Governing Cardiology organizations lately met and conferred and produce new guidelines for the evaluation and management of patients who present with cardiac ischemia and certain types of myocardial infarctions. These guidelines constitute the current acceptable standard of practice, and should be generally followed by all medical practitioners. In any medical-legal action, these standards with constitute the benchmark against which any alleged malpractice will be judged. The full paper is listed below.
ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography
Cardiac Computed Tomography Writing Group; Technical Panel
Posted: 12/29/2010; J Am Coll Cardiol. 2010;56(22):1864-1894. © 2010 Elsevier Science, Inc.
A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance
Abstract and Introduction
Abstract
The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance (CMR) appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria.[1]
The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use.
In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease (CAD) was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography (CT) for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research.
Preface
In an effort to respond to the need for the rational use of imaging services in the delivery of high-quality care, the ACCF has undertaken a process to determine the appropriate use of cardiovascular imaging for selected patient indications.
Appropriate use criteria publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on current understanding of the technical capabilities of the imaging modalities examined. Although not intended to be entirely comprehensive, the indications are meant to identify common scenarios encompassing the majority of contemporary practice. Given the breadth of information they convey, the indications do not directly correspond to the ninth revision of the International Classification of Diseases (ICD-9) system as these codes do not include clinical information, such as symptom status.
The ACCF believes that careful blending of a broad range of clinical experiences and available evidence-based information will help guide a more efficient and equitable allocation of healthcare resources in cardiovascular imaging. The ultimate objective of appropriate use criteria is to improve patient care and health outcomes in a cost-effective manner but is not intended to ignore ambiguity and nuance intrinsic to clinical decision making. Local parameters, such as the availability or quality of equipment or personnel, may influence the selection of appropriate imaging procedures. Appropriate use criteria thus should not be considered substitutes for sound clinical judgment and practice experience.
The ACCF appropriate use criteria process itself is also evolving. In the current iteration, technical panel members were asked to rate indications for CCT in a manner independent and irrespective of the prior published ACCF ratings for CCT and CMR[1] as well as the prior ACCF ratings for similar diagnostic stress imaging modalities such as cardiac radionuclide imaging[2] or stress echocardiography[3] (see Appendix A for the definitions of terms used throughout the indication set). Given the iterative nature of the process, readers are counseled not to compare too closely individual appropriate use ratings among modalities rated at different times over the past 2 years. A comparative evaluation of the appropriate use of multiple imaging techniques is currently being undertaken to assess the relative strengths of each modality for various clinical scenarios.
We are grateful to the technical panel, a professional group with a wide range of skills and insights, for their thoughtful and thorough deliberation of the merits of CCT for various indications. In addition to our thanks to the technical panel for their dedicated work and review, we would like to offer special thanks to the many individuals who provided a careful review of the draft indications; to Peggy Christiansen, the ACCF librarian for her comprehensive literature searches; to Lindsey Law, Starr Webb, and Joseph M. Allen, who continually drove the process forward; and to Allen J. Taylor, MD, the chair of the writing committee for his dedication, insight, and leadership.
Christopher M. Kramer, MD, FACC, FAHA
Moderator, Cardiac Computed Tomography Technical Panel
Michael J. Wolk, MD, MACC
Chair, Appropriate Use Criteria Task Force
1. Introduction
This report addresses the appropriate use of CCT. Improvements in cardiovascular imaging technology and their application, coupled with increasing therapeutic options for cardiovascular disease, have led to an increase in cardiovascular imaging. At the same time, the armamentarium of noninvasive diagnostic tools has expanded with innovations in new contrast agents, molecular radionuclide imaging, perfusion echocardiography, computed tomography for coronary angiography and calcium scoring, and magnetic resonance imaging for myocardial structure and viability. As the field of CCT continues to advance along with other imaging modalities, the healthcare community needs to understand how to best incorporate this technology into daily clinical care.
All prior appropriate use criteria publications from the ACCF and collaborating organizations have reflected an ongoing effort to critically and systematically create, review, and categorize the appropriate use of certain cardiovascular diagnostic tests. The ACCF recognizes the importance of revising these criteria in a timely manner in order to provide the cardiovascular community with the most accurate indications. The present document is the second update to an existing appropriate use criteria document, the "ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging," published in 2006.[1] Clinicians, payers, and patients are interested in the specific benefits of CCT. Of importance, inappropriate use of CCT may be potentially harmful to patients and generate unwarranted costs to the health care system, whereas appropriate procedures should likely improve patients' clinical outcomes. This is a critical shift because the intent is for the potential benefits and risks of the treatment to be explicitly considered, rather than the potential usefulness of a diagnostic test as a prelude to further treatment. This document presents the results of this effort, but it is critical to understand the background and scope of this document before interpreting the rating tables.
2. Methods
The indications included in this review are purposefully broad, and they comprise a wide array of cardiovascular signs and symptoms as well as clinical judgment as to the likelihood of cardiovascular findings.
Further description of the methods used for ranking of the selected clinical indications is outlined in Appendix B and is also found more generally in a previous publication, "ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging".[4] Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise. Because the original CCT/CMR criteria document and methods paper was published, several important processes have been put in place to further enhance this process. They include convening a formal writing committee with diverse expertise in imaging, circulating the indications for external review prior to rating by the technical panel, ensuring appropriate balance of the technical panel, a standardized rating package, and creating formal roles for facilitating panel interaction at the face-to-face meeting.
The panel first rated indications independently. In rating these criteria, the Cardiac Computed Tomography Appropriate Use Criteria Technical Panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate as defined in the following text.
An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences* by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.
The technical panel scores each indication as follows:
Score 7 to 9
Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).
Score 4 to 6
Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). (Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.)
Score 1 to 3
Inappropriate test for specific indication (test is not generally acceptable and is not a reasonable approach for the indication).
Then the panel was convened for a face-to-face meeting for discussion of each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers' scores. After the consensus meeting, panel members were then asked to independently provide their final scores for each indication. Following the second round ratings, a supplemental rating process was conducted for a revised set of criteria for preoperative testing (31 to 38) and the clinical scenario of prior revascularization (40 to 41). Although these categories had been considered within the original 2 rounds of rating, the clinical scenarios were rewritten to more closely mirror prior documents, and the balloting was repeated.
The contributors acknowledge that the division of these scores into 3 categories of appropriate use is somewhat arbitrary and that the numeric designations should be viewed as a continuum. The contributors also recognize diversity in clinical opinion for particular clinical scenarios. Scores in the intermediate level of appropriate use should therefore be labeled uncertain, as critical patient or research data may be lacking or discordant. This designation should be a prompt to the field to carry out definitive research, whenever possible. It is anticipated that the appropriate use criteria reports will require updates as further data are generated and information from the implementation of the criteria is accumulated.
To avoid bias in the scoring process, the technical panel deliberately was not comprised solely of specialists in the particular procedure under evaluation. Specialists, while offering important clinical and technical insights, might have a natural tendency to rate the indications within their specialty as more appropriate than nonspecialists. In addition, care was taken in providing objective, nonbiased information, including guidelines and key references, to the technical panel. Panel members were not provided explicit cost information to help determine their appropriate use ratings, but they were asked to implicitly consider cost as an additional factor in their evaluation of appropriate use.
The level of agreement among panel members, as defined by RAND,[5] was analyzed for each indication based on the BIOMED rule for a panel of 14 to 16 (a simplified RAND method for determining disagreement). Per the BIOMED definition, agreement was defined as an indication where 4 or fewer panel members ratings fell outside the 3-point region containing the median score. Disagreement was defined as a situation where at least 5 panel members ratings fell in both the appropriate and the inappropriate categories. Because the panel had 17 representatives, which exceeded the 16 addressed in this rule, an additional level of agreement analysis as described by RAND was performed that examines the interpercentile range (IPR) compared with the interpercentile range adjusted for symmetry (IPRAS). This information was used by the moderator to guide the panel's discussion by highlighting areas of differences among the panel members. There was also a third category for indications that were not classified in either the agreement or disagreement categories. Any indication having disagreement was categorized as uncertain regardless of the final median score. Indications that met neither definition for agreement or disagreement are in a third, unlabeled, category.
3. General Assumptions
All indications were considered with the following important assumptions for CCT:
- CCT is performed in accordance with best practice standards as delineated in the imaging guidelines of the Society of Cardiovascular Computed Tomography,[6,7] by competent[8] and appropriately credentialed physicians. This includes the optimization of the scan protocol to limit radiation exposure.
- CCT imaging equipment is available that has the minimal technical capabilities required for the indication. Typical technical parameters for studies performed on multi-detector row scanners include CT equipment enabling 64 or more slices, submillimeter spatial resolution, and gantry rotation time no greater than 420 milliseconds. Appropriate computer software must be available for image analysis.
- Patients are optimally suited for CCT under the following conditions:
- Regular heart rate and rhythm including a heart rate at a level commensurate with the temporal resolution of the available scanner.
- Body mass index below 40 kg/m2.
- Normal renal function.
- For CT angiography, patient requirements may include the ability to:
- Hold still and follow breathing instructions.
- Tolerate beta blockers.
- Tolerate sublingual nitroglycerin.
- Lift both arms above the shoulders.
- All indications for CCT were considered with the following important assumptions:
- All indications should first be evaluated based on the available medical literature.
- In many cases, studies published in the medical literature are reflections of the capabilities and limitations of the test but provide minimal information about the role of the test in clinical decision making.
- Appropriate use criteria development requires determination of a reasonable course of action for clinical decision making based on a risk/benefit trade-off as determined by individual patient indications.
- For all stress imaging referenced in the indications, the mode of stress testing was assumed to be exercise for patients able to exercise. For patients unable to exercise, pharmacological stress testing was assumed to be used. Further background on the rationale for the assumption of exercise testing is available in the ACC/AHA 2002 Guideline Update for Exercise Testing.[9]
4. Definitions
A complete set of definitions of terms used throughout the indication set is listed in Appendix A. These definitions were provided and discussed with the technical panel prior to ratings of indications.
Ischemic Equivalent Chest Pain Syndrome, Anginal Equivalent, or Ischemic Electrocardiographic Abnormalities: Any constellation of clinical findings that is clinically judged to be consistent with obstructive CAD. Examples of such findings include, but are not limited to, chest pain, chest tightness, burning, shoulder pain, jaw pain, and new electrocardiographic abnormalities suggestive of ischemic heart disease. Nonchest pain symptoms, such as dyspnea or worsening effort tolerance that are felt to be consistent with CAD may also be considered to be an anginal equivalent.
Determining Pretest Risk Assessment for Risk Stratification
Coronary Heart Disease (CHD) Risk in Asymptomatic Patients: Estimation of CHD risk applied to asymptomatic patients without known CHD. It is assumed that clinicians will use CCT studies in addition to standard methods of risk assessment as presented in the National Heart, Lung, and Blood Institute report[10] on "Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III])."
Absolute risk is defined as the probability of developing CHD, including myocardial infarction or CHD death over a given time period. The ATP III report specifies absolute risk for CHD over the next 10 years. CHD risk refers to 10-year risk for any hard cardiac event. However, in acknowledgment that global absolute risk scores may be miscalibrated to certain populations (e.g., women, younger men), clinical judgment must be applied in selecting categorical risk thresholds.
- CHD Risk—Low
Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk <10%. - CHD Risk—Intermediate
Defined by the age-specific risk level that is average or above average. In general, moderate risk will correlate with a 10-year absolute CHD risk between 10% to 20%. Among women and younger men, an expanded intermediate risk range of 6% to 20% may be appropriate. - CHD Risk—High
Defined as the presence of diabetes mellitus in a patient =40 years of age, peripheral arterial disease or other coronary risk equivalents, or the 10-year absolute CHD risk of >20%.
Pretest Probability of Obstructive/Significant CAD for Symptomatic (Ischemic Equivalent) Patients: Once the physician determines the presence of symptoms that may represent obstructive CAD (ischemic equivalent present), the pretest probability of CAD should be assessed. There are a number of risk algorithms[11,12] available that can be used to calculate this probability. Clinicians should become familiar with those that pertain to the populations they encounter most often. In scoring the indications, the following probabilities as calculated from any of the various available algorithms should be applied:
- Low pretest probability: <10% pretest probability of CAD.
- Intermediate pretest probability: Between 10% and 90% pretest probability of CAD.
- High pretest probability: >90% pretest probability of CAD.
The method recommended by the ACC/AHA Guidelines for Chronic Stable Angina[13] is provided in the following text as 1 example of a method used to calculate pretest probability and is a modification of a previously published literature review.[14] Please refer to definitions of angina and Table A. Please note that the table only predicts pretest probability in patients based upon presenting symptoms, age, and sex. Additional history and electrocardiographic evidence of prior infarction dramatically affect pretest probability. Although they are not incorporated into the algorithm, cardiovascular risk factors, discussed in risk assessment indications, may also affect pretest likelihood of CAD. Detailed normograms are available that incorporate the effects of a history of prior infarction, electrocardiographic Q waves, electrocardiographic ST- and T-wave changes, diabetes, smoking, and hypercholesterolemia.[9]
|
Table A Pretest Probability of CAD by Age, Sex, and Symptoms |
|||||
|
Age |
Sex |
Typical/Definite Angina Pectoris |
Atypical/Probable Angina Pectoris |
Nonanginal Chest Pain |
Asymptomatic |
|
<39 |
Men |
Intermediate |
Intermediate |
Low |
Very low |
|
|
Women |
Intermediate |
Very low |
Very low |
Very low |
|
40–49 |
Men |
High |
Intermediate |
Intermediate |
Low |
|
|
Women |
Intermediate |
Low |
Very low |
Very low |
|
50–59 |
Men |
High |
Intermediate |
Intermediate |
Low |
|
|
Women |
Intermediate |
Intermediate |
Low |
Very low |
|
>60 |
Men |
High |
Intermediate |
Intermediate |
Low |
|
|
Women |
High |
Intermediate |
Intermediate |
Low |
|
High: >90% pretest probability; intermediate: between 10% and 90% pretest probability; low: between 5% and 10% pretest probability; and very low: <5% pretest probability. Modified from Gibbons et al. (9) to reflect all age ranges. |
|||||
5. Abbreviations
ACS = acute coronary syndrome
CABG = coronary artery bypass grafting surgery
CAD = coronary artery disease
CCS = coronary calcium score
CHD = coronary heart disease
CT = computed tomography
CTA = computed tomographic angiography
ECG = electrocardiogram
HF = heart failure
MET = estimated metabolic equivalent of exercise
MI = myocardial infarction
PCI = percutaneous coronary intervention
6. Results of Ratings
The final ratings for CCT (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, and Table 7) are listed by indication sequentially as obtained from second round rating sheets submitted by each panel member. The final score reflects the median score of the 17 panel members and has been labeled according to the 3 appropriate use categories of appropriate, uncertain, and inappropriate. Table 8, Table 9, and Table 10 present the indications by these categories. Algorithm Figures 1 to 10 describe the application of criteria as presented in these tables.
Table 1. Detection of CAD in Symptomatic Patients Without Known Heart Disease*
|
Indication |
Appropriate Use Score (1–9) |
|||
|
Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
1. |
|
U (5) |
A (7) |
I (3) |
|
2. |
|
A (7) |
A (8) |
U (4) |
|
Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||||
|
3. |
|
I (1) |
||
|
4. |
|
U (6) |
||
|
5. |
|
U (6) |
||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
6. |
|
A (7) |
A (7) |
U (4) |
|
7. |
|
A (7) |
A (7) |
U (4) |
|
8. |
|
A (7) |
A (7) |
U (4) |
* Note: All indications are for CTA unless otherwise noted.
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 2. Detection of CAD/Risk Assessment in Asymptomatic Patients Without Known CAD
|
Indication |
Appropriate Use Score (1–9) |
|||
|
Noncontrast CT for CCS |
||||
|
|
Global CHD Risk Estimate |
Low |
Intermediate |
High |
|
9. |
|
A (7) |
|
|
|
10. |
|
I (2) |
A (7) |
U (4) |
|
Coronary CTA |
||||
|
|
Global CHD Risk Estimate |
Low |
Intermediate |
High |
|
11. |
|
I (2) |
I (2) |
U (4) |
|
Coronary CTA Following Heart Transplantation |
||||
|
12. |
|
U (6) |
||
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 3. Detection of CAD in Other Clinical Scenarios
|
Indication |
Appropriate Use Score (1–9) |
|||
|
New-Onset or Newly Diagnosed Clinical HF and No Prior CAD |
||||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
13. |
|
A (7) |
A (7) |
U (4) |
|
14. |
|
U (5) |
U (5) |
U (4) |
|
Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
15. |
|
U (6) |
A (7) |
I (3) |
|
Arrhythmias—Etiology Unclear After Initial Evaluation |
||||
|
16. |
|
I (2) |
||
|
17. |
|
U (6) |
||
|
18. |
|
U (4) |
||
|
Elevated Troponin of Uncertain Clinical Significance |
||||
|
19. |
|
U (6) |
||
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 4. Use of CTA in the Setting of Prior Test Results
|
Indication |
Appropriate Use Score (1–9) |
||||
|
Prior ECG Exercise Testing |
|||||
|
20. |
|
A (7) |
|||
|
|
Duke Treadmill Score—Risk Findings |
Low |
Intermediate |
High |
|
|
21. |
|
I (2) |
A (7) |
I (3) |
|
|
Sequential Testing After Stress Imaging Procedures |
|||||
|
22. |
|
A (8) |
|||
|
|
Test Result/Ischemia |
Equivocal |
Mild |
Moderate or Severe |
|
|
23. |
|
A (8) |
U (6) |
I (2) |
|
|
Prior CCS |
|||||
|
24. |
|
U (4) |
|||
|
25. |
|
I (2) |
|||
|
|
CCS |
<100 |
100–400 |
401–1000 |
>1000 |
|
26. |
Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients |
A (8) |
A (8) |
U (6) |
U (4) |
|
Asymptomatic OR Stable Symptoms Periodic Repeat Testing in the Setting of Prior Stress Imaging or Prior Coronary Angiography |
|||||
|
|
Last Study Done |
<2 y Ago |
=2 y Ago |
||
|
27. |
|
I (2) |
I (3) |
||
|
28. |
|
I (2) |
I (3) |
||
|
Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study |
|||||
|
|
Previous Stress Imaging Study |
Normal |
Abnormal |
||
|
29. |
|
A (8) |
U (6) |
||
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 5. Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions
|
Indication |
Appropriate Use Score (1–9) |
|
|
Low-Risk Surgery |
||
|
30. |
|
I (1) |
|
Intermediate-Risk Surgery |
||
|
31. |
|
I (2) |
|
32. |
|
I (2) |
|
33. |
|
U (5) |
|
34. |
|
I (1) |
|
Vascular Surgery |
||
|
35. |
|
I (2) |
|
36. |
|
I (2) |
|
37. |
|
U (6) |
|
38. |
|
I (2) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 6. Risk Assessment Postrevascularization (PCI or CABG)
|
Indication |
Appropriate Use Score (1–9) |
||
|
Symptomatic (Ischemic Equivalent) |
|||
|
39. |
|
A (8) |
|
|
40. |
|
I (3) |
|
|
41. |
|
U (6) |
|
|
Asymptomatic—CABG |
|||
|
|
Time Since CABG |
<5 y Ago |
=5 y Ago |
|
42. |
|
I (2) |
U (5) |
|
Asymptomatic—Prior Coronary Stenting |
|||
|
43. |
|
A (7) |
|
|
|
Time Since PCI |
<2 y |
=2 y |
|
44. |
|
I (2) |
I (2) |
|
45. |
|
I (3) |
U (4) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 7. Evaluation of Cardiac Structure and Function
|
Indication |
Appropriate Use Score (1–9) |
|
|
Adult Congenital Heart Disease |
||
|
46. |
|
A (9) |
|
47. |
|
A (8) |
|
Evaluation of Ventricular Morphology and Systolic Function |
||
|
48. |
|
I (2) |
|
49. |
|
A (7) |
|
50. |
|
A (7) |
|
51. |
|
A (7) |
|
52. |
|
U (5) |
|
Evaluation of Intra- and Extracardiac Structures |
||
|
53. |
|
A (8) |
|
54. |
|
A (8) |
|
55. |
|
I (3) |
|
56. |
|
A (8) |
|
57. |
|
A (8) |
|
58. |
|
A (8) |
|
59. |
|
A (8) |
|
60. |
|
A (8) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 8. Appropriate Indications (Median Score 7–9)
|
Indication |
Appropriate Use Score (1–9) |
|
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||
|
1. |
|
A (7) |
|
2. |
|
A (7) |
|
2. |
|
A (8) |
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||
|
6. |
|
A (7) |
|
6. |
|
A (7) |
|
7. |
|
A (7) |
|
7. |
|
A (7) |
|
8. |
|
A (7) |
|
8. |
|
A (7) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS |
||
|
9. |
|
A (7) |
|
10. |
|
A (7) |
|
Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD |
||
|
13. |
|
A (7) |
|
13. |
|
A (7) |
|
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||
|
15. |
|
A (7) |
|
Use of CTA in the Setting of Prior Test Results—Prior ECG Exercise Testing |
||
|
20. |
|
A (7) |
|
21. |
|
A (7) |
|
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures |
||
|
22. |
|
A (8) |
|
23. |
|
A (8) |
|
Use of CTA in the Setting of Prior Test Results—Prior CCS |
||
|
26. |
|
A (8) |
|
26. |
|
A (8) |
|
Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study |
||
|
29. |
|
A (8) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent) |
||
|
39. |
|
A (8) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting |
||
|
43. |
|
A (7) |
|
Evaluation of Cardiac Structure and Function—Adult Congenital Heart Disease |
||
|
46. |
|
A (9) |
|
47. |
|
A (8) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function |
||
|
49. |
|
A (7) |
|
50. |
|
A (7) |
|
51. |
|
A (7) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Intra- and Extracardiac Structures |
||
|
53. |
|
A (8) |
|
54. |
|
A (8) |
|
56. |
|
A (8) |
|
57. |
|
A (8) |
|
58 |
|
A (8) |
|
59. |
|
A (8) |
|
60. |
|
A (8) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 9. Uncertain Indications (Median Score 4–6)
|
Indication |
Appropriate Use Score (1–9) |
|
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||
|
1. |
|
U (5) |
|
2. |
|
U (4) |
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||
|
4. |
|
U (6) |
|
5. |
|
U (6) |
|
6. |
|
U (4) |
|
7. |
|
U (4) |
|
8. |
|
U (4) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS |
||
|
10. |
|
U (4) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA |
||
|
11. |
|
U (4) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA Following Heart Transplantation |
||
|
12. |
|
U (6) |
|
Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD |
||
|
13. |
|
U (4) |
|
14. |
|
U (5) |
|
14. |
|
U (5) |
|
14. |
|
U (4) |
|
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||
|
15. |
|
U (6) |
|
Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation |
||
|
17. |
|
U (6) |
|
18. |
|
U (4) |
|
Detection of CAD in Other Clinical Scenarios—Elevated Troponin of Uncertain Clinical Significance |
||
|
19. |
|
U (6) |
|
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures |
||
|
23. |
|
U (6) |
|
Use of CTA in the Setting of Prior Test Results—Prior CCS |
||
|
24. |
|
U (4) |
|
26. |
|
U (6) |
|
26. |
|
U (4) |
|
Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study |
||
|
29. |
|
U (6) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery |
||
|
33. |
|
U (5) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery |
||
|
37. |
|
U (6) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent) |
||
|
41. |
|
U (6) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG |
||
|
42. |
|
U (5) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting |
||
|
44. |
|
U (4) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function |
||
|
52. |
|
U (5) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 10. Inappropriate Indications (Median Score 1–3)
|
Indication |
Appropriate Use Score (1–9) |
|
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||
|
1. |
|
I (3) |
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||
|
3. |
|
I (1) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS |
||
|
10. |
|
I (2) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA |
||
|
11. |
|
I (2) |
|
11. |
|
I (2) |
|
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||
|
15. |
|
I (3) |
|
Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation |
||
|
16. |
|
I (2) |
|
Use of CTA in the Setting of Prior Test Results—ECG Exercise Testing |
||
|
21. |
|
I (2) |
|
21. |
|
I (3) |
|
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures |
||
|
23. |
|
I (2) |
|
Use of CTA in the Setting of Prior Test Results—Prior CCS |
||
|
25. |
|
I (2) |
|
Periodic Repeat Testing in Asymptomatic OR Stable Symptoms With Prior Stress Imaging or Coronary Angiography |
||
|
27. |
|
I (2) |
|
27. |
|
I (3) |
|
28. |
|
I (2) |
|
28. |
|
I (3) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Low-Risk Surgery |
||
|
30. |
|
I (1) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery |
||
|
31. |
|
I (2) |
|
32. |
|
I (2) |
|
34. |
|
I (1) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery |
||
|
35. |
|
I (2) |
|
36. |
|
I (2) |
|
38. |
|
I (2) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent) |
||
|
40. |
|
I (3) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG |
||
|
42. |
|
I (2) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting |
||
|
44. |
|
I (2) |
|
44. |
|
I (2) |
|
45. |
|
I (3) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function |
||
|
48. |
|
I (2) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Intra- and Extracardiac Structures |
||
|
55. |
|
I (3) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Figure 1. Hierarchy of Potential Test Ordering Based on Clinical Presentation
Figure 2. Risk Assessment Preoperative Evaluation of Noncardiac Surgery
Figure 3. Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic Acute Presentation
Figure 4. Risk Assessment Postrevascularization (PCI or CABG)
Figure 5. Use of CT Angiography in the Setting of Prior Test Results
Figure 6. Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Presentation
Figure 7. Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known Coronary Artery Disease
Figure 8. Detection of CAD in Other Clinical Scenarios
Figure 9. Evaluation of Cardiac Structure and Function
Figure 10. Evaluation of Cardiac Structure and Function: Evaluation of Intra- and Extracardiac Structures
A majority of ratings were in agreement as defined in the preceding text, including 66% of appropriate and 55% of inappropriate indications. In contrast, only 7% of indications rated as uncertain showed agreement, indicating greater diversity of opinion on these indications. Only 2 of the 93 indications (Indications 1 [low] and 15 [low], both of which were rated as uncertain), were statistically classified as being in disagreement. Because these indications were already placed in the uncertain category, no changes were required to reflect disagreement.
7. Cardiac Computed Tomography Appropriate Use Criteria (By Indication)
Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7
Table 1. Detection of CAD in Symptomatic Patients Without Known Heart Disease*
|
Indication |
Appropriate Use Score (1–9) |
|||
|
Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
1. |
|
U (5) |
A (7) |
I (3) |
|
2. |
|
A (7) |
A (8) |
U (4) |
|
Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||||
|
3. |
|
I (1) |
||
|
4. |
|
U (6) |
||
|
5. |
|
U (6) |
||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
6. |
|
A (7) |
A (7) |
U (4) |
|
7. |
|
A (7) |
A (7) |
U (4) |
|
8. |
|
A (7) |
A (7) |
U (4) |
* Note: All indications are for CTA unless otherwise noted.
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 2. Detection of CAD/Risk Assessment in Asymptomatic Patients Without Known CAD
|
Indication |
Appropriate Use Score (1–9) |
|||
|
Noncontrast CT for CCS |
||||
|
|
Global CHD Risk Estimate |
Low |
Intermediate |
High |
|
9. |
|
A (7) |
|
|
|
10. |
|
I (2) |
A (7) |
U (4) |
|
Coronary CTA |
||||
|
|
Global CHD Risk Estimate |
Low |
Intermediate |
High |
|
11. |
|
I (2) |
I (2) |
U (4) |
|
Coronary CTA Following Heart Transplantation |
||||
|
12. |
|
U (6) |
||
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 3. Detection of CAD in Other Clinical Scenarios
|
Indication |
Appropriate Use Score (1–9) |
|||
|
New-Onset or Newly Diagnosed Clinical HF and No Prior CAD |
||||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
13. |
|
A (7) |
A (7) |
U (4) |
|
14. |
|
U (5) |
U (5) |
U (4) |
|
Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||||
|
|
Pretest Probability of CAD |
Low |
Intermediate |
High |
|
15. |
|
U (6) |
A (7) |
I (3) |
|
Arrhythmias—Etiology Unclear After Initial Evaluation |
||||
|
16. |
|
I (2) |
||
|
17. |
|
U (6) |
||
|
18. |
|
U (4) |
||
|
Elevated Troponin of Uncertain Clinical Significance |
||||
|
19. |
|
U (6) |
||
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 4. Use of CTA in the Setting of Prior Test Results
|
Indication |
Appropriate Use Score (1–9) |
||||
|
Prior ECG Exercise Testing |
|||||
|
20. |
|
A (7) |
|||
|
|
Duke Treadmill Score—Risk Findings |
Low |
Intermediate |
High |
|
|
21. |
|
I (2) |
A (7) |
I (3) |
|
|
Sequential Testing After Stress Imaging Procedures |
|||||
|
22. |
|
A (8) |
|||
|
|
Test Result/Ischemia |
Equivocal |
Mild |
Moderate or Severe |
|
|
23. |
|
A (8) |
U (6) |
I (2) |
|
|
Prior CCS |
|||||
|
24. |
|
U (4) |
|||
|
25. |
|
I (2) |
|||
|
|
CCS |
<100 |
100–400 |
401–1000 |
>1000 |
|
26. |
Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients |
A (8) |
A (8) |
U (6) |
U (4) |
|
Asymptomatic OR Stable Symptoms Periodic Repeat Testing in the Setting of Prior Stress Imaging or Prior Coronary Angiography |
|||||
|
|
Last Study Done |
<2 y Ago |
=2 y Ago |
||
|
27. |
|
I (2) |
I (3) |
||
|
28. |
|
I (2) |
I (3) |
||
|
Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study |
|||||
|
|
Previous Stress Imaging Study |
Normal |
Abnormal |
||
|
29. |
|
A (8) |
U (6) |
||
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 5. Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions
|
Indication |
Appropriate Use Score (1–9) |
|
|
Low-Risk Surgery |
||
|
30. |
|
I (1) |
|
Intermediate-Risk Surgery |
||
|
31. |
|
I (2) |
|
32. |
|
I (2) |
|
33. |
|
U (5) |
|
34. |
|
I (1) |
|
Vascular Surgery |
||
|
35. |
|
I (2) |
|
36. |
|
I (2) |
|
37. |
|
U (6) |
|
38. |
|
I (2) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 6. Risk Assessment Postrevascularization (PCI or CABG)
|
Indication |
Appropriate Use Score (1–9) |
||
|
Symptomatic (Ischemic Equivalent) |
|||
|
39. |
|
A (8) |
|
|
40. |
|
I (3) |
|
|
41. |
|
U (6) |
|
|
Asymptomatic—CABG |
|||
|
|
Time Since CABG |
<5 y Ago |
=5 y Ago |
|
42. |
|
I (2) |
U (5) |
|
Asymptomatic—Prior Coronary Stenting |
|||
|
43. |
|
A (7) |
|
|
|
Time Since PCI |
<2 y |
=2 y |
|
44. |
|
I (2) |
I (2) |
|
45. |
|
I (3) |
U (4) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 7. Evaluation of Cardiac Structure and Function
|
Indication |
Appropriate Use Score (1–9) |
|
|
Adult Congenital Heart Disease |
||
|
46. |
|
A (9) |
|
47. |
|
A (8) |
|
Evaluation of Ventricular Morphology and Systolic Function |
||
|
48. |
|
I (2) |
|
49. |
|
A (7) |
|
50. |
|
A (7) |
|
51. |
|
A (7) |
|
52. |
|
U (5) |
|
Evaluation of Intra- and Extracardiac Structures |
||
|
53. |
|
A (8) |
|
54. |
|
A (8) |
|
55. |
|
I (3) |
|
56. |
|
A (8) |
|
57. |
|
A (8) |
|
58. |
|
A (8) |
|
59. |
|
A (8) |
|
60. |
|
A (8) |
A indicates appropriate; I, inappropriate; and U, uncertain.
8. Cardiac Computed Tomography Appropriate Use Criteria (By Appropriate Use Criteria)
Table 8, Table 9, Table 10
Table 8. Appropriate Indications (Median Score 7–9)
|
Indication |
Appropriate Use Score (1–9) |
|
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||
|
1. |
|
A (7) |
|
2. |
|
A (7) |
|
2. |
|
A (8) |
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||
|
6. |
|
A (7) |
|
6. |
|
A (7) |
|
7. |
|
A (7) |
|
7. |
|
A (7) |
|
8. |
|
A (7) |
|
8. |
|
A (7) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS |
||
|
9. |
|
A (7) |
|
10. |
|
A (7) |
|
Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD |
||
|
13. |
|
A (7) |
|
13. |
|
A (7) |
|
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||
|
15. |
|
A (7) |
|
Use of CTA in the Setting of Prior Test Results—Prior ECG Exercise Testing |
||
|
20. |
|
A (7) |
|
21. |
|
A (7) |
|
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures |
||
|
22. |
|
A (8) |
|
23. |
|
A (8) |
|
Use of CTA in the Setting of Prior Test Results—Prior CCS |
||
|
26. |
|
A (8) |
|
26. |
|
A (8) |
|
Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study |
||
|
29. |
|
A (8) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent) |
||
|
39. |
|
A (8) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting |
||
|
43. |
|
A (7) |
|
Evaluation of Cardiac Structure and Function—Adult Congenital Heart Disease |
||
|
46. |
|
A (9) |
|
47. |
|
A (8) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function |
||
|
49. |
|
A (7) |
|
50. |
|
A (7) |
|
51. |
|
A (7) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Intra- and Extracardiac Structures |
||
|
53. |
|
A (8) |
|
54. |
|
A (8) |
|
56. |
|
A (8) |
|
57. |
|
A (8) |
|
58 |
|
A (8) |
|
59. |
|
A (8) |
|
60. |
|
A (8) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 9. Uncertain Indications (Median Score 4–6)
|
Indication |
Appropriate Use Score (1–9) |
|
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||
|
1. |
|
U (5) |
|
2. |
|
U (4) |
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||
|
4. |
|
U (6) |
|
5. |
|
U (6) |
|
6. |
|
U (4) |
|
7. |
|
U (4) |
|
8. |
|
U (4) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS |
||
|
10. |
|
U (4) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA |
||
|
11. |
|
U (4) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA Following Heart Transplantation |
||
|
12. |
|
U (6) |
|
Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD |
||
|
13. |
|
U (4) |
|
14. |
|
U (5) |
|
14. |
|
U (5) |
|
14. |
|
U (4) |
|
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||
|
15. |
|
U (6) |
|
Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation |
||
|
17. |
|
U (6) |
|
18. |
|
U (4) |
|
Detection of CAD in Other Clinical Scenarios—Elevated Troponin of Uncertain Clinical Significance |
||
|
19. |
|
U (6) |
|
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures |
||
|
23. |
|
U (6) |
|
Use of CTA in the Setting of Prior Test Results—Prior CCS |
||
|
24. |
|
U (4) |
|
26. |
|
U (6) |
|
26. |
|
U (4) |
|
Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study |
||
|
29. |
|
U (6) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery |
||
|
33. |
|
U (5) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery |
||
|
37. |
|
U (6) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent) |
||
|
41. |
|
U (6) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG |
||
|
42. |
|
U (5) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting |
||
|
44. |
|
U (4) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function |
||
|
52. |
|
U (5) |
A indicates appropriate; I, inappropriate; and U, uncertain.
Table 10. Inappropriate Indications (Median Score 1–3)
|
Indication |
Appropriate Use Score (1–9) |
|
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent |
||
|
1. |
|
I (3) |
|
Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation) |
||
|
3. |
|
I (1) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS |
||
|
10. |
|
I (2) |
|
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA |
||
|
11. |
|
I (2) |
|
11. |
|
I (2) |
|
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery |
||
|
15. |
|
I (3) |
|
Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation |
||
|
16. |
|
I (2) |
|
Use of CTA in the Setting of Prior Test Results—ECG Exercise Testing |
||
|
21. |
|
I (2) |
|
21. |
|
I (3) |
|
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures |
||
|
23. |
|
I (2) |
|
Use of CTA in the Setting of Prior Test Results—Prior CCS |
||
|
25. |
|
I (2) |
|
Periodic Repeat Testing in Asymptomatic OR Stable Symptoms With Prior Stress Imaging or Coronary Angiography |
||
|
27. |
|
I (2) |
|
27. |
|
I (3) |
|
28. |
|
I (2) |
|
28. |
|
I (3) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Low-Risk Surgery |
||
|
30. |
|
I (1) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery |
||
|
31. |
|
I (2) |
|
32. |
|
I (2) |
|
34. |
|
I (1) |
|
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery |
||
|
35. |
|
I (2) |
|
36. |
|
I (2) |
|
38. |
|
I (2) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent) |
||
|
40. |
|
I (3) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG |
||
|
42. |
|
I (2) |
|
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting |
||
|
44. |
|
I (2) |
|
44. |
|
I (2) |
|
45. |
|
I (3) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function |
||
|
48. |
|
I (2) |
|
Evaluation of Cardiac Structure and Function—Evaluation of Intra- and Extracardiac Structures |
||
|
55. |
|
I (3) |
A indicates appropriate; I, inappropriate; and U, uncertain.
9. Discussion
Appropriate use criteria define common patient subgroups where expert opinion and the available medical evidence are combined to assess the net benefit of a test or procedure, in this instance CCT. The intent of these criteria is to guide the rational use of the procedure, namely avoidance of either under- or overutilization, and thereby lead to more optimal healthcare delivery and justifiable healthcare expenditures.
This document is an update to the original appropriateness criteria for CCT published in 2006,[1] written to reflect changes in test utilization in the context of rapidly developing technical and clinical applications and within the conceptual framework of dynamic appropriate use criteria development. Several aspects of the present document are noteworthy, including careful alignment to and, where possible, definition oflanguage in the radionuclide imaging appropriate use criteria[2] to enhance integration into comparable decision support tools and performance metrics. The underlying assumptions for the document are intended to broadly reflect the present community standards of technology and performance of the technique with an emphasis on adherence to imaging guidelines, patient safety, and laboratory quality and accreditation.
The clinical scenarios included in this report were designed to reflect the most common and important potential applications for CCT imaging. After the initial writing by the writing group, extensive review from external editors, and then ranking by the technical panel itself, the result is a set of scenarios that define patient-specific applications. The appropriate use criteria in this report provide a consensus judgment of whether it is reasonable to use CCT imaging for the particular clinical scenario described, such as those 93 indications listed in this document. These criteria are expected to be useful for clinicians, healthcare facilities, and third-party payers engaged in the delivery of cardiovascular imaging services. Although numerous, the indications are commonly divided among subclasses of patient CHD risk or pretest probability of CAD, as such characteristics are important considerations within the test performance characteristics. In total, 35 of 93 indications were judged to be appropriate, and 58 were judged to be either inappropriate or uncertain. It is important to note however, that an understanding of pretest patient characteristics is an important determinant of the appropriate use ratings. Few categories are uniform in the ratings for all patient characteristics.
Appropriate use criteria represent the first component of the chain of quality recommendations for cardiovascular imaging.[15] In addition to appropriate use, patient safety also should be considered when ordering coronary computed tomographic angiography (CTA), as it should be when ordering any cardiac imaging test. A consideration of the appropriate balance of using radiation dose reduction techniques to minimize radiation exposure while preserving image quality and the related benefits of imaging for a specific patient should be undertaken. This issue is discussed in more depth in a 2010 expert consensus document on coronary CTA.[16] The present document greatly expands the number of potential clinical scenarios in comparison to the original 2006 document. The clinical scenarios include acute and chronic chest pain, testing in symptomatic and asymptomatic patients, heart failure, preoperative risk assessment before both cardiac and noncardiac surgery, testing in the setting of prior test results (exercise testing, stress imaging procedures, coronary calcium scores, and repeat testing), prior revascularization, and the evaluation of cardiac structure and function. Although these criteria are intended to provide guidance for patients and clinicians, they are not intended to serve as substitutes for sound clinical judgment and practice experience. The writing group recognizes that many patients encountered in clinical practice may not be represented in these appropriate use criteria or may have extenuating features when compared with the clinical scenarios presented. Although the appropriate use ratings reflect critical medical literature as well as expert consensus, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient. Additionally, uncertain indications often require individual physician judgment and understanding of the patient to better determine the usefulness of a test for a particular scenario. As such, the ranking of an indication as uncertain (4 to 6) should not be viewed as limiting the use of CCT imaging for such patients. It should be emphasized that the technical panel was instructed that the uncertain designation was still designed to be considered as a "reimbursable" category.
These ratings are intended to evaluate the appropriate use of specific patient scenarios to determine overall patterns of care regarding CCT. In situations where there is substantial variation between the appropriate use rating and what the clinician believes is the best recommendation for the patient, further considerations or actions, such as a second opinion, may be appropriate. Moreover, it is not anticipated that all physicians or facilities will have 100% of their CCT procedures deemed appropriate. However, related to the overall patterns of care, if the national average of appropriate and uncertain ratings is 80%, for example, and a physician or facility has a 40% rate of inappropriate procedures, further examination of the patterns of care may be warranted and helpful. Implementation of these criteria is highly encouraged through provider education, as it is anticipated that increasing emphasis by laboratory accreditation bodies and other organizations focused on provider quality will apply.
9.1 Clinical Scenarios and their Ratings
Direct comparison to the 2006 document is difficult because of the many changes in the number and wording of clinical scenarios. In summary:
- A total of 31 indications were carried forward from the 2006 document, including prior ratings where 10 were appropriate, 10 were uncertain, and 11 were inappropriate. Among these, 8 shifted up 1 category from either uncertain to appropriate (Indications 1 [intermediate], 6 [low], 10 [intermediate], 39, 49, 54) or from inappropriate to uncertain (Indications 2 [high], 42 [>5 y]). The other 23 indications had unchanged appropriate use ratings.
- One area of expansion compared with the 2006 criteria involves symptomatic patients without known heart disease. CCT was felt to be appropriate primarily for situations involving a low or intermediate pretest probability of obstructive CAD. Scenarios involving high-probability CAD patients were rated as uncertain with the exceptions of a patient with an interpretable ECG who was able to exercise, and for definite myocardial infarction.
- Noncontrast CT calcium scoring was judged as appropriate for intermediate CHD risk patients, and for the specific subset of low-risk patients in whom a family history of premature CHD was present. Intermediate risk was defined as a 10-year risk of between 10% and 20%, although individual patient exceptions to a broadened intermediate risk range of 6% to 20% were recognized for certain patient subsets with generally low absolute risk but high relative risk (younger men and women). Screening asymptomatic patients using coronary CT angiography was considered inappropriate, as was repeat coronary calcium testing. Repeat CT angiography in asymptomatic patients or patients with stable symptoms with prior test results was broadly considered inappropriate.
- Within heart failure, CT angiography was appropriate or uncertain as a test across both normal (new to this document) and abnormal left ventricular ejection fraction, although the only appropriate scenarios were with reduced left ventricular ejection fraction with low or intermediate pretest CAD probability.
- As part of the preoperative evaluation, CT angiography was viewed as a potential option among patients undergoing heart surgery for noncoronary indications (e.g., valve replacement surgery or atrial septal defect closure) when the pretest CAD risk was either intermediate (appropriate) or low (uncertain). In comparison, there were no appropriate indications for coronary CT angiography as part of the preoperative evaluation for noncardiac surgery.
- The evaluation of coronary stents was considered as a function of patient symptom status, time from revascularization, and stent size. Only with larger stents (=3 mm in diameter) after long time periods (=2 years) was stent imaging considered uncertain, and only with left main stents was imaging of stents considered appropriate.
- A strength of cardiac CT imaging is the evaluation of cardiac structure and function. Appropriate indications incl