The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR).
A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data, and expert opinion in the field of AS. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and its 2017 focused update paper were used as the primary guiding references in developing these indications. The writing group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent rating panel was asked to score each indication from 1 to 9, with 1–3 categorized as “Rarely Appropriate,” 4–6 as “May Be Appropriate,” and 7–9 as “Appropriate.”
After considering factors such as symptom status, left ventricular (LV) function, surgical risk, and the presence of concomitant coronary or other valve disease, the rating panel determined that either SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for SAVR or TAVR are less clear, including situations in which 1 form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option.
The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.
In an effort to address the rational use of tests and procedures in the delivery of high-quality cardiovascular care, the American College of Cardiology (ACC) and numerous partnering societies have undertaken a process to determine the appropriate use of treatment options for selected patient scenarios. Ever since the first Appropriate Use Criteria (AUC) were developed in 2005 as a response to the overutilization of cardiovascular imaging, numerous other cardiac sub-specialty topics have been explored and translated into appropriate use ratings.
AUC publications reflect an ongoing effort by the ACC to critically and systematically create, review, and categorize clinical situations where tests and procedures are utilized by providers caring for patients with known or suspected cardiovascular diseases. Although not intended to be entirely comprehensive due to the wide diversity of clinical disease, the indications included in this document are meant to identify common patient scenarios encountered by the majority of practitioners. The AUC indications are often chosen based on gaps in Clinical Practice Guidelines and lack of evidence-based data, therefore relying on clinical practice experience and physician judgment to determine the final AUC ratings. The ultimate objective of AUC is to improve patient care and health outcomes in a cost-effective manner, but they are not intended to ignore ambiguity and nuance intrinsic to clinical decision-making. Local parameters, such as the availability or quality of equipment and personnel, may influence the selection of certain treatments or procedures; therefore, AUC should be considered complementary to sound clinical judgment and practice experience.
I am grateful to the writing group for the development of the severe aortic stenosis patient scenarios and overall framework of the document, and to the rating panel, an independent group of experts who thoughtfully scored the patient scenarios resulting in the final AUC ratings. A special thanks to Dr. Gregory Dehmer for serving as an expert moderator at the in-person rating panel meeting. We would also like to thank the AUC Task Force members who provided insight and guidance, and the ACC staff—Leah White and especially Lara Gold—for their skilled support in the creation and championing of this document.
Robert O. Bonow, MD, MACC
Chair, Aortic Stenosis Writing Group