AIM: Appropriateness criteria can assess which patients require angiography
Patient-specific appropriateness criteria are a promising tool for improving care of patients with suspected angina with coronary angiography, according to a prospective, observational study in the Aug. 19 issue of the Annals of Internal Medicine.

Harry Hemingway, MBBChir, from the University College London Medical School, and colleagues undertook the study to determine the reliability and prognostic validity of patient-specific appropriateness criteria for coronary angiography among patients with suspected angina pectoris.

In the study, two independent panels of clinicians scored 2,400 patient-specific indications for coronary angiography as inappropriate, uncertain or appropriate at six urban U.K. ambulatory care clinics.

The investigators tracked the appropriateness ratings and clinical outcomes (coronary death and acute coronary syndrome (ACS) events) over a median of three years of follow-up.

Using a computer algorithm, researchers matched the devised appropriateness indications to 9,356 clinic patients with recent-onset chest pain. They found that many patients judged as appropriate candidates did not undergo angiography and that this group had more subsequent coronary events than did patients, who “appropriately” did have angiography.

Hemingway and colleagues found that 660 coronary deaths or ACS events occurred, and an agreement between the two panels (reliability) on appropriateness category was moderate. Use of subsequent angiography was strongly related to appropriateness category, according to scores from either panel.

Among patients judged as appropriate candidates for angiography, researchers reported that underuse was common (57 percent according to panel A and 71.3 percent according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure.

The authors wrote that the hazard ratio after adjustment for age, sex, exercise electrocardiography result and secondary prevention medication was similar according to panel A (2.78) and panel B (2.47).

Appropriateness scores offer prognostically valid criteria for judging which specific patients might benefit from coronary angiography, the researchers concluded. Patient-specific appropriateness scores help pinpoint areas where judgments diverge and are a promising tool for making guidelines more effective.