Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisationrate? The ACRE study

Objective - To determine whether ratings of coronary angiography appropriat eness derived by an expert panel on hypothetical patients are associated wi th actual angiographic findings, mortality, and subsequent revascularisatio n in the ACRE (appropriateness of coronary revascularisation) study. Design - Population based, prospective study. The ACRE expert panel rated h ypothetical clinical indications as inappropriate, uncertain, or appropriat e: before recruitment of a cohort of real patients. Setting - Royal Hospitals Trust, London, UK. Participants - 3631 consecutiv e patients undergoing coronary angiography (no exclusion criteria). Main outcome measures-Angiographic findings, mortality (n = 226 deaths), an d revascularisation (n = 1556 procedures) over 2.5 years of follow up. Results - The indications for coronary angiography were rated appropriate i n 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indi cations rated inappropriate, largely for asymptomatic or atypical chest pai n presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in pa tients with unstable angina controlled by inpatient management. Three vesse l disease was more likely among appropriate cases and normal coronaries wer e more likely among inappropriate cases (p < 0.001). Mortality and revascul arisation rates were highest among patients with an appropriate: indication , intermediate in those with an uncertain indication, and lowest in the ina ppropriate group (log rank p = 0.018 and p < 0.0001, respectively). Conclusion - The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findin gs support the clinical usefulness of expert panel methods in defining crit eria for performing coronary angiography.