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It is appropriate in certain circumstances to revascularize a nonculprit artery in patients with acute coronary syndromes during their index hospitalization, according to updated cardiovascular society appropriate use criteria (AUC).

Last updated in 2012, the new criteria signal a catch-up with the latest guidelines and studies. "An additional goal was to address several of the shortcomings of the initial document that became evident as experience with the use of the AUC accumulated in clinical practice," wrote , of Duke University Health System, and colleagues.

The updated document was published online in the Journal of the American College of Cardiology, Catheterization and Cardiovascular Interventions, and the Journal of Nuclear Cardiology.

Among other changes, revascularization of a nonculprit artery during the index hospitalization was deemed appropriate when there are symptoms of myocardial ischemia, when ischemia is found on noninvasive testing, and when fractional flow reserve is less than or equal to 0.80.

With no additional testing, however, it "may be appropriate" for asymptomatic patients with severe stenoses to get revascularization but is "rarely appropriate" for asymptomatic patients with intermediate stenoses.

"Previously, treatment of nonculprit stenoses during the initial procedure or during the same hospitalization in the absence of clinical instability or further testing documenting ischemia was assigned a Class III recommendation in guideline documents and is thus considered inappropriate using the original terminology for the AUC," according to the authors.

The PRAMI, CvLPRIT, and DANAMI3-PRIMULTI studies challenged all that. Their findings led to a new Class IIb recommendation for treatment of nonculprit stenoses in the setting of primary PCI -- and the current update to the AUC.

The document was drafted by the American College of Cardiology, American Heart Association, American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society of Thoracic Surgeons.

A separate set of AUC for coronary revascularization in the setting of stable ischemic heart disease is in the works.

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