Appropriate Use CriteriaACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons
Introduction
Since the introduction of AUC in 2005, the ACCF has produced a number of documents that synthesize evidence for a specific cardiovascular procedure into appropriateness standards. The AUC were developed to support utilization of high-quality patterns of procedure use (i.e., appropriate use) while informing efforts to reduce resource use when benefits to patients are unlikely.1, 2, 3
The range of tools used to evaluate cardiovascular disease has expanded over the past decade, especially in the field of noninvasive imaging. The purpose of this document is to delineate the appropriate use of various invasive and noninvasive testing modalities for the diagnosis and/or evaluation of SIHD across common patient presentations (indications), including:
- 1
Patients with signs and/or symptoms and/or various levels of risk for coronary disease (Sect. 1);
- 2
Patients with prior test results or coronary revascularization for follow-up evaluation (Sect. 2);
- 3
Patients scheduled for noncardiac surgery (Sect. 3);
- 4
Patients with an exercise prescription or referral to cardiac rehabilitation (Sect. 4).
Section snippets
Methods
The methods for development of AUC have evolved over time and were recently updated.2,3 A general overview of the methods is described in the following text.
The document is organized around the diagnostic and prognostic capabilities of anatomic and stress testing procedures to guide therapeutic choices for common clinical scenarios in the evaluation and follow-up of stable ischemic heart disease (SIHD). This document considers symptomatic and asymptomatic presentations for patients with and
Assumptions
To limit inconsistencies in interpretation, these specific assumptions should be considered when interpreting the ratings.
Definitions
Definitions of terms used throughout the indication set are listed here.
Abbreviations
AUC = Appropriate Use Criteria
CABG = coronary artery bypass graft
CAD = coronary artery disease
CHD = coronary heart disease
CMR = cardiac magnetic resonance
CCTA = coronary computed tomography angiography
ECG = electrocardiogram
ECHO = echocardiogram
METS = metabolic equivalents
PCI = percutaneous coronary intervention
PVC = premature ventricular contraction
RNI = radionuclide imaging
SIHD = stable ischemic heart disease
VT = ventricular tachycardia
Results of Ratings
The final ratings for Multimodality AUC on the Detection and Risk Assessment of SIHD are listed by indication in Tables 1.1, 1.2, 1.3, 2.0, 2.1,2.2, 2.3, 2.4, 2.5, 3.1, 3.2, 3.3, 4.1, and 4.2. The final score reflects the median score of the 17 rating panel members and has been labeled according to the categories of Appropriate (median 7-9), May Be Appropriate (median 4-6), and Rarely Appropriate (median 1-3) (Online Appendix 3). Eighteen of the 80 indications were considered Rarely Appropriate
Section 1. Detection of CAD/Risk Assessment
See Tables 1.1, 1.2, and 1.3.
Section 2.1. Prior Testing Without Intervening Revascularization (If Intervening Revascularization Since Most Recent Test, Refer to Sect. 2.2)
See Tables 2.0, 2.1, 2.2, and 2.3.
Section 2.2: Post-revascularization (PCI or CABG)
See Tables 2.4 and 2.5.
Section 3. Pre-Operative Evaluation for Noncardiac Surgery
See Tables 3.1, 3.2, and 3.3.
Section 4: Determine Exercise Level Prior to Initiation of Exercise Prescription or Cardiac Rehabilitation
See Tables 4.1 and 4.2.
Discussion
The current paper represents considerable progress in the development and evolution of the depth and extensiveness of AUC documents on cardiovascular imaging procedures. Initial AUC publications on indications for imaging in the detection and risk assessment of SIHD were centered around individual procedures. In the current document, we present a synthesis of evidence and clinical experience for all commonly employed noninvasive and invasive procedures for diagnosis of CAD. Importantly, this is
Conclusions
In summary, this document presents for the first time, side-by-side ratings of the multiple tests that are available to the clinician for the detection of SIHD or risk assessment purposes in the setting of 80 common scenarios. The document is not intended to foster or imply competition amongst modalities. It is intended to provide a practical guide to individual clinicians and patients when considering 1 of these procedures, based on any number of important local and patient-specific variables,
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This document was approved by the American College of Cardiology Foundation Board of Trustees in September 2013.
The American Society of Nuclear Cardiology requests that this document be cited as follows: Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, Min JK, Patel MR, Rosenbaum L, Shaw LJ, Stainback RF, Allen JM. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Nucl Cardiol. DOI [xxx]. Online date [xxx].
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