Appropriate Use Criteria
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

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Abstract

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting.

The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1–9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology.

The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes.

Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.

Preface

In an effort to respond to the need for the rational use of imaging services in the delivery of high-quality care, the American College of Cardiology Foundation (ACCF) has undertaken a process to determine the appropriate use of cardiovascular imaging for selected patient indications.

Appropriate Use Criteria (AUC) publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where 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 procedures examined, evidence base, and clinical experience. 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 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 health care resources in cardiovascular imaging. The ultimate objective of AUC 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. AUC, thus, should not be considered substitutes for sound clinical judgment and practice experience.

We are grateful to the rating panel, a professional group with a wide range of skills and insights, for their thoughtful and thorough deliberation of the merits of cardiac testing for stable ischemic heart disease (SIHD). In addition to our thanks to the rating 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 Jenissa Haidari and Joseph Allen, who continually drove the process forward; and to the entire Task Force for their dedication, insight, and leadership.

Michael J. Wolk, MD, MACC

Past Chair, Appropriate Use Criteria Task Force

Ralph G. Brindis, MD, MPH, FACC, FSCAI

Moderator, Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease Rating Panel

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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