The American College of Cardiology (ACC) established the CathPCI Registry in 1998 to collect detailed clinical, process-of-care, and outcomes data on patients undergoing diagnostic cardiac catheterization and percutaneous coronary intervention (PCI) for the purposes of quality assessment and improvement. CathPCI has gone through several revisions to improve data collection to adapt to evolving clinical practice and science.^1,2 Subsequently, the Society for Cardiovascular Angiography and Interventions (SCAI) became a partner with the ACC for the CathPCI registry. CathPCI has a steering committee charged with operational and strategic oversight.³ This committee assesses the registry data elements based upon the extent to which they contribute to the calculation of performance measures, risk-adjustment models, procedural appropriateness, or in-hospital outcomes. Research from CathPCI is overseen by a subcommittee that enacts strategic research priorities and reviews research proposals and publications (the CathPCI Research and Publications Subcommittee).

The current CathPCI Version 4 was implemented in July 2009. The appropriate use criteria (AUC) for PCI and diagnostic cardiac catheterization were incorporated into the reports provided to participating centers in 2012.^4,5 However, some clinical scenarios cannot not be mapped due to the need for data elements not included in CathPCI Version 4. Because the AUC for PCI were recently revised,⁶ an update to the CathPCI Registry was implemented in 2015 in parallel to ensure concordance with the latest AUC. As such, a principal objective of the Version 5 upgrade was to include updated data elements and clinical definitions necessary to report the AUC for coronary revascularization and diagnostic catheterization. Additional data elements as recommended by the Steering Committee and Research and Publications Subcommittee were also considered to address strategic priorities.

The Version 5 update was overseen by a workgroup consisting of members of ACC and SCAI as well as representation from contracted data analytic centers that perform analyses with CathPCI data. In addition to addressing the issues outlined above, the group reviewed all Version 4 data elements to identify those that were not used adequately to justify their collection. The data elements were also assessed for consistency with other relevant National Cardiovascular Data Registry (NCDR) programs to ensure harmonization among the NCDR registries. A public comment period was held for feedback. The final Version 5 update was approved by the CathPCI Steering Committee, the NCDR Science and Quality Oversight Committee, and ultimately the NCDR Management Board.

Documentation of ischemia around the time of revascularization is important to the AUC for PCI and has been limited in Version 4 of CathPCI. Version 4 includes only assessment of ischemia using fractional flow reserve (FFR) or intravascular ultrasound (IVUS) in the setting of an intermediate stenosis (40 to ≤70% stenosis) and only if PCI was performed. With this update, documentation of ischemia and assessment of stenosis severity will be captured in all cases even when PCI is not performed, allowing for appropriate deferral of PCI to be captured based on anatomic or functional imaging data. This will include FFR, instant wave-free ratio, IVUS, and optical coherence tomography imaging of the coronaries. Pre-procedural noninvasive assessment will also permit for documentation of ischemia using computed tomography-derived FFR, recently approved by the Food and Drug Administration.

The clinical indications for diagnostic cardiac catheterization will be broadened to include data elements that allow the calculation of AUC for these procedures. Data elements have been revised to include important indications for catheterization that have been missing from the current version, including angiography prior to cardiac surgery, as part of solid organ transplant evaluation or for surveillance following cardiac transplantation.

Additional clinical information will be captured to better evaluate patient- or provider-level decision-making about revascularization. Patient risk assessment will include frailty using standardized definitions utilized in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve (STS/ACC TVT) Registry. Patient selection for PCI including whether surgical consultation was obtained and outcome of this consultation (e.g., surgical "turndown" patient preference to avoid surgery) will be captured. To better identify case risk and resource utilization, concomitant procedures performed during diagnostic catheterization (i.e., valvuloplasty, alcohol septal ablation, left atrial appendage occlusion, and structural interventions) will be better assessed. This will include use of multiple arterial or venous access sites as well as capture of crossover to an alternate access site.

Because cardiogenic shock and cardiac arrest are particularly important topics for consideration in risk-adjusted outcomes models, more data will be captured to enhance outcomes models and reports. More granular information regarding cardiac arrest details and level of consciousness during catheterization and PCI will be evaluated and will be harmonized with an update to the ACTION Registry–Get With the Guidelines for acute myocardial infarction. Timing and specific type of mechanical circulatory support will be collected in greater detail. Decision-making about withdrawal of care and more specific evaluation of cause of death similar to that captured in the STS/ACC TVT registry will also be included.

In order to allow sites to record clinical outcomes during follow-up after PCI, optional follow-up modules for 30-day and 12-month follow-up after PCI are being introduced for data collection. Finally, evaluation of the impact of angina on patient-reported health status and its response to treatment with PCI can be evaluated in more detail using an optional Seattle Angina Questionnaire module. The capacity to collect patient-reported outcomes such as the Seattle Angina Questionnaire is likely to become more important as healthcare reimbursement evolves to focus on outcomes rather than procedural volume (Table 1).

Table 1: Selected Examples of Data Element Changes With Version 5 CathPCI Update

Data Elements Deleted	Data Elements Revised	Data Elements Added
Catheterization history, prior valve surgery Other mechanical support 40-70% stenosis, IVUS performed 40-70% stenosis, FFR performed Discharge medication, ticlopidine	Mechanical ventricular support Revised to collect all types Indications for cardiac catheterization FFR, IVUS collected for all lesions Pre-operative evaluation Include prior to cardiac surgery and solid organ transplant	FFR value from coronary computed tomography angiogram Cumulative air kerma; Dose area product Surgical consult obtained Surgical turndown Out of hospital cardiac arrest Initiation of hypothermia protocol Frailty assessment Withdrawal of care/hospice care

The CathPCI Version 5 will be released in late 2017. This update will improve data collection necessary for both the diagnostic catheterization AUC and the recently revised AUC for PCI. It will also better characterize patient selection for PCI and provide the capacity to collect longitudinal outcomes data. Finally, important clinical and procedural factors regarding cardiac arrest and cardiogenic shock will be better captured to help identify patients at high risk of adverse events to better inform risk models and public reporting efforts, including exclusion of high-risk populations from these efforts. Thus, this long-awaited update will be responsive to the evolution of clinical care and practice, supporting CathPCI participants in demonstrating the quality and value of care they deliver.

References

1. Weintraub WS, McKay CR, Riner RN, et al. The American College of Cardiology National Database: progress and challenges. American College of Cardiology Database Committee. J Am Coll Cardiol 1997;29:459-65.
2. Brindis RG, Fitzgerald S, Anderson HV, Shaw RE, Weintraub WS, Williams JF. The American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR): building a national clinical data repository. J Am Coll Cardiol 2001;37:2240-5.
3. Moussa I, Hermann A, Messenger JC, et al. The NCDR CathPCI Registry: a US national perspective on care and outcomes for percutaneous coronary intervention. Heart 2013;99:297-303.
4. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857-81.
5. 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;59:1995-2027.
6. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2016 Appropriate Use Criteria for Coronary Revascularization in Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, 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. J Am Coll Cardiol 2016 Dec 14 [Epub ahead of print].

Keywords: Angiography, Atrial Appendage, Cardiac Catheterization, Constriction, Pathologic, Heart Transplantation, Hypothermia, Percutaneous Coronary Intervention, Risk Assessment, Shock, Cardiogenic, Tomography, Optical Coherence, Cardiology Interventions, National Cardiovascular Data Registries, CathPCI Registry

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