD and better define the role of MPI in current SIHD pathways of care.

A systematic review of mobility/immobility in thromboembolism risk assessment models for hospitalized patients.

Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.

Perceptions of patients and providers on myocardial perfusion imaging for asymptomatic patients, choosing wisely, and professional liability.

BACKGROUND: Despite efforts by professional societies to reduce low value care, many reports indicate that unnecessary tests, such as nuclear myocardial perfusion imaging (MPI), are commonly used in contemporary practice. The degree to which lack of awareness and professional liability concerns drive these behaviors warrants further study. We sought to investigate patient and provider perceptions about MPI in asymptomatic patients, the Choosing Wisely (CW) campaign, and professional liability concerns. METHODS: We administered an anonymous, paper-based survey with both discrete and open-response queries to subjects in multiple outpatient settings at our facilities. The survey was completed by 456 respondents including 342 patients and 114 physicians and advanced practice providers between May and August 2014. Our outcome was to compare patient and provider perceptions about MPI in asymptomatic patients and related factors. RESULTS: Patients were more likely than providers to report that MPI was justified for asymptomatic patients (e.g. asymptomatic with family history of heart disease 75% versus 9.2%, p < 0.0001). In free responses to the question "What would be an inappropriate reason for MPI?" many responses echoed the goals of CW (for example, "If you don't have symptoms", "If the test is too risky", "For screening or in asymptomatic patients"). A minority of providers were aware of CW while even fewer patients were aware (37.2% versus 2.7%, p < 0.0001). Over one third of providers (38.9%) admitted to ordering MPI out of concern for professional liability including 48.3% of VA affiliated providers. CONCLUSIONS: While some patients and providers are aware of the low value of MPI in patients without symptoms, others are enthusiastic to use it for a variety of scenarios. Concerns about professional liability likely contribute, even in the VA setting. Awareness of the Choosing Wisely campaign is low in both groups.

Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis.

BACKGROUND: The relationship between inappropriate MPI and cardiovascular outcomes is poorly understood. We sought to systematically review the literature on appropriate use criteria (AUC) for MPI, including temporal trend of inappropriate testing and resulting cardiovascular outcomes. METHODS: We searched the MEDLINE database for studies related to AUC and MPI. The co-primary outcomes were abnormal test results and the presence of cardiac ischemia. Random effects odds ratios (OR) were constructed using DerSimonian-Laird method. RESULTS: A total of 22 studies with 23,443 patients were included. The prevalence of inappropriate testing was 14.8% [95% confidence interval (CI) 11.6%-18.7%]. Inappropriate MPI studies were less likely to be abnormal (OR 0.41 95% CI 0.35-0.49, P < .0001) and to demonstrate ischemia (OR 0.40, 95% CI 0.24-0.67, P < .0001) compared to appropriate testing. No difference in the rate of inappropriate tests was detected based on the midpoint of the enrollment year (P = .54). The pattern of ordering inappropriate studies was not different between cardiology and non-cardiology providers (OR 0.74, 95% CI 0.51-1.06, P = .10). CONCLUSION: Inappropriate MPI studies are less likely to yield abnormal results or demonstrate myocardial ischemia. The rate of inappropriate MPI has not decreased over time.

Determining the Role of Thiamine Deficiency in Systolic Heart Failure: A Meta-Analysis and Systematic Review.

BACKGROUND: Approximately 5.7 million Americans carry the diagnosis of systolic heart failure (HF), a major health care burden. HF is a known manifestation of thiamine deficiency (TD). HF patients are at unique risk for developing TD, which may contribute to further altered cardiac function and symptoms. METHODS AND RESULTS: We performed a systematic review of the literature and a meta-analysis to evaluate the prevalence of TD in HF patients, risk factors for and mechanisms of development of TD in HF population, and outcomes of thiamine supplementation in HF patients. We found 54 studies that met our selection criteria, 9 of which were suitable for meta-analysis. TD is more common in HF patients than control subjects (odds ratio 2.53, 95% confidence interval 1.65-3.87). Diuretic use, changes in dietary habits, and altered thiamine absorption and metabolism were identified as possible mechanisms of TD in HF patients. Small observational studies and randomized control trials suggest that thiamine supplementation in HF population may improve ejection fraction and reduce symptoms. CONCLUSIONS: Thiamine deficiency is more prevalent in the HF population, and its supplementation may be beneficial. The therapeutic role of thiamine in HF warrants further study.

Clinical utility of inappropriate positron emission tomography myocardial perfusion imaging: test results and cardiovascular events.

BACKGROUND: Appropriate use criteria for myocardial perfusion imaging (MPI) were developed to categorize scenarios where MPI might be beneficial (appropriate) or not (inappropriate). Few investigations have evaluated the clinical utility of this categorization strategy, particularly with positron emission tomography (PET) MPI. METHODS AND RESULTS: We conducted this retrospective cohort investigation in a Veterans Affairs (VA) medical center, on predominantly male subjects who underwent PET-MPI. We correlated appropriateness to test result and cardiovascular events. Of 521 subjects, 414 (79.5%) were appropriate, 54 (10.4%) were uncertain, and 53 (10.2%) were inappropriate. PET-MPI was abnormal more often when appropriate or uncertain (28% and 34.6%, respectively, vs 7.7% for inappropriate, P = .003). Among abnormal inappropriate tests, none detected occult ischemia. By Cox regression, summed difference score ≥5 (HR 5.06, 95% CI 2.72-9.44) and an abnormal test result (HR 4.48, 95% CI 2.19-9.14) were associated with higher likelihood of catheterization. Log-rank analysis demonstrated similar likelihood of catheterization when comparing abnormal vs normal test result (P < .0001) and between appropriate, uncertain, and inappropriate tests (P = .024). CONCLUSIONS: Inappropriate PET-MPI was rarely abnormal, associated with low catheterization rates, and failed to detect occult ischemia for any subjects. The clinical utility of inappropriate PET-MPI is negligible.

Angina treatments and prevention of cardiac events: an appraisal of the evidence.

Angina pectoris is the symptomatic manifestation of transient myocardial ischaemia. At the most fundamental level, angina arises when myocardial oxygen demand exceeds the ability of the coronary circulation to provide adequate oxygen delivery to maintain normal myocardial metabolic function. In vivo, the balance of oxygen demand and delivery is a complex physiological process that can be altered by a variety of interventions. Lifestyle modification is a cornerstone of cardiovascular disease management, with or without angina. Additional pharmaceutical and physical interventions are usually applied to patients with angina. Mechanisms of action for these interventions include heart rate modulation, vascular smooth muscle relaxation, metabolic manipulation, revascularization, and others. A number of these interventions have overlapping mechanisms that target angina. Additionally, some interventions may directly or indirectly prevent or delay adverse outcomes such as myocardial infarction or death. This review summarizes current evidence for many applied ischaemia treatments documented to modify angina and comments on available evidence relating to improvement in cardiovascular outcomes.