title: Validation of the appropriate use criteria for percutaneous coronary intervention in patients with stable coronary artery disease (from the COURAGE trial).
abstract: Establishing the validity of appropriate use criteria (AUC) for percutaneous coronary intervention (PCI) in the setting of stable ischemic heart disease can support their adoption for quality improvement. We conducted a post hoc analysis of 2,287 Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial patients with stable ischemic heart disease randomized to PCI with optimal medical therapy (OMT) or OMT alone. Within appropriateness categories, we compared rates of death, myocardial infarction, revascularization subsequent to initial therapy, and angina-specific health status as determined by the Seattle Angina Questionnaire in patients randomized to PCI + OMT to those randomized to OMT alone. A total of 1,987 patients (87.9%) were mapped to the 2012 publication of the AUC, with 1,334 (67.1%) classified as appropriate, 551 (27.7%) uncertain, and 102 (5.1%) as inappropriate. There were no significant differences between PCI and OMT alone in the rate of mortality and myocardial infarction by appropriateness classification. Rates of revascularization were significantly lower in patients initially receiving PCI + OMT who were classified as appropriate (hazard ratio 0.65; 95% confidence interval 0.53 to 0.80; p <0.001) or uncertain (hazard ratio 0.49; 95% confidence interval 0.32 to 0.76; p = 0.001). Furthermore, among patients classified as appropriate by the AUC, Seattle Angina Questionnaire scores at 1 month were better in the PCI-treated group compared with the medical therapy group (80 ± 23 vs 75 ± 24 for angina frequency, 73 ± 24 vs 68 ± 24 for physical limitations, and 68 ± 23 vs 60 ± 24 for quality of life; all p <0.01), with differences generally persisting through 12 months. In contrast, health status scores were similar throughout the first year of follow-up in PCI + OMT patients compared with OMT alone in patients classified as uncertain or inappropriate. In conclusion, these findings support the validity of the AUC in efforts to improve health care quality through optimal use of PCI.
authors.affiliation: Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver, Colorado; Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora, Colorado. Electronic address: smbradle@gmail.com.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Bradley
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Missouri; Department of Medicine, University of Missouri-Kansas City, Missouri.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
authors.affiliation: Department of Medicine, Clinical Epidemiology Research Center, VA Connecticut Healthcare Center, West Haven, Connecticut.
authors.forename: Pamela M
authors.initials: PM
authors.lastname: Hartigan
authors.affiliation: Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan.
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.affiliation: Department of Medicine, Christiana Care Health System, Newark, Delaware.
authors.forename: William S
authors.initials: WS
authors.lastname: Weintraub
authors.affiliation: Division of Cardiology, Department of Medicine, VA New York Harbor Health Care System, New York, New York; Department of Medicine, New York University School of Medicine, New York, New York.
authors.forename: Steven P
authors.initials: SP
authors.lastname: Sedlis
authors.affiliation: Department of Medicine, Hartford Hospital, Hartford, Connecticut.
authors.forename: Marcin
authors.initials: M
authors.lastname: Dada
authors.affiliation: Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: David J
authors.initials: DJ
authors.lastname: Maron
authors.affiliation: Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada.
authors.forename: William J
authors.initials: WJ
authors.lastname: Kostuk
authors.affiliation: Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Berman
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Koon K
authors.initials: KK
authors.lastname: Teo
authors.affiliation: Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: G B John
authors.initials: GB
authors.lastname: Mancini
authors.affiliation: Department of Medicine, Western New York VA Healthcare Network, Buffalo, New York; Buffalo General Hospital, SUNY, Buffalo, New York.
authors.forename: William E
authors.initials: WE
authors.lastname: Boden
authors.affiliation: Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Missouri; Department of Medicine, University of Missouri-Kansas City, Missouri.
authors.forename: John A
authors.initials: JA
authors.lastname: Spertus
mesh_terms: D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000601:surgery*; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D011788:Quality of Life; D015203:Reproducibility of Results; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome