title: Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease.
abstract: OBJECTIVE
  To evaluate how a comprehensive evidence-based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons-derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization.
  
  
  BACKGROUND
  Decision-making regarding the use of revascularization for coronary artery disease has come under major scrutiny due to inappropriate overuse of revascularization. There is little data in routine clinical practice evaluating how a structured, multidisciplinary heart team approach may be used in combination with the Appropriate Use Criteria for revascularization.
  
  
  METHODS
  From May 1, 2012 to January 1, 2015, multidisciplinary revascularization heart team meetings were convened to discuss evidence-based management of 301 patients with complex coronary artery disease. Heart team recommendations were adjudicated with the Appropriate Use Criteria for coronary revascularization for each clinical scenario using the Society for Cardiovascular Angiography and Interventions' Quality Improvement Toolkit (SCAI-QIT) Appropriate Use Criteria App.
  
  
  RESULTS
  Concordance of the Heart Team to Appropriate Use Criteria had a 99.3% appropriate primary indication for coronary revascularization. Among patients who underwent percutaneous revascularization, 34.9% had an inappropriate or uncertain indication as recommended by the Heart Team. Patients with uncertain or inappropriate percutaneous coronary interventions had significantly higher SYNTAX score (27.3 ± 6.6; 28.5 ± 5.5; 19.2 ± 6; P < 0.0001) and Society of Thoracic Surgeons-Predicted Risk of Mortality (6.1% ± 4.7%; 8.1% ± 6.3%; 3.7% ± 4.1%; P < 0.0081) compared to appropriate indications, frequently had concomitant forms of advanced comorbidities and frailty in the setting of symptomatic coronary artery disease.
  
  
  CONCLUSIONS
  A formal, multidisciplinary revascularization heart team can provide proper validation for clinical decisions and should be considered in combination with the Appropriate Use Criteria for coronary revascularization to formulate revascularization strategies for individuals in a patient-centered fashion. © 2015 Wiley Periodicals, Inc.
authors.affiliation: Department of Internal Medicine, Division of Cardiology, Riverside Methodist Hospital, Columbus, Ohio.
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Sanchez
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Anthony
authors.initials: A
authors.lastname: Dota
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania.
authors.forename: Vinay
authors.initials: V
authors.lastname: Badhwar
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Dustin
authors.initials: D
authors.lastname: Kliner
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: A J Conrad
authors.initials: AJ
authors.lastname: Smith
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania.
authors.forename: Danny
authors.initials: D
authors.lastname: Chu
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Catalin
authors.initials: C
authors.lastname: Toma
authors.affiliation: Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, Pennsylvania.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Wei
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Oscar C
authors.initials: OC
authors.lastname: Marroquin
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: John
authors.initials: J
authors.lastname: Schindler
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Joon S
authors.initials: JS
authors.lastname: Lee
authors.affiliation: Department of Internal Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. mulukutlasr@upmc.edu.|Department of Internal Medicine, Division of Cardiology, VA Medical Center, Pittsburgh, Pennsylvania. mulukutlasr@upmc.edu.
authors.forename: Suresh R
authors.initials: SR
authors.lastname: Mulukutla
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D019091:Critical Pathways; D003661:Decision Support Techniques; D019317:Evidence-Based Medicine / Q000592:standards; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000401:mortality / Q000592:standards; D010348:Patient Care Team / Q000592:standards; D018579:Patient Selection; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: angiography; appropriate use; comparative effectiveness/patient centered outcomes research; coronary