New criteria provide guidance about when to use cardiac catheterization to look for heart problems

May 9, 2012

Cardiac catheterization – an invasive diagnostic procedure that allows doctors to see the vessels and arteries leading to the heart and its chambers – is performed thousands of times in the United States each year and, in some cases, can be the best method to diagnose heart problems. Still, the procedure is costly and may pose risks to certain patients, so determining when the benefits of performing the procedure outweigh the risks is essential. A new report issued today by the American College of Cardiology Foundation (ACCF) and the Society for Cardiovascular Angiography and Interventions (SCAI) in collaboration with a dozen other professional societies provides detailed criteria to help clinicians determine when cardiac catheterization is a reasonable option for the evaluation of patients for heart disease.

"Invasive coronary catheterization is a cornerstone for how we diagnose and care for people with heart disease," said Manesh Patel, MD, the John Bush Simpson Assistant Professor of Cardiology at Duke University and co-chair of the writing group. "We want to encourage the appropriate and judicious use of all of our techniques and procedures. With this document, we aim to help all clinicians – not just cardiologists – determine when it would be reasonable to perform diagnostic ."

The panel identified 166 possible clinical scenarios when referral for diagnostic catheterization might be considered – drawn from the medical literature and anticipated clinical applications – and then assessed the appropriateness for each indication. Altogether, the group determined cardiac catheterization to be "appropriate" in about half of the clinical situations evaluated. Nearly 30 percent of the scenarios were rated as "uncertain," where the procedure may be considered reasonable. The authors stress an uncertain designation should not be used as grounds for denial of reimbursement. Notably, cardiac catheterization was deemed not reasonable or "inappropriate" for 25 percent of the indications rated. Dr. Patel adds these are cases for which the procedure is not needed most of the time, but it is expected that a small percentage of the cases may be justified based on extenuating clinical circumstances.

"When the procedure and the incremental information it provides outweighs the risk, it allows us to provide differential care that can help improve a patient's symptoms, health status and long-term clinical outcomes," said Dr. Patel. "In our ongoing effort to provide efficient, quality cardiovascular care, we hope these criteria will support real-time clinical decisions."

While the document primarily focuses on the standard use of catheterization to detect blockages in the arteries that are indicative of coronary artery disease, the writing group also considered its application as part of an arrhythmia work up, in pre-operative testing and to evaluate patients with possible valve disease, pulmonary hypertension or issues with the heart muscles' squeezing capacity. Although experts want to guard against overuse of cardiac catheterization and spare patients unnecessary procedures, there is also concern about underuse of the test, especially in patients who need more timely diagnosis and for whom a cardiac stress test, for example, might delay a correct diagnosis and add unnecessary costs. In general, the technical panel advises that cardiac catheterization is appropriate in patients:

  • Without prior stress testing but who report symptoms and have a high pretest probability, or high likelihood of disease in the physician's judgment
  • With definite or suspected acute coronary syndrome
  • With typical symptoms and intermediate- or high-risk findings on prior diagnostic testing
The panel noted certain situations in which individuals should not be referred directly to cardiac catheterization. Among others, these include diagnostic workups for:
  • Asymptomatic patients at low risk for CAD or without significant symptoms suggestive of heart disease
  • As part of a preoperative work up for non-cardiac surgery in patients with good functional or exercise capacity and/or
  • Those undergoing low-risk surgeries (if a patient has significant risk factors or is undergoing transplantation or heart valve surgery, diagnostic catheterization is warranted)
Dr. Patel says because there are many nuances in caring for patients with heart disease, clinical judgment should play a role for individual patients and there might be other valid reasons to do a catheterization. The writing group and technical panel favor the collaborative interaction between patients, referring clinicians and cardiologists in determining the need for these invasive procedures. As always, careful assessment of patients' risk and presenting symptoms, as well as results of any stress and other noninvasive tests, should factor into decisions to refer to the cath lab.

This document will be translated into order sheets and decision support tools as part of both ACCF's and SCAI's ongoing commitment to improving cardiac care. In addition, the writing group intended that these indications would be linked with the coronary revascularization AUC to increase the right patients undergoing appropriate invasive catheterization procedures before discussions and considerations around revascularization.

The appropriate use criteria were developed in collaboration with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance and the Society of Thoracic Surgeons.

Explore further: Some hospitals better than others in selecting patients to undergo cardiac catheterization

More information: Flow diagrams and a referral sheet for diagnostic catheterization are included with the report. Full text of the report will be published in the May 29, 2012, issue of the Journal of the American College of Cardiology and on the ACC web site (www.cardiosource.org ). It will also be co-published in Catheterization and Cardiovascular Interventions and the Journal of Thoracic and Cardiovascular Surgery.

Related Stories

Some hospitals better than others in selecting patients to undergo cardiac catheterization

August 9, 2011
(Medical Xpress) -- Hospitals vary markedly when it comes to the rate at which diagnostic coronary angiography or catheterization – an invasive procedure that allows doctors to see the vessels and arteries leading to ...

New appropriate use criteria reflect latest scientific data on restoring blood flow to heart

January 30, 2012
Updated appropriate use criteria released today offer detailed guidance on when to use an invasive procedure to improve blood flow to the heart and how to choose the best procedure for each patient. The clinical scenarios, ...

ACCF, SCAI publish new standards defining best practices for modern cardiac cath labs

May 8, 2012
Modern cardiac catheterization laboratories bear scant resemblance to the cath labs of a decade ago. An updated consensus statement released today offers physicians guidance on how to excel in this new diagnostic and therapeutic ...

Recommended for you

Newborns with trisomy 13 or 18 benefit from heart surgery, study finds

October 18, 2017
Heart surgery significantly decreases in-hospital mortality among infants with either of two genetic disorders that cause severe physical and intellectual disabilities, according to a new study by a researcher at the Stanford ...

High blood pressure linked to common heart valve disorder

October 17, 2017
For the first time, a strong link has been established between high blood pressure and the most common heart valve disorder in high-income countries, by new research from The George Institute for Global Health at the University ...

Saving hearts after heart attacks: Overexpression of a gene enhances repair of dead muscle

October 17, 2017
University of Alabama at Birmingham biomedical engineers report a significant advance in efforts to repair a damaged heart after a heart attack, using grafted heart-muscle cells to create a repair patch. The key was overexpressing ...

Blood cancer gene could be key to preventing heart failure

October 16, 2017
A new study, published today in Circulation, shows that the gene Runx1 increases in damaged heart muscle after a heart attack. An international collaboration led by researchers from the University of Glasgow, found that mice ...

Mitochondrial DNA could predict risk for sudden cardiac death, heart disease

October 11, 2017
Johns Hopkins researchers report that the level, or "copy number," of mitochondrial DNA—genetic information stored not in a cell's nucleus but in the body's energy-creating mitochondria—is a novel and distinct biomarker ...

Tai chi holds promise as cardiac rehab exercise

October 11, 2017
The slow and gentle movements of Tai Chi hold promise as an alternative exercise option for patients who decline traditional cardiac rehabilitation, according to preliminary research in Journal of the American Heart Association, ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.