ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria for Diagnostic Catheterization

Manesh R. Patel; Steven R. Bailey; Robert O. Bonow; Charles E. Chambers; Paul S. Chan; Gregory J. Dehmer; Ajay J. Kirtane; L. Samuel Wann; R. Parker Ward

doi:10.1016/j.jacc.2012.03.003

Technical Panel

Pamela S. Douglas, MD, MACC, FAHA, FASE, Moderator

Manesh R. Patel, MD, FACC, Writing Group Liaison

Steven R. Bailey, MD, FACC, FSCAI, FAHA, Writing Group Liaison

Philip Altus, MD, MACP†

Denise D. Barnard, MD, FACC‡

James C. Blankenship, MD, MACC, FSCAI⁎

Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA†

Larry S. Dean, MD, FACC, FAHA, FSCAI⁎

Reza Fazel, MD, MSc, FACC§

Ian C. Gilchrist, MD, FACC, FSCAI, FCCM∥

Clifford J. Kavinsky, MD, PhD, FACC, FSCAI⁎

Susan G. Lakoski, MD, MS¶

D. Elizabeth Le, MD, FACC, FASE#

John R. Lesser, MD, FACC, FSCAI, FSCCT⁎⁎

Glenn N. Levine, MD, FACC, FAHA††

Roxana Mehran, MD, FACC, FACP, FCCP, FESC, FAHA, FSCAI‡‡

Andrea M. Russo, MD, FACC, FHRS§§

Matthew J. Sorrentino, MD, FACC‡‡

Mathew R. Williams, MD, FACC∥∥

John B. Wong, MD, FACP‡‡

Appropriate Use Criteria Task Force

Michael J. Wolk, MD, MACC, Chair

Steven R. Bailey, MD, FACC, FSCAI, FAHA

Pamela S. Douglas, MD, MACC, FAHA, FASE

Robert C. Hendel, MD, FACC, FAHA, FASNC

Christopher M. Kramer, MD, FACC, FAHA

James K. Min, MD, FACC

Manesh R. Patel, MD, FACC

Leslee Shaw, PhD, FACC, FASNC

Raymond F. Stainback, MD, FACC, FASE

Joseph M. Allen, MA

Abstract......0
Preface......0
1Introduction......0
2Methods......0
3Assumptions......0
4Definitions......0
- (Table 1a). Pretest Probability of CAD by Age, Gender, and Symptoms......0
- (Figure 8). Stepwise Approach to Perioperative Cardiac Assessment......0
- (Table 1b). Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)......0
- (Table 1c). Perioperative Clinical Risk Factors......0
5Abbreviations......0
6Results of Ratings......0
7Diagnostic Catheterization Appropriate Use Criteria (by Indication)......0
- (Table 1.1). Suspected or Known Acute Coronary Syndrome......0
- (Table 1.2). Suspected CAD: No Prior Noninvasive Stress Imaging (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)......0
- (Table 1.3). Suspected CAD: Prior Noninvasive Testing (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)......0
- (Table 1.4). Adjunctive Invasive Diagnostic Testing in Patients Undergoing Appropriate Diagnostic Coronary Angiography......0
- (Table 1.5). Patients With Known Obstructive CAD (e.g., Prior MI, Prior PCI, Prior CABG, or Obstructive Disease on Invasive Angiography)......0
- (Table 1.6). Arrhythmias......0
- (Table 1.7). Preoperative Coronary Evaluation for Noncardiac Surgery in Stable Patients......0
- (Table 2.1). Valvular Disease......0
- (Table 2.2). Pericardial Diseases......0
- (Table 2.3). Cardiomyopathies......0
- (Table 3.1). Pulmonary Hypertension or Intracardiac Shunt Evaluation......0
8Diagnostic Catheterization Appropriate Use Criteria (by Appropriate Use Rating)......0
- (Table 4). Appropriate Indications (Median Score 7–9)......0
- (Table 5). Uncertain Indications (Median Score 4–6)......0
- (Table 6). Inappropriate Indications (Median Score 1–3)......0
9Figures......0
- (Figure 1). Suspected CAD: No Prior Noninvasive Stress Imaging......0
- (Figure 2). Suspected CAD: Prior Noninvasive Stress Testing......0
- (Figure 3). Suspected CAD: Prior Noninvasive Cardiac CT (Calcium Score and CTA)......0
- (Figure 4). Patients With Known Obstructive CAD......0
- (Figure 5). Evaluation of Arrhythmias......0
- (Figure 6). Preoperative Coronary Evaluation: Patients With No Prior Noninvasive Stress Testing......0
- (Figure 7). Evaluation of Valvular Disease......0
10Discussion......0
- 10.1Assessment for CAD......0
- 10.2Assessment for Conditions Other Than CAD......0
- 10.3Application of the Criteria......0
Appendix A: Additional Diagnostic Catheterization Definitions......0
Appendix B: Additional Methods......0
- Relationships With Industry and Other Entities......0
- Literature Review......0
Appendix C: ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria For Diagnostic Catheterization Participants......0
Appendix D: ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria For Diagnostic Catheterization Writing Group, Technical Panel, Indication Reviewers, and Task Force—Relationships With Industry and Other Entities (in Alphabetical Order)......0
References......0

Abstract

The American College of Cardiology Foundation, in collaboration with the Society for Cardiovascular Angiography and Interventions and key specialty and subspecialty societies, conducted a review of common clinical scenarios where diagnostic catheterization is frequently considered.

The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of noninvasive imaging appropriate use criteria. The 166 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3).

Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease with other procedure components (e.g., hemodynamic measurements, ventriculography) at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the use of coronary angiography at the discretion of the operator. Seventy-five indications were rated as appropriate, 49 were rated as uncertain, and 42 were rated as inappropriate.

The appropriate use criteria for diagnostic catheterization have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Preface

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

Appropriate use criteria (AUC) publications reflect an ongoing effort to critically and systematically create, review, and categorize clinical situations where diagnostic tests and therapeutic procedures are utilized by physicians caring for patients with cardiovascular disease. The process is based on understanding the technical capabilities of the procedures examined. The diversity of clinical disease present makes it difficult to be comprehensive, but the indications presented hopefully identify common scenarios encompassing the majority of situations encountered in contemporary practice. Given the breadth of information conveyed, 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 and the Society for Cardiovascular Angiography and Interventions (SCAI) believe 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 care and invasive catheterization. The ultimate objective of the AUC is to improve patient care and health outcomes in a cost-effective manner while recognizing that some ambiguity and nuance is intrinsic to clinical decision making. Therefore, the AUC should not be considered substitutes for sound clinical judgment and practice experience. However, when the clinical judgment and practice patterns routinely conflict with AUC ratings, further evaluation of the specific clinical circumstances should be considered.

The AUC development process itself is also evolving. Given the iterative nature of the process and incorporation of new information about the role for diagnostic and therapeutic interventions, readers are counseled that comparison of individual appropriate use ratings developed at different times over the past several years may not reflect the comparative utility of different modalities for a given indication, as the ratings may vary over time. Cardiac catheterization plays a central role in the care of patients with cardiovascular disease, and guidance around the rationale and evidence based use of the procedure is the goal of the current document.

We are grateful to the technical panel and its moderator, Pamela S. Douglas, MD, MACC, FAHA, FASE, a professional group with a wide range of skills and insights, for their thoughtful and thorough deliberation of the merits of diagnostic catheterization for various indications. We would also like to thank the 28 individuals who provided a careful review of the draft of indications, the parent AUC Task Force, and the ACCF staff, specifically Joseph M. Allen and Lea Binder for their exceptionally skilled support in the generation of this document.

Manesh R. Patel, MD, FACC Co-Chair, Diagnostic Catheterization Writing Group

Steven R. Bailey, MD, FACC, FSCAI, FAHA Co-Chair, Diagnostic Catheterization Writing Group

Michael J. Wolk, MD, MACC Chair, Appropriate Use Criteria Task Force

Introduction

The ACCF, in collaboration with SCAI and several other professional organizations, developed common clinical scenarios where diagnostic cardiac catheterization is frequently considered. The indications, as presented in these clinical scenarios, were derived from common presentations or anticipated uses, as well as from current clinical practice guidelines. The 166 indications in this document were developed by a writing group with diverse clinical expertise and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median scores 7 to 9), uncertain use (median scores 4 to 6), and inappropriate use (median scores 1 to 3).

The AUC for diagnostic catheterization has the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, it is hoped that recognition of uncertain clinical scenarios facilitates identification of areas that could benefit from future research.

This report addresses the appropriate use of diagnostic catheterization. Improvements in cardiovascular imaging technology and an expanding array of noninvasive diagnostic tools and therapeutic options for patients with cardiovascular disease have led to many more choices than in the past. As the field advances, the healthcare community needs to understand how to best incorporate this technology into daily clinical care. ACCF and SCAI are dedicated to this effort.

Methods

The indications included in this publication cover a variety of cardiovascular signs and symptoms as well as clinical judgments as to the likelihood of cardiovascular findings. Within each main disease category, a standardized approach was used to capture a significant number of clinical scenarios without making the list of indications excessive. The term “indication” is used interchangeably with “clinical scenario” in the document for brevity and does not imply that imaging should necessarily be done. Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease (CAD), with other procedure components (e.g., hemodynamic measurements, ventriculography) performed at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the addition of coronary angiography at the discretion of the operator.

The spectrum of cardiovascular disease was addressed as it would apply to the standard adult catheterization laboratory. The writing group did not consider invasive evaluations of complex adult congenital heart disease in this document, with the belief that such complex cases would be best performed by individuals with considerable specialized expertise and at institutions with sufficient patient volume. Recommendations in this area are addressed in separate subspecialty publications. Additionally, invasive procedures such as endomyocardial biopsy, pericardiocentesis, or right heart catheterization not performed in the catheterization laboratory are not covered in this document.

The indications were constructed by a varied group of experts in both invasive and noninvasive diagnostic cardiac imaging. Subsequent modifications in the indications were made based on discussions with the task force and feedback from independent reviewers. Wherever possible, indications were mapped to relevant clinical guidelines and key publications/references (see Online Appendix).

A detailed description of the methods used for rating the selected clinical indications is found in a previous publication, “ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging” (1). Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise. The technical panel first rated the indications independently, after which the results were summarized and the panel convened for a face-to-face meeting to discuss each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers' scores. After the meeting, panel members once again independently rated each indication to determine the final scores.

Although panel members were not provided explicit cost information to help determine their ratings, they were asked to implicitly consider costs as an additional factor in their evaluation of appropriate use. In rating these criteria, the technical panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate, and was provided with the following definition of appropriate use:

An appropriate diagnostic cardiac catheterization (left heart, right heart, ventriculography, and/or coronary angiography) is one in which the expected incremental information combined with clinical judgment exceeds the 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.

Each member of the technical panel assigned a score to each indication, and the scores of the technical panel were tabulated for the final ratings and assigned an appropriateness rating as follows:

Median Score 7 to 9

Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).

Median 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.

Median Score 1 to 3

Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).

The division of these scores into 3 levels of appropriateness should be viewed as a continuum. It is important to emphasize that the category of “uncertain” is a distinct category and must not be considered either “appropriate” or “inappropriate” or lumped together with the other categories when characterizing appropriateness ratings. A rating of uncertain will exist if: 1) there is considerable diversity in the ratings among individual members of the technical panel indicating a wide range of opinions; 2) there is insufficient clinical information provided in the clinical scenario for the raters to reach a firm conclusion about appropriateness; or 3) there is a lack of specific information in the medical literature to make a firm recommendation regarding appropriateness. The uncertain category designation should encourage investigators to perform definitive research whenever possible. A designation of “uncertain” does not imply that the test should not be used in a specific clinical scenario. Many other factors known by the clinician and difficult to characterize within the structure of the AUC could affect a decision to perform or not perform a procedure in a specific patient. It is anticipated that the AUC reports will continue to be revised as further data are generated and information from the implementation of the criteria is accumulated. The writing group recognizes that a large portion of routine medical care would be rated as uncertain when held to the standards of the AUC and therefore hope this rating is correctly interpreted and can be placed in proper context.

To prevent bias in the scoring process, the technical panel was deliberately comprised of a minority of specialists in cardiac catheterization. Specialists, although 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.

The level of agreement among panelists as defined by RAND (2) was analyzed based on the BIOMED rule for a panel of 14 to 16 members. As such, agreement is defined as an indication where 4 or fewer panelists' ratings fell outside the 3-point region containing the median score.

Disagreement was defined as where at least 5 panelists' ratings fell in both the appropriate and the inappropriate categories. Any indication having disagreement was categorized as uncertain regardless of the final median score.

Assumptions

To limit inconsistencies in interpretation, specific assumptions were used by the writing group in drafting indications and by the technical panel when rating the clinical indications for the appropriate use of diagnostic catheterization.

1The clinical scenarios were rated based on published literature and clinical practice guidelines regarding the risks and benefits of diagnostic catheterization, if available. In general, there are few randomized trials specifically examining diagnostic catheterization as a procedure. However, diagnostic catheterization was used within the study design of many randomized trials in which specific therapies were tested. Specific patient groups not well represented in the literature are not presented in the current clinical scenarios. However, the writing group recognizes that decisions about diagnostic catheterization in such patients are frequently required. Examples of such patients include those with end-stage renal disease, advanced age, or malignancy.
2All patients are attempting to achieve optimal care, including guideline-based risk factor modification for primary or secondary prevention in cardiovascular patients unless specifically noted (3- 7).
3Despite the best efforts of the clinician, all patients may not achieve target goals for risk factor modification. However, a plan of care to address risk factors is assumed to be occurring in patients represented in the indications. For patients with chronic stable angina, the writing group recognizes that there is a wide variance in the medical therapy for angina.
4Operators performing diagnostic catheterization have appropriate clinical training and experience and have satisfactory outcomes as assessed by quality assurance monitoring (8- 9).
5Diagnostic catheterization (left heart, right heart, and/or coronary angiography) is performed in a manner consistent with established standards of care (8- 9).
6All indications for diagnostic catheterization were considered with the following important assumptions:
- aAll indications were first evaluated on the basis of the available medical literature.
- bIn many cases, studies published in the medical literature provide minimal information about the role of the test in clinical decision making.
- cAppropriate use criteria development requires a risk/benefit trade-off as determined by individual patient indications. Radiation exposure should be considered in risk estimates.
- dNo circumstances exist that would preclude cardiac catheterization (e.g., severe coagulopathy, patient refusal).
7A complete clinical history and physical exam has been completed by a qualified clinician such that the clinical status of the patient can be assumed to be valid as stated in the indication (e.g., asymptomatic patient is truly asymptomatic for the condition in question and that sufficient questioning of the patient has been undertaken).
8Cost was be considered implicitly in the appropriate use determination.
9For each indication, the rating reflected whether diagnostic catheterization is reasonable for the patient and not whether it is preferred over another modality.
10The category of “uncertain” was used when insufficient clinical data are available for a definitive categorization or there is substantial disagreement regarding the appropriateness of that indication. Those scenarios designated as uncertain reflect variations in clinical practice patterns. The designation of “uncertain” should not be used as grounds for denial of reimbursement.
11All procedures presented are to be considered for clinical indications and not part of a research protocol.
12All prior noninvasive testing was adequately completed.

Definitions

Definitions of terms used throughout the indication set are listed here. These definitions were provided to and discussed with the technical panel prior to rating of indications.

Stress Testing and Risk of Findings on Noninvasive Testing: Stress testing is commonly used for both diagnosis (possible/presumed) and risk stratification of patients with established CAD. Using criteria defined for traditional exercise stress tests (10- 11):

•Low-risk stress test findings: associated with a cardiac mortality of <1% per year
•Intermediate-risk stress test findings: associated with a 1% to 3% per year cardiac mortality
•High-risk stress test findings: associated with a >3% per year cardiac mortality

Symptomatic/Ischemic Equivalent: Chest Pain Syndrome, Anginal Equivalent, or Ischemic Electrocardiogram (ECG) Abnormalities: Any constellation of clinical findings that the physician believes is consistent with CAD manifestations. Examples of such findings include, but are not limited to, chest pain, chest tightness, chest burning, shoulder pain, left arm pain, jaw pain, new ECG abnormalities, or other symptoms/findings suggestive of CAD. Clinical presentations in the absence of chest pain (e.g., dyspnea with exertion or reduced/worsening effort tolerance) that are thought to be consistent with CAD may also be considered to be an ischemic equivalent.

Clinical Classification of Chest Pain:

•Typical Angina (Definite): defined as 1) substernal chest pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin (12).
•Atypical Angina (Probable): chest pain or discomfort that lacks 1 of the characteristics of definite or typical angina.
•Nonanginal Chest Pain: chest pain or discomfort that meets 1 or none of the typical angina characteristics.

Grading of Angina Pectoris by the Canadian Cardiovascular Society Classification System ((13)):

Class I: ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.
Class II: slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and in normal condition.
Class III: marked limitations of ordinary physical activity. Angina occurs on walking 1 or 2 blocks on the level and climbing 1 flight of stairs in normal conditions and at a normal pace.
Class IV: inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.

Pretest Probability of Coronary Artery Disease: Symptomatic (Ischemic Equivalent) Patients: Once the physician determines that symptoms are present that may represent CAD, the pretest probability of CAD should be assessed. There are a number of risk algorithms (14- 15) available that can be used to calculate this probability. Clinicians should be familiar with those algorithms that pertain to the populations they encounter most often. In rating the appropriateness of cardiac catheterization for specific indications, the following probabilities, as calculated from any of the various available validated algorithms, should be applied (10):

•Very low pretest probability: <5% pretest probability of CAD
•Low pretest probability: between 5% and 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 ACCF/AHA guidelines for chronic stable angina (10) is provided as one example of a method used to calculate pretest probability and is a modification of a previously published literature review (16). Please refer to (Table 1a) and the clinical classification of chest pain definition angina characteristics. It is important to note that other historical factors or ECG findings (e.g., prior infarction) can affect pretest probability, although these factors are not accounted for in (Table 1a). Similarly, while not incorporated into the algorithm, other CAD risk factors may also affect pretest likelihood of CAD. Detailed nomograms are available that incorporate the effects of a history of prior infarction, ECG Q waves and ST- and T-wave changes, diabetes, smoking, and hypercholesterolemia (17).

Table APretest Probability of CAD by Age, Gender, and Symptoms(fn1)

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Age (Yrs)	Gender	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

⁎Modified from the ACC/AHA Exercise Testing Guidelines to reflect all age ranges (18).

Global CAD Risk: It is assumed that clinicians will use current standard methods of global risk assessment such as those presented in the National Heart, Lung, and Blood Institute report on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) (19) or similar national guidelines.

Absolute risk is defined as the probability of developing CAD over a given time period. The ATP III report estimates the absolute risk for CAD over the next 10 years. CAD risk refers to 10-year risk for any hard cardiac event (e.g., myocardial infarction or CAD death). However, acknowledging that global absolute risk scores may have not been evaluated in certain populations (e.g., women, younger men, minority populations), clinical judgment must be applied in assigning categorical risk thresholds in such subpopulations.

•Low global CAD risk
- Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk <6%.

•Intermediate global CAD risk
- Defined by the age-specific risk level that is average. In general, moderate risk will correlate with a 10-year absolute CAD risk range of 10% to 20%. Among women and younger men, an expanded intermediate risk range of 6% to 20% may be appropriate.

•High global CAD risk
- Defined by the age-specific risk level that is above average. In general, high risk will correlate with a 10-year absolute CAD risk of >20%. CAD equivalents (e.g., diabetes mellitus, peripheral arterial disease) can also define high risk.

Duke Treadmill Score ((20)): The equation for calculating the Duke treadmill score (DTS) is DTS = exercise time in minutes − (5 × ST-segment deviation) − (4 × exercise angina), with 0 = none, 1 = nonlimiting, and 2 = exercise-limiting.

The score typically ranges from −25 to +15. These values correspond to low-risk (with a score of ≥+5), moderate-risk (with scores ranging from −10 to +4), and high-risk (with a score of ≤−11) categories.

ECG—Uninterpretable: Refers to ECGs with resting ST-segment depression (≥0.10 mV), left bundle branch block (LBBB), pre-excitation (Wolff-Parkinson-White Syndrome), or paced rhythm.

Adjunct Invasive Diagnostic Testing:

•Fractional flow reserve (FFR)
- An invasive diagnostic tool used to provide physiological measurements as an adjunct to coronary angiography for the determination of lesion severity and to assist in decisions about revascularization. FFR is calculated using the ratio of the mean arterial pressure distal to a stenosis to the mean aortic pressure during maximal hyperemia. FFR measurements <0.75 are associated with ischemia on exercise testing and adjunct imaging (echo or nuclear) with high sensitivity (88%), specificity (100%), and overall accuracy (93%). FFR measurements >0.80 are associated with negative ischemic results with a predictive accuracy of 95%. Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents with deferral of lesions with FFR >0.80 has been shown to significantly reduce the rate of the composite endpoint of death, nonfatal myocardial infarction, and repeat revascularization at 1 year (21).

•Intravascular ultrasound
- An invasive diagnostic test performed as an adjunct to diagnostic catheterization to provide an ultrasound-based anatomic assessment that extends beyond conventional angiography. This technique is used to identify lesion and vessel characteristics and obtain basic measurements for diagnostic and interventional application (minimal and maximal luminal diameters, cross-sectional area, and plaque area).

Evaluating Perioperative Risk for Noncardiac Surgery:

See (Figure 8), “Stepwise Approach to Perioperative Cardiac Assessment,” from the ACCF/AHA 2009 perioperative guidelines (22). According to the algorithm, once it is determined that the patient does not require urgent surgery, the clinician should determine the patient's active cardiac conditions (see Table 1b) and/or perioperative risk predictors (see Table 1c). If any active cardiac conditions and/or major risk predictors are present, (Figure 8) suggests consideration of guideline-based care that may include coronary angiography and postponing or canceling noncardiac surgery. Once perioperative risk predictors are assessed, the surgical risk and the patient's functional status should be used to establish the need for noninvasive testing.

Grahic Jump Location

Figure A

Stepwise Approach to Perioperative Cardiac Assessment

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients ≥50 years of age. HR = heart rate; LOE = level of evidence; MET = metabolic equivalent. Modified from Fleisher et al. (22).

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Table BActive Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Noncardiac Surgery (Class I, Level of Evidence: B)

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Condition	Examples
Unstable coronary syndromes	Unstable or severe angina(fn2) (CCS class III or IV)(fn3)
	Recent MI(fn4)
Decompensated HF (NYHA functional class IV; worsening or new-onset HF)
Significant arrhythmias	High-grade atrioventricular block
	Mobitz II atrioventricular block
	Third-degree atrioventricular heart block
	Symptomatic ventricular arrhythmias
	Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR >100 beats/min at rest)
	Symptomatic bradycardia
	Newly recognized ventricular tachycardia
Severe valvular disease	Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm², or symptomatic)
	Symptomatic mitral stenosis (progressive dyspnea on exertion, extertional presyncope, or HF)

⁎According to Campeau (13);

†may include “stable” angina in patients who are unusually sedentary;

‡the American College of Cardiology National Database Library defines recent MI as >7 days but ≤1 month (within 30 days).

Table CPerioperative Clinical Risk Factors(fn5)

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•History of ischemic heart disease•History of compensated or prior heart failure•History of cerebrovascular disease•Diabetes mellitus (requiring insulin)•Renal insufficiency (creatinine >2.0)

⁎As defined by the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery (22). Note that these are not standard coronary artery disease risk factors.

Abbreviations

ACS = acute coronary syndrome AV = atrioventricular CABG = coronary artery bypass grafting surgery CAD = coronary artery disease ECG = electrocardiogram FFR = fractional flow reserve LBBB = left bundle branch block LV = left ventricular

Results of Ratings

The final ratings for diagnostic catheterization are listed by indication in (Tables 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 2.1, 2.2, 2.3, 3.1). The final score reflects the median score of the 17 technical panel members and has been labeled according to the 3 appropriate use categories of appropriate (median 7 to 9), uncertain (median 4 to 6), and inappropriate (median 1 to 3). (Tables 4, 5, 6) present the same indications by the appropriate use categories.

Table 1.1Suspected or Known ACS

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Indication		Appropriate Use Score (1–9)
1.	•Cardiogenic shock due to suspected ACS	A (9)
2.	•STEMI or suspected STEMI	A (9)
Risk Score (e.g., TIMI, GRACE)		Low	Intermediate	High
3.	•UA/NSTEMI	A (7)	A (8)	A (9)
4.	•Suspected ACS with newly diagnosed LV wall motion abnormality or newly diagnosed resting myocardial perfusion defect	A (7)	A (8)	A (9)

Table 1.2Suspected CAD: No Prior Noninvasive Stress Imaging (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)

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Indication		Appropriate Use Score (1–9)
Asymptomatic
5.	•Low global CAD risk	I (1)
6.	•Intermediate global CAD risk	I (3)
7.	•High global CAD risk	U (4)
Symptomatic
8.	•Low pretest probability	I (3)
9.	•Intermediate pretest probability	U (6)
10.	•High pretest probability	A (7)

Table 1.3Suspected CAD: Prior Noninvasive Testing (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)

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Indication		Appropriate Use Score (1–9)
ECG Stress Testing		Pretest Symptom Status
ECG Stress Testing		Asymptomatic	Symptomatic
11.	•Low-risk findings (e.g., Duke treadmill score ≥5)	I (1)	U (4)
12.	•Intermediate-risk findings (e.g., Duke treadmill score 4 to −10)	U (4)	U (6)
13.	•High-risk findings (e.g., Duke treadmill score ≤−11)	A (7)	A (8)
14.	•Other high-risk findings (ST-segment elevation, hypotension with exercise, ventricular tachycardia, prolonged ST-segment depression)	A (7)	A (9)
Stress Test With Imaging (SPECT MPI, Stress Echocardiography, Stress PET, Stress CMR)		Pretest Symptom Status
		Asymptomatic	Symptomatic
15.	•Low-risk findings (e.g., <5% ischemic myocardium on stress SPECT MPI or stress PET, no stress-induced wall motion abnormalities on stress echo or stress CMR)	I (2)	U (4)
16.	•Intermediate-risk findings (e.g., 5% to 10% ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall motion abnormality in a single segment on stress echo or stress CMR)	U (4)	A (7)
17.	•High-risk findings (e.g., >10% ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall motion abnormality in 2 or more segments on stress echo or stress CMR)	A (7)	A (9)
18.	•Other high-risk findings (e.g., TID, significant stress-induced LV dysfunction)	A (7)	A (8)
19.	•Discordant findings (e.g., low-risk prior imaging with ongoing symptoms consistent with ischemic equivalent)	Not rated	A (7)
20.	•Discordant findings (e.g., low-risk stress imaging with high-risk stress ECG response or stress-induced typical angina)	U (5)	A (7)
21.	•Equivocal/uninterpretable findings (e.g., perfusion defect vs. attenuation artifact, uninterpretable stress imaging)	U (5)	A (7)
22.	•Fixed perfusion defect on SPECT MPI or a persistent wall motion abnormality on stress echo consistent with infarction without significant ischemia (<5% ischemic myocardium)	U (4)	U (6)
23.	•Baseline resting LV dysfunction (i.e., LVEF ≤40%) AND•Evidence (e.g., PET, CMR, delayed thallium uptake, dobutamine echo) of myocardial viability in dysfunctional segment	A (7)	A (8)
Echocardiography (TTE)		Pretest Symptom Status
Echocardiography (TTE)		Asymptomatic	Symptomatic
24.	•Newly recognized LV systolic dysfunction (i.e., LVEF ≤40%) with an unknown etiology	U (6)	A (8)
25.	•Newly recognized LV systolic dysfunction (i.e., LVEF 41% to 49%) with an unknown etiology	U (5)	A (8)
26.	•New regional wall motion abnormality with an unknown etiology and normal LV systolic function	U (5)	A (7)
27.	•Suspected significant ischemic complication related to CAD (e.g., ischemic mitral regurgitation or VSD)	A (9)
Coronary Calcium Score		Pretest Symptom Status
Coronary Calcium Score		Asymptomatic	Symptomatic(fn6)
28.	•Agatston score <100	I (1)	Not rated
29.	•Agatston score 100–400	I (2)	Not rated
30.	•Agatston score 400–1,000	I (3)	Not rated
31.	•Agatston score >1,000	I (3)	Not rated
Coronary CTA		Pretest Symptom Status
Coronary CTA		Asymptomatic	Symptomatic
32.	•Lesion <50% non-left main	I (1)	U (4)
33.	•Lesion ≥50% non-left main	U (4)	A (7)
34.	•Lesion ≥50% left main	Not rated	A (8)
35.	•Lesions ≥50% in more than 1 coronary territory	U (5)	A (7)
36.	•Lesion of unclear severity, possibly obstructive (non-left main)	U (4)	A (7)
37.	•Lesion of unclear severity, possibly obstructive (left main)	A (7)	A (8)
38.	•Lesion <50% with extensive partly calcified and non-calcified plaque	I (3)	U (5)
CMR		Pretest Symptom Status
CMR		Asymptomatic	Symptomatic
39.	•Area of delayed gadolinium myocardial enhancement of unknown etiology	I (3)	Not rated

⁎Coronary calcium score only rated for asymptomatic patients as these patients are the population in which it is used.

Table 1.4Adjunctive Invasive Diagnostic Testing in Patients Undergoing Appropriate Diagnostic Coronary Angiography

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Indication		Appropriate Use Score (1–9)
		Unexpected Angiographic Finding or No Prior Noninvasive Testing	Prior Testing = No Ischemic Findings	Prior Testing = Concordant(fn7)Ischemic Findings
FFR for Lesion Severity
40.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)	A (7)	A (7)	A (7)
41.	•Nonobstructive disease by angiography (non-left main) <50%	I (3)	I (2)	U (5)
42.	•Angiographically intermediate disease (non-left main) 50% to 69%	A (7)	U (6)	A (7)
43.	•Angiographically obstructive significant disease (non-left main) ≥70% stenosis	A (7)	A (7)	I (3)
IVUS for Lesion Severity
44.	•Angiographically indeterminate left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)	A (7)	A (7)	A (7)
45.	•Nonobstructive disease by angiography (non-left main) <50%	I (3)	I (3)	U (6)
46.	•Angiographically intermediate disease (non-left main) 50% to 69%	U (5)	U (5)	U (6)
47.	•Angiographically obstructive significant disease (non-left main) ≥70% stenosis	U (4)	U (5)	I (3)
IVUS—Examination of Lesion or Artery Morphology
48.	•Coronary lesions or structures difficult to characterize angiographically (e.g., aneurysm, extent of calcification, stent fracture, stent apposition, stent expansion, dissections) or for sizing of vessel before stent placement			A (8)

⁎Concordance refers to noninvasive imaging studies that demonstrate evidence of abnormal myocardial perfusion that is in the same distribution as a coronary artery stenosis, or degree of valvular disease that is similar to clinical impression.

Table 1.5Patients With Known Obstructive CAD (e.g., Prior MI, Prior PCI, Prior CABG, or Obstructive Disease on Invasive Angiography)

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Indication		Appropriate Use Score (1–9)
Medically Managed Patients		Asymptomatic/Controlled Symptoms OR Unchanged Findings	Worsening or Limiting Symptoms AND Worsening Findings
49.	•Low-risk noninvasive findings	I (2)	U (6)
50.	•Intermediate-risk noninvasive findings	U (4)	A (7)
51.	•High-risk noninvasive findings	A (7)	A (9)
Post Revascularization (PCI or CABG)
52.	•Asymptomatic or stable symptoms		I (1)
53.	•Low-risk noninvasive findings•Worsening or limiting symptoms		U (6)
54.	•Intermediate-risk noninvasive findings•Worsening or limiting symptoms		A (7)
55.	•High-risk noninvasive findings•Worsening or limiting symptoms		A (8)
Post Revascularization (PCI)
56.	•Asymptomatic•Prior unprotected left main PCI		U (5)

Table 1.6Arrhythmias

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Indication		Appropriate Use Score (1–9)
Etiology Unclear After Initial Evaluation
57.	•Resuscitated cardiac arrest with return of spontaneous circulation	A (8)
58.	•VF or sustained VT with or without symptoms	A (8)
59.	•Nonsustained VT (<6 beats VT)•Normal LV systolic function	U (5)
No Prior Noninvasive Assessment of Ischemia With Normal Systolic Function
CHD Risk		Low	Intermediate	High
60.	•Syncope	I (2)	U (4)	U (6)
61.	•New-onset atrial fibrillation or flutter	I (2)	I (3)	U (5)
62.	•Heart block (e.g., second-degree type II or third-degree AV block) OR•Symptomatic bradyarrhythmias	I (2)	I (3)	U (5)
63.	•Newly diagnosed LBBB	U (4)	U (5)	U (6)

Table 1.7Preoperative Coronary Evaluation for Noncardiac Surgery in Stable Patients

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Indication		Appropriate Use Score (1–9)
64.	•Low-risk surgery	I (2)
65.	•≥4 METS functional capacity without symptoms	I (2)
66	•Prior to solid organ transplantation	U (5)
<4 METS Functional Capacity, No Noninvasive Testing Performed, With or Without Clinical Risk Factors Present (Preoperative Clinical Risk Factors: Ischemic Heart Disease, Heart Failure, Cerebrovascular Disease, Insulin-Requiring Diabetes Mellitus, Renal Insufficiency Cr >2.0)
Procedure Planned		Intermediate-Risk Surgery	Vascular Surgery
67.	•No risk factors	I (2)	I (3)
68.	•1 to 2 risk factors	I (3)	U (4)
69.	•≥3 risk factors	U (4)	U (6)

Table 2.1Valvular Disease

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Indication		Appropriate Use Score (1–9)
70.	•Preoperative assessment before valvular surgery	A (7)
71.	•Pulmonary hypertension out of proportion to the severity of valvular disease	A (8)
72.	•Left ventricular dysfunction out of proportion to the severity of valvular disease	A (8)
Chronic Native or Prosthetic Valvular Disease Asymptomatic Related to Valvular Disease
73.	•Mild or moderate mitral stenosis	I (2)
74.	•Severe mitral stenosis	U (6)
75.	•Mild or moderate mitral regurgitation	I (2)
76.	•Severe mitral regurgitation	U (5)
77.	•Mild or moderate aortic stenosis	I (2)
78.	•Severe aortic stenosis	U (4)
79.	•Mild or moderate aortic regurgitation	I (2)
80.	•Severe aortic regurgitation	U (5)
Chronic Native or Prosthetic Valvular Disease Symptomatic Related to Valvular Disease
Noninvasive Imaging for Valvular Disease		Concordant With Clinical Impression of Severity	Conflicting With Clinical Impression of Severity
81.	•Mild or moderate mitral stenosis	I (2)	A (7)
82.	•Severe mitral stenosis	I (3)	A (7)
83.	•Mild or moderate mitral regurgitation	I (2)	A (7)
84.	•Severe mitral regurgitation	I (3)	A (7)
85.	•Mild or moderate aortic stenosis	I (3)	A (7)
86.	•Severe aortic stenosis	I (3)	A (8)
87.	•Equivocal aortic stenosis/low gradient aortic stenosis•May include pharmacological challenge (e.g., dobutamine)	Not rated	A (8)
88.	•Mild or moderate aortic regurgitation	I (2)	A (7)
89.	•Severe aortic regurgitation	I (3)	A (8)
90.	•Acute moderate or severe mitral or aortic regurgitation	U (4)	A (8)

Table 2.2Pericardial Diseases

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Indication		Appropriate Use Score (1–9)
91.	•Suspected pericardial tamponade	A (8)
92.	•Suspected or clinical uncertainty between constrictive vs. restrictive physiology	A (8)

Table 2.3Cardiomyopathies

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Indication		Appropriate Use Score (1–9)
93.	•Known or suspected cardiomyopathy with or without heart failure	A (7)
94.	•Re-evaluation of known cardiomyopathy•Change in clinical status or cardiac exam or to guide therapy	A (7)
95.	•Suspected arrhythmogenic right ventricular dysplasia•Assessment of right ventricular morphology	U (5)

Table 3.1Pulmonary Hypertension or Intracardiac Shunt Evaluation

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Indication		Appropriate Use Score (1–9)
96.	•Known or suspected intracardiac shunt with indeterminate shunt anatomy or shunt fraction	A (8)
Evaluation of Pulmonary Hypertension
97.	•Suspected pulmonary artery hypertension•Equivocal or borderline elevated estimated right ventricular systolic pressure on resting echo study	A (7)
98.	•Suspected pulmonary hypertension•Elevated estimated right ventricular systolic pressure on resting echo study	A (7)
99.	•Resting pulmonary hypertension•Determine response to pulmonary vasodilators given in cath lab	A (8)
100.	•Resting pulmonary hypertension•Determine response after initiation of drug therapy	A (7)
101.	•Post heart transplant patient•With or without the performance of endomyocardial biopsy	A (7)
102.	•Indeterminate intravascular volume status•Etiology unclear after initial evaluation	A (7)

Table 4Appropriate Indications (Median Score 7–9)

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Indication		Appropriate Use Score (1–9)
Suspected Acute Coronary Syndrome
1.	•Cardiogenic shock due to suspected ACS	A (9)
2.	•STEMI or suspected STEMI	A (9)
3.	•UA/NSTEMI•Low-risk score (e.g., TIMI, GRACE)	A (7)
3.	•UA/NSTEMI•Intermediate-risk score (e.g., TIMI, GRACE)	A (8)
3.	•UA/NSTEMI•High-risk score (e.g., TIMI, GRACE)	A (9)
4.	•Suspected ACS with newly diagnosed LV wall motion abnormality or newly diagnosed resting myocardial perfusion defect•Low-risk score (e.g., TIMI, GRACE)	A (7)
4.	•Suspected ACS with newly diagnosed LV wall motion abnormality or newly diagnosed resting myocardial perfusion defect•Intermediate risk score (e.g., TIMI, GRACE)	A (8)
4.	•Suspected ACS with newly diagnosed LV wall motion abnormality or newly diagnosed resting myocardial perfusion defect•High-risk score (e.g., TIMI, GRACE)	A (9)
Suspected CAD: No Prior Noninvasive Stress Imaging (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)
10.	•High pretest probability•Symptomatic	A (7)
Suspected CAD: Prior Noninvasive Testing (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)
ECG Stress Testing
13.	•High-risk findings (e.g., Duke treadmill score ≤−11)•Asymptomatic	A (7)
13.	•High-risk findings (e.g., Duke treadmill score ≤−11)•Symptomatic	A (8)
14.	•Other high-risk finding (ST-segment elevation, hypotension with exercise, ventricular tachycardia, prolonged ST-segment depression)•Asymptomatic	A (7)
14.	•Other high-risk finding (ST-segment elevation, hypotension with exercise, ventricular tachycardia, prolonged ST-segment depression)•Symptomatic	A (9)
Stress Test With Imaging (SPECT MPI, Stress Echocardiography, Stress PET, Stress CMR)
16.	•Intermediate-risk findings (e.g., 5% to 10% ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall motion abnormality in a single segment on stress echo or stress CMR)•Symptomatic	A (7)
17.	•High-risk findings (e.g., >10% ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall motion abnormality in 2 or more segments on stress echo or stress CMR)•Asymptomatic	A (7)
17.	•High-risk findings (e.g., >10% ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall motion abnormality in 2 or more segments on stress echo or stress CMR)•Symptomatic	A (9)
18.	•Other high-risk finding (e.g., TID, significant stress-induced LV dysfunction)•Asymptomatic	A (7)
18.	•Other high-risk finding (e.g., TID, significant stress-induced LV dysfunction)•Symptomatic	A (8)
19.	•Discordant findings (e.g., low-risk prior imaging with ongoing symptoms consistent with ischemic equivalent)•Symptomatic	A (7)
20.	•Discordant findings (e.g., low-risk stress imaging with high-risk stress ECG response or stress-induced typical angina)•Symptomatic	A (7)
21.	•Equivocal/uninterpretable findings (e.g., perfusion defect vs. attenuation artifact, uninterpretable stress imaging)•Symptomatic	A (7)
23.	•Baseline resting LV dysfunction (i.e., LVEF ≤40%) AND•Evidence (e.g., PET, CMR, delayed thallium uptake, dobutamine echo) of myocardial viability in dysfunctional segment•Asymptomatic	A (7)
23.	•Baseline resting LV dysfunction (i.e., LVEF ≤40%) AND•Evidence (e.g., PET, CMR, delayed thallium uptake, dobutamine echo) of myocardial viability in dysfunctional segment•Symptomatic	A (8)
Echocardiography (TTE)
24.	•Newly recognized LV systolic dysfunction (i.e., LVEF ≤40%) with an unknown etiology•Symptomatic	A (8)
25.	•Newly recognized LV systolic dysfunction (i.e., LVEF 41% to 49%) with an unknown etiology•Symptomatic	A (8)
26.	•New regional wall motion abnormality with an unknown etiology and normal LV systolic function•Symptomatic	A (7)
27.	•Suspected significant ischemic complication related to CAD (e.g., ischemic mitral regurgitation or VSD)	A (9)
Coronary CTA
33.	•Lesion ≥50% non-left main•Symptomatic	A (7)
34.	•Lesion ≥50% left main•Symptomatic	A (8)
35.	•Lesions ≥50% in more than 1 coronary territory•Symptomatic	A (7)
36.	•Lesion of unclear severity, possibly obstructive (non-left main)•Symptomatic	A (7)
37.	•Lesion of unclear severity, possibly obstructive (left main)•Asymptomatic	A (7)
37.	•Lesion of unclear severity, possibly obstructive (left main)•Symptomatic	A (8)
Adjunctive Invasive Diagnostic Testing in Patients Undergoing Appropriate Diagnostic Coronary Angiography
FFR for Lesion Severity
40.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)•Unexpected angiographic finding or no prior noninvasive testing	A (7)
40.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)•Prior testing = no ischemic findings	A (7)
40.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)•Prior testing = concordant ischemic findings	A (7)
42.	•Angiographically intermediate disease (non-left main) 50% to 69%•Unexpected angiographic finding or no prior noninvasive testing	A (7)
42.	•Angiographically intermediate disease (non-left main) 50% to 69%•Prior testing = concordant ischemic findings	A (7)
43.	•Angiographically obstructive significant disease (non-left main) ≥70% stenosis•Unexpected angiographic finding or no prior noninvasive testing	A (7)
43.	•Angiographically obstructive significant disease (non-left main) ≥70% stenosis•Prior testing = no ischemic findings	A (7)
IVUS for Lesion Severity
44.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)•Unexpected angiographic finding or no prior noninvasive testing	A (7)
44.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)•Prior testing = no ischemic findings	A (7)
44.	•Angiographically indeterminate severity left main stenosis (defined as 2 or more orthogonal views contradictory whether stenosis >50%)•Prior testing = concordant ischemic findings	A (7)
IVUS—Examination of Lesion or Artery Morphology
48.	•Coronary lesions or structures difficult to characterize angiographically (e.g., aneurysm, extent of calcification, stent fracture, stent apposition, stent expansion, dissections) or for sizing of vessel before stent placement	A (8)
Patients With Known Obstructive CAD (e.g., Prior MI, Prior PCI, Prior CABG, or Obstructive Disease on Invasive Angiography)
Medically Managed Patients
50.	•Intermediate-risk noninvasive findings•Worsening or limiting symptoms and worsening findings	A (7)
51.	•High-risk noninvasive findings•Asymptomatic/controlled symptoms or unchanged findings	A (7)
51.	•High-risk noninvasive findings•Worsening or limiting symptoms and worsening findings	A (9)
Post Revascularization (PCI or CABG)
54.	•Intermediate-risk noninvasive findings•Worsening or limiting symptoms	A (7)
55.	•High-risk noninvasive findings•Worsening or limiting symptoms	A (8)
Arrhythmias
Etiology Unclear After Initial Evaluation
57.	•Resuscitated cardiac arrest with return of spontaneous circulation	A (8)
58.	•VF or sustained VT with or without symptoms	A (8)
Valvular Disease
70.	•Preoperative assessment before valvular surgery	A (7)
71.	•Pulmonary hypertension out of proportion to the severity of valvular disease	A (8)
72.	•Left ventricular dysfunction out of proportion to the severity of valvular disease	A (8)
Chronic Native or Prosthetic Valvular Disease Symptomatic Related to Valvular Disease
81.	•Mild or moderate mitral stenosis•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (7)
82.	•Severe mitral stenosis•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (7)
83.	•Mild or moderate mitral regurgitation•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (7)
84.	•Severe mitral regurgitation•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (7)
85.	•Mild or moderate aortic stenosis•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (7)
86.	•Severe aortic stenosis•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (8)
87.	•Equivocal aortic stenosis/low gradient aortic stenosis•May include pharmacological challenge (e.g., dobutamine)•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (8)
88.	•Mild or moderate aortic regurgitation•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (7)
89.	•Severe aortic regurgitation•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (8)
90.	•Acute moderate or severe mitral or aortic regurgitation•Noninvasive imaging for valvular disease conflicting with clinical impression of severity	A (8)
Pericardial Diseases
91.	•Suspected pericardial tamponade	A (8)
92.	•Suspected or clinical uncertainty between constrictive vs. restrictive physiology	A (8)
Cardiomyopathies
93.	•Known or suspected cardiomyopathy with or without heart failure	A (7)
94.	•Re-evaluation of known cardiomyopathy•Change in clinical status or cardiac exam or to guide therapy	A (7)
Pulmonary Hypertension or Intracardiac Shunt Evaluation
96.	•Known or suspected intracardiac shunt with indeterminate shunt anatomy or shunt fraction	A (8)
Evaluation of Pulmonary Hypertension
97.	•Suspected pulmonary artery hypertension•Equivocal or borderline elevated estimated right ventricular systolic pressure on resting echo study	A (7)
98.	•Suspected pulmonary hypertension•Elevated estimated right ventricular systolic pressure on resting echo study	A (7)
99.	•Resting pulmonary hypertension•Determine response to pulmonary vasodilators given in cath lab	A (8)
100.	•Resting pulmonary hypertension•Determine response after initiation of drug therapy	A (7)
101.	•Post heart transplant patient•With or without the performance of endomyocardial biopsy	A (7)
102.	•Indeterminate intravascular volume status•Etiology unclear after initial evaluation	A (7)

Diagnostic Catheterization Appropriate Use Criteria (by Indication)

ACAD Assessment
- 1Coronary Angiography With or Without Left Heart Catheterization and Left VentriculographyCoronary angiography is widely used to evaluate patients with known or suspected CAD. Depending on the clinical circumstances and prior testing, coronary angiography may be coupled with the measurement of left ventricular (LV) pressures (left heart catheterization) and/or the evaluation of LV systolic function and wall motion (left ventriculography).The indications developed in Section A relate to appropriateness of coronary angiography. A decision about the performance of left heart catheterization and left ventriculography is left to the discretion of the operator and the patient's primary physician.
BAssessment for Conditions Other Than Coronary Artery Disease
- 2Right and Left Heart Catheterization or Right Heart Catheterization Alone With or Without Left Ventriculography and Coronary AngiographyRight and left heart catheterization (including the measurement of cardiac output and intracardiac oxygen saturations) is used to evaluate a variety of conditions. The syndrome of heart failure may or may not be present in these clinical scenarios. Depending on the clinical circumstances and prior testing, coronary angiography, left or right ventriculography, and additional angiography such as supravalvular aortography may be coupled with hemodynamic measurements. A decision about the need for coronary angiography in addition to the hemodynamic study should be at the discretion of the operator and the patient's primary physician.
- 2.1Valvular DiseasePatients with valvular heart disease can be challenging to evaluate, and these challenges are even greater in the setting of multivalve involvement. Failure to intervene with appropriate therapies at the correct time can result in the permanent impairment of heart function and a poor prognosis. The evaluation of valvular disease should start with a careful history and physical examination and is then augmented by noninvasive imaging, most frequently echocardiography. One of the challenges faced by clinicians occurs when the clinical impression of valve lesion severity based on the history and physical exam differs from that derived from an imaging test. The presence of concordant or conflicting impressions may affect the decision to perform an invasive evaluation and this is tested in the table below. For patients in whom valve surgery is planned, the indication for cardiac catheterization is covered in Indication 70.(Table 2.1) only considers isolated lesions of left-sided valves and does not consider mixed disease of a valve (e.g., aortic stenosis and regurgitation) or multivalve disease. Invasive evaluation may be necessary in these settings but often requires the assessment of several other variables such as LV function and should be at the discretion of the clinician. Scenarios were not developed for isolated or mixed disease of the tricuspid or pulmonic valve because they are relatively uncommon in adults and, when present, are often associated with left-sided valve lesions.
- 2.2CardiomyopathiesA variety of conditions present with signs and/or symptoms of heart failure. Right heart catheterization alone or combined right and left heart catheterization (including the measurement of cardiac and pulmonary pressures, cardiac output, vascular resistance, and intracardiac oxygen saturations) is used to evaluate many of these conditions. Depending on the clinical circumstances and prior testing, coronary angiography, left or right ventriculography, and additional angiography may be coupled with these hemodynamic measurements. The indications developed below relate to appropriateness of the right and left heart catheterization. A decision about the performance of coronary angiography should be at the discretion of the operator and the patient's primary physician.
- 3Right Heart CatheterizationIn several clinical situations, the performance of right heart catheterization (hemodynamics and cardiac output) alone is used. This can be performed in the cardiac catheterization laboratory.

Diagnostic Catheterization Appropriate Use Criteria (by Appropriate Use Rating)

Table 5Uncertain Indications (Median Score 4–6)

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Indication		Appropriate Use Score (1–9)
Suspected CAD: No Prior Noninvasive Stress Imaging (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)
7.	•High global CAD risk•Asymptomatic	U (4)
9.	•Intermediate pretest probability•Symptomatic	U (6)
Suspected CAD: Prior Noninvasive Testing (No Prior PCI, CABG, or Angiogram Showing ≥50% Angiographic Stenosis)
ECG Stress Testing
11.	•Low-risk findings (e.g., Duke treadmill score ≥5)•Symptomatic	U (4)
12.	•Intermediate-risk findings (e.g., Duke treadmill score 4 to −10)•Asymptomatic	U (4)
12.	•Intermediate-risk findings (e.g., Duke treadmill score 4 to −10)•Symptomatic	U (6)
Stress Test With Imaging (SPECT MPI, Stress Echocardiography, Stress PET, Stress CMR)
15.	•Low-risk findings (e.g., <5% ischemic myocardium on stress SPECT MPI or stress PET, no stress-induced wall motion abnormalities on stress echo or stress CMR)•Symptomatic	U (4)
16.	•Intermediate-risk findings (e.g., 5% to 10% ischemic myocardium on stress SPECT MPI or stress PET, stress-induced wall motion abnormality in a single segment on stress echo or stress CMR)•Asymptomatic	U (4)
20.	•Discordant findings (e.g., low-risk stress imaging with high-risk stress ECG response or stress-induced typical angina)•Asymptomatic	U (5)
21.	•Equivocal/uninterpretable findings (e.g., perfusion defect vs. attenuation artifact, uninterpretable stress imaging)•Asymptomatic	U (5)
22.	•Fixed perfusion defect on SPECT MPI or a persistent wall motion abnormality on stress echo consistent with infarction without significant ischemia (<5% ischemic myocardium)•Asymptomatic	U (4)
22.	•Fixed perfusion defect on SPECT MPI or a persistent wall motion abnormality on stress echo consistent with infarction without significant ischemia (<5

ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria for Diagnostic Catheterization FREE

Figures in this Article

Technical Panel

Appropriate Use Criteria Task Force

Table of Contents

Abstract

Preface

Introduction

Methods

Assumptions

Definitions

Abbreviations

Results of Ratings

Diagnostic Catheterization Appropriate Use Criteria (by Indication)

Diagnostic Catheterization Appropriate Use Criteria (by Appropriate Use Rating)