Michael M. Mohareb, MD; Feng Qiu, MSc; Warren J. Cantor, MD; Kori J. Kingsbury, MSN, MPA; Dennis T. Ko, MD, MSc; Harindra C. Wijeysundera, MD, PhD
Note: Dr. Wijeysundera had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors acknowledge that the clinical registry data used in this publication are from the CCN of Ontario and its member hospitals. The CCN of Ontario serves as an advisory body to the MOHLTC and is dedicated to improving the quality, efficiency, access, and equity of adult cardiovascular services in Ontario.
Financial Support: By the ICES, which is funded by an annual grant from the Ontario MOHLTC. The funding agencies were the Canadian Institutes of Health Research, the Schulich Heart Centre, and the Sunnybrook Research Institute. Dr. Wijeysundera was supported by a Distinguished Clinician Scientist Award from the Heart and Stroke Foundation of Canada. Dr. Ko was supported by a Phase 2 Clinician Scientist Award from the Ontario Provincial Office of the Heart and Stroke Foundation.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-1889.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Wijeysundera (e-mail, email@example.com). Data set: Not available.
Requests for Single Reprints: Harindra C. Wijeysundera, MD, PhD, Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, Ontario M4N 3M5, Canada.
Current Author Addresses: Drs. Mohareb and Wijeysundera: Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Suite A202, Toronto, Ontario M4N 3M5, Canada.
Mr. Qiu and Dr. Ko: Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
Dr. Cantor: Southlake Regional Health Centre, Medical Arts Building, 681 Davis Drive, Suite 602, Newmarket, Ontario L3Y 2P6, Canada.
Ms. Kingsbury: Cardiac Care Network of Ontario, 4100 Yonge Street, Suite 502, Toronto, Ontario M2P 2B5, Canada.
Author Contributions: Conception and design: M.M. Mohareb, K.J. Kingsbury, D.T. Ko, H.C. Wijeysundera.
Analysis and interpretation of the data: M.M. Mohareb, F. Qiu, D.T. Ko, H.C. Wijeysundera.
Drafting of the article: M.M. Mohareb, H.C. Wijeysundera.
Critical revision of the article for important intellectual content: W.J. Cantor, D.T. Ko, H.C. Wijeysundera.
Final approval of the article: M.M. Mohareb, W.J. Cantor, D.T. Ko, H.C. Wijeysundera.
Provision of study materials or patients: K.J. Kingsbury.
Obtaining of funding: K.J. Kingsbury, H.C. Wijeysundera.
Administrative, technical, or logistic support: K.J. Kingsbury.
Mohareb MM, Qiu F, Cantor WJ, Kingsbury KJ, Ko DT, Wijeysundera HC. Validation of the Appropriate Use Criteria for Coronary Angiography: A Cohort Study. Ann Intern Med. 2015;162:549-556. doi: 10.7326/M14-1889
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Published: Ann Intern Med. 2015;162(8):549-556.
The use of invasive coronary angiography in stable ischemic heart disease (IHD) varies widely.
To validate the 2012 appropriate use criteria for diagnostic catheterization by examining the relationship between the appropriateness of cardiac catheterization in patients with suspected stable IHD and the proportion of patients with obstructive coronary artery disease (CAD) and subsequent revascularization.
Population-based, observational, multicenter cohort study.
The Cardiac Care Network, a registry of all patients having elective angiography at 18 hospitals in Ontario, Canada, between 1 October 2008 and 30 September 2011.
Persons without prior coronary revascularization or myocardial infarction who had angiography for suspected stable CAD.
Appropriateness scores were ascertained by using data collected at the time of the index angiography and were categorized as appropriate, inappropriate, or uncertain.
Among the final cohort of 48 336 patients, 58.2% of angiographic studies were classified as appropriate, 10.8% were classified as inappropriate, and 31.0% were classified as uncertain. Overall, 45.5% of patients had obstructive CAD. In patients with appropriate indications for angiography, 52.9% had obstructive CAD, with 40.0% undergoing revascularization. In those with inappropriate indications, 30.9% had obstructive CAD and 18.9% underwent revascularization; in those with uncertain indications, 36.7% had obstructive CAD and 25.9% had revascularization. Although more patients with appropriate indications had obstructive CAD and underwent revascularization (P < 0.001), a substantial proportion of those with inappropriate or uncertain indications had important coronary disease.
Data were not available on whether symptoms were atypical.
Despite the association between appropriateness category and obstructive CAD, this study raises concerns about the ability of the appropriate use criteria to guide clinical decision making.
Canadian Institutes of Health Research.
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Cardiology, Pulmonary/Critical Care, Cardiac Diagnosis and Imaging, Coronary Heart Disease.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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