Consensus Document Outlines Guidelines for Cardiac Cath Use

As a diagnostic tool, cardiac catheterization has become central to many a cardiologist’s practice. Yet because it is so popular, a new set of criteria seeks to help clinicians understand procedure appropriateness, avoid overuse and balance the risks and benefits.

The criteria, published online May 9, 2012, ahead of print in the Journal of the American College of Cardiology, were developed by an expert panel of the American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions, in collaboration with multiple relevant professional societies. It also will be published in a forthcoming issue of Catheterization and Cardiovascular Interventions and the Journal of Thoracic and Cardiovascular Surgery.

“With this document, we aim to help all clinicians—not just cardiologists—determine when it would be reasonable to perform diagnostic cardiac catheterization,” said writing group co-chair Manesh R. Patel, MD, of Duke University (Durham, NC), in a press release.

Clarifying What Is and Is Not Appropriate

The statement identifies 166 possible clinical scenarios when referral for diagnostic cath might be considered, and categorizes the appropriateness of each. About half of the indications were deemed appropriate by the group, while nearly 30% were rated as uncertain and 25% as inappropriate (table 1).

Table 1. Examples of Cardiac Cath Appropriateness




Symptomatic patient without prior stress testing who has a high pretest probability in the physician’s judgment


Patient with low-risk stress test who is symptomatic, or asymptomatic with high-risk stress test


Asymptomatic patient at low risk for CAD or without significant symptoms suggestive of heart disease


Dr. Patel clarified that for the inappropriate designation, while cardiac cath is not needed most of the time, it is expected that a small percentage of the cases may be justified based on extenuating clinical circumstances.

Primarily focusing on the standard use of cardiac cath to detect significant coronary stenosis, the document also outlines its application as part of an arrhythmia workup, in preoperative testing, and to evaluate patients with possible valve disease, pulmonary hypertension, or ventricular dysfunction. While overuse of the procedure is carefully considered by the writing group, underuse also is a concern, especially when time is limited to find a correct diagnosis.

According to the press release, the document will be translated into order sheets and decision support tools. In addition, the writing group intends that cath indications be linked with the appropriate use criteria for revascularization to increase the likelihood that the right patients undergo appropriate invasive catheterization procedures before discussion of revascularization.

Ultimately the paper stresses collaboration among patients, referring clinicians, and cardiologists to achieve optimal outcomes.

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

100% Appropriate Not Desirable

In a telephone interview with TCTMD, writing group member Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said the criteria represent “a way to go beyond guidelines” and aid in standardizing practice.

However, “this is not the only solution,” he said, acknowledging ongoing criticism over the word ‘inappropriate’ in other recently published criteria.

“You would not want or expect a hospital or operator to have 100% appropriate procedures based upon these criteria,” he continued. “Based upon conventional logic, you would hope it to be appropriate, but based on these criteria you are going to be doing [some] procedures that are rated uncertain or inappropriate because the clinical scenario is always going to dictate that more so than just a guidance document.”

A major issue, though, is undertreatment, Dr. Kirtane said.

“These criteria can clearly prevent overuse, and that’s how they’ve been employed. But there’s no way to ensure that the patients for whom the procedures are appropriate are being offered them,” he concluded. “And I think that’s fundamentally important, because if you just curb overuse but don’t address underuse, from a public health standpoint you may decrease costs, but you may actually worsen health status.”


Patel MR, Bailey SR, Bonow RO, et al. ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: A report of the American College of Cardiology Foundation appropriate use criteria task force, Society for Cardiovascular Angiography and Interventions, 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, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons J Am Coll Cardiol. 2012;Epub ahead of print.



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  • Drs. Patel and Kirtane report no relevant conflicts of interest.

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