Perspective: Panel members rated various common clinical scenarios where revascularization would be considered appropriate, inappropriate, and uncertain. Coronary revascularization is considered appropriate when the expected benefits, in terms of survival or health outcomes (symptoms, functional status, and/or quality of life), exceed the expected risk. The following are 10 points to remember about these appropriateness criteria for coronary revascularization:

1. In patients with ST-elevation myocardial infarction (STEMI), revascularization of the culprit vessel in patients presenting within 12 hours is considered appropriate.

2. In patients with STEMI who present between 12-24 hours of symptom onset, revascularization is appropriate in patients who have persistent symptoms, severe heart failure, or hemodynamic or electrical instability, whereas percutaneous coronary intervention (PCI) is considered inappropriate in the absence of these features.

3. In patients with STEMI who have undergone primary PCI or fibrinolytic therapy and have no symptoms, electrical or hemodynamic instability, or provokable ischemia, revascularization of a nonculprit vessel in the same hospitalization is considered inappropriate. In patients with STEMI who have no symptoms after primary PCI or fibrinolysis, but have a depressed left ventricular ejection fraction (LVEF) and three-vessel coronary artery disease (CAD), elective or semi-elective revascularization is appropriate.

4. In patients who have undergone PCI of the culprit vessel for STEMI or non-STEMI and have symptoms of recurrent ischemia or high-risk findings on noninvasive testing performed after index hospitalization, revascularization of one or more vessels is considered appropriate.

5. Revascularization of more than one vessel is appropriate in patients with cardiogenic shock or in patients with non-STEMI when the culprit artery cannot be clearly identified.

6. In asymptomatic patients, revascularization is considered inappropriate in patients with low-risk findings on noninvasive testing and one- or two-vessel disease.

7. In asymptomatic patients with three-vessel disease, revascularization is considered appropriate in patients with high- or intermediate-risk features on noninvasive testing or in the presence of abnormal LV function, or in patients with left main artery disease.

8. In asymptomatic patients with proximal left anterior descending artery disease (and one- or two-vessel CAD), and presence of high-risk features on stress testing, revascularization is considered appropriate, while it is of uncertain value if the noninvasive findings are of intermediate or low risk.

9. Revascularization is considered inappropriate in patients with class III or IV angina in the presence of borderline stenosis (50-60%) in the absence of high-risk noninvasive features or in the absence of further invasive evaluation (fractional flow reserve or intravascular ultrasound).

10. In asymptomatic patients with chronic total occlusions (CTOs), revascularization is either inappropriate (low-risk features on noninvasive testing) or of uncertain value. Revascularization is considered appropriate in patients with a CTO who have high-risk features and have class III or IV angina on maximal therapy.  Hitinder S. Gurm, M.B.B.S., F.A.C.C.