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APPROPRIATE USE CRITERIA

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging

Key Words: ACCF Appropriate Use Criteria • cardiac radionuclide imaging • SPECT MPI • PET • coronary artery disease • cardiac imaging • diagnostic testing

	Technical Panel

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

Robert C. Hendel, MD, FACC, FAHA, FASNC, Methodology/Writing Group Liaison

Patricia A. Pellikka, MD, FACC, FAHA, FASE, Writing Group Liaison

Peter Alagona, JR, MD, FACC^_*

Timothy M. Bateman, MD, FACC

Manuel D. Cerqueira, MD, FACC, FAHA, FASNC

James R. Corbett, MD, FACC

Anthony J. Dean, MD, FACEP

Gregory J. Dehmer, MD, FACC, FAHA^_*

Peter Goldbach, MD, FACC^||

Leonie Gordon, MB CHB^¶

Frederick G. Kushner, MD, FACC^#

Raymond Y. Kwong, MD, MPH, FACC^_**

James Min, MD, FACC

Miguel A. Quinones, MD, FACC

R. Parker Ward, MD, FACC

Michael J. Wolk, MD, MACC^_*

Scott H. Yang, MD, PHD, FACC^_*

	Appropriate Use Criteria Task Force

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
Michael J. Wolk, MD, MACC, Chair

Joseph Allen, MA

Ralph G. Brindis, MD, MPH, FACC

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

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

Manesh Patel, MD

Eric Peterson, MD, MPH, FACC, FAHA

	Table of contents

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 

Abstract......XXXX

Preface......XXXX

1 Introduction......XXXX

2 Methods......XXXX

3 General Assumptions......XXXX

4 Definitions......XXXX

5 Abbreviations......XXXX

6 Results of Ratings......XXXX

7 Cardiac Radionuclide Imaging Appropriate Use Criteria (By Indication)......XXXX

Table 1. Detection of Coronary Artery Disease: Symptomatic......XXXX

Table 2. Detection of Coronary Artery Disease/Risk Assessment Without Ischemic Equivalent......XXXX

Table 3. Risk Assessment With Prior Test Results and/or Known Chronic Stable Coronary Artery Disease......XXXX

Table 4. Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions......XXXX

Table 5. Risk Assessment: Within 3 Months of an Acute Coronary Syndrome......XXXX

Table 6. Risk Assessment: Postrevascularization (Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting Surgery)......XXXX

Table 7. Assessment of Viability/Ischemia......XXXX

Table 8. Evaluation of Ventricular Function......XXXX

8 Cardiac Radionuclide Imaging Appropriateness Criteria (By Appropriateness Category)......XXXX

Table 9. Appropriate Indications (Median Score 7–9)......XXXX

Table 10. Uncertain Indications (Median Score 4–6)......XXXX

Table 11. Inappropriate Indications (Median Score 1–3)......XXXX

9 Discussion......XXXX

9.1 Radionuclide Imaging Appropriate Use Criteria......XXXX

9.2 Application of Criteria......XXXX

Appendix A: Additional Cardiac Radionuclide Imaging Definitions......XXXX

Appendix B: Additional Methods......XXXX

Relationships With Industry ......XXXX

Literature Review......XXXX

Appendix C: ACCF Appropriate Use Criteria for Cardiac Radionuclide Imaging Participants......XXXX

Appendix D: ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM Cardiac Radionuclide Imaging Appropriate Use Criteria Writing Group, Technical Panel, Task Force, and Indication Reviewers—Relationships With Industry And Other Entities (In Alphabetical Order)......XXXX

References......XXXX

	Abstract

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Sixty-seven 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 cardiac RNI for diagnosis and risk assessment in intermediate- and high-risk patients with coronary artery disease (CAD) was viewed favorably, while testing in low-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Additionally, use for perioperative testing was found to be inappropriate except for high selected groups of patients. It is anticipated that these results will have a significant impact on physician decision making, test performance, and reimbursement policy, and will help guide future research.

	Preface

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
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 a 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 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 it 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 a substitute for sound clinical judgment and practice experience.

The ACCF AUC process itself is also evolving. In the current iteration, technical panel members were asked to rate indications for cardiac RNI in a manner independent and irrespective of the prior published ACCF ratings for SPECT MPI (1) as well as the prior ACCF ratings for similar diagnostic stress imaging modalities, such as stress echocardiography (2), cardiac computed tomography, or cardiac magnetic resonance (3). 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. Since this process is iterative and evolving, readers are counseled that individual appropriate use ratings among modalities rated at different times over the past 2 years may not be consistent. A comparative evaluation of the appropriate use of multiple imaging techniques will be undertaken in the near future 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 on the merits of cardiac RNI 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 and Kennedy Elliott, who continually drove the process forward; and to Robert Hendel, MD, the chair of the writing committee, for his dedication, insight, and leadership.

Michael J. Wolk, MD, MACC

Moderator, Cardiac Radionuclide Imaging Technical Panel

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

Chair, Appropriate Use Criteria Task Force

	1. Introduction

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
This report addresses the appropriate use of cardiac RNI. Improvements in cardiovascular imaging technology and its 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 RNI, perfusion echocardiography, computed tomography for coronary angiography and calcium score, and magnetic resonance imaging for myocardial structure and viability. As the field of cardiac radionuclide cardiovascular imaging continues to advance along with other imaging modalities, the health care community needs to understand how to best incorporate these technologies into daily clinical care.

All prior AUC 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 American College of Cardiology recognizes the importance of revising these criteria in a timely manner in order to provide the cardiovascular community with the most accurate indications. This document presents the first attempt to update an existing AUC document, the 2005 published ACCF/ASNC Appropriate Use Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) (1). Clinicians, payers, and patients are interested in the specific benefits of cardiac RNI. Importantly, inappropriate use of cardiac RNI 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 since the intent is for the potential benefits and risks of the treatment to be explicitly considered, rather than just 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

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
The indications included in this publication are purposefully broad, and comprise a wide array of cardiovascular signs and symptoms as well as clinical judgment as to the likelihood of cardiovascular findings.

A detailed description of the methods used for ranking the selected clinical indications is outlined in Appendix B and is also found more generally in a previous publication entitled, "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. Since the original SPECT document (1) and methods paper (4) were published, several important processes have been put in place to further enhance this process. They include convening a formal writing group with diverse expertise in imaging, circulating the indications for external review prior to rating by the technical panel, and ensuring appropriate balance of the technical panel, a standardized rating package, and formal roles for facilitating panel interaction at the face-to-face meeting. These changes are detailed in a separate manuscript, which is in preparation.

The panel first rated indications independently. 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.

While panel members were not provided explicit cost information to help determine their appropriate use ratings, they were asked to implicitly consider cost as an additional factor in their evaluation of appropriate use.

In developing these criteria, the AUC Technical Panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate, and was provided the following definition of appropriate use:

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 7–9

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

Score 4–6

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 1–3

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

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 investigation whenever possible. It is anticipated that the AUC reports will require updates as further data are generated and information from the implementation of the criteria is accumulated.

To prevent bias in the scoring process, the technical panel was deliberately 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.

The level of agreement among panelists as defined by RAND (5) was analyzed based on the BIOMED rule for a panel of 14 to 16 members. As such, agreement was 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. Indications which met neither definition for agreement or disagreement are in a third, unlabeled category.

	3. General Assumptions

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
To prevent anyinconsistencies in interpretation, specific assumptions are provided that were considered by the technical panel in rating the relevant clinical indications for the appropriate use of RNI:

1 Panel members were to assume that all radionuclide techniques with different radiopharmaceuticals and imaging protocols were available for each indication and that each was performed in a manner similar to that found in the published literature.

2 Radionuclide imaging is performed in accordance with best practice standards as delineated in the imaging guidelines for nuclear cardiology procedures (6). It is also assumed that procedures are performed in an accredited facility with appropriately credentialed physicians.

3 Unless otherwise noted, all indications referred to SPECT MPI and positron emission tomography myocardial perfusion imaging. All radionuclide perfusion imaging indications also assume the use of ECG gating, whenever possible, with determination of global ventricular function (i.e., left ventricular ejection fraction) and regional wall motion as part of the evaluation.

4 For all stress imaging, the mode of stress testing was assumed to be exercise for patients able to exercise. For patients unable to exercise, pharmacologic 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 (7).

5 In the setting of a known acute coronary syndrome (ACS), the use of stress testing should be performed in conjunction with pharmacologic stress testing, not exercise.

6 The use of testing in the perioperative setting is assumed to have the potential to impact clinical decision making and to direct therapeutic interventions.

7 The category of "uncertain" should be used when insufficient clinical data is available for a definitive categorization or there is substantial disagreement regarding the appropriateness of that indication. The designation of "uncertain" is assumed to not provide grounds for denial of reimbursement.

	4. Definitions

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
A complete set of definitions of terms used throughout the indication set are 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 Electrocardiogram (ECG) Abnormalities: Any constellation of clinical findings that the physician feels is consistent with obstructive CAD. Examples of such findings include, but are not exclusive to, chest pain, chest tightness, burning, shoulder pain, palpitations, jaw pain, and new ECG abnormalities suggestive of ischemic heart disease. Non-chest 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.   Risk Assessment for Asymptomatic Patients

The indications on risk assessment include asymptomatic patients with suspected CAD. It is assumed that clinicians will use RNI studies in addition to standard methods of risk assessment as 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) (8).

Coronary Heart Disease (CHD) Risk* (Based on the ACC/AHA Scientific Statement on Cardiovascular Risk Assessment [ 9])

Absolute risk is defined as the probability of developing CHD, including myocardial infarction or CHD death over a given time period. The Adult Treatment Panel III report specifies absolute risk for CHD over the next 10 years. CHD risk refers to 10-year risk for any hard cardiac event.

• 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 less than 10%.

• CHD Risk—Moderate
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% and 20%.

• CHD Risk—High
Defined as the presence of diabetes mellitus in a patient 40 years of age or older, peripheral arterial disease or other coronary risk equivalents, or a 10-year absolute CHD risk of greater than 20%.

Pretest Probability of 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 (10,11) available that can be used to calculate this probability. Clinicians should become familiar with those algorithms 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.

• Very low pretest probability: Less than 5% pretest probability of CAD

• Low pretest probability: Less than 10% pretest probability of CAD

• Intermediate pretest probability: Between 10% and 90% pretest probability of CAD

• High pretest probability: Greater than 90% pretest probability of CAD

The method recommended by the ACC/AHA Guidelines for Chronic Stable Angina (12) is provided below as one example of a method used to calculate pretest probability and is a modification of a previously published literature review (13). Please refer to definitions of angina and to Table A . Please note that Table A only predicts pretest probability in patients without other complicating history or ECG findings. History and electrocardiographic evidence of prior infarction dramatically affect pretest probability. While not incorporated into the algorithm, CAD risk factors, discussed in the previous section, Determining Pretest Risk Assessment for Risk Stratification, may also affect pretest likelihood of CAD. Detailed nomograms 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 (14).

	5. Abbreviations

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

	6. Results of Ratings

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
The final ratings for cardiac RNI (Tables 1 to 8) are listed by indication sequentially as obtained from second-round rating sheets submitted by each panelist. The final score reflects the median score of the 15 panelists and has been labeled according to the 3 appropriate use categories of appropriate, uncertain, and inappropriate. Tables 9 to 11 present the indications by these categories.

There was generally less variation in ratings for the indications labeled as either appropriate or inappropriate, with 73% and 64%, respectively, showing agreement as defined in Section 2, Methods. There was, however, greater variability (less agreement) in the rating scores for indications defined as uncertain, with 11% showing agreement as defined above, suggesting greater variation in opinion. Two indications, 26 and 28, were distributed into each extreme such that the panel was classified as being in disagreement. However, these indications were already placed in the uncertain category so no changes were required to reflect disagreement. Across all categories, several indications failed to meet the definition of agreement. In such cases, the final distribution of scores across the panel contained a greater diversity of scores among panel members, but the scores were not so divergent (as defined by disagreement) as to necessitate a change in the final score.

	7. Cardiac Radionuclide Imaging Appropriate Use Criteria (By Indication)

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 

	8. Cardiac Radionuclide Imaging Appropriateness Criteria (By Appropriateness Criteria)

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 

	9. Discussion

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
This document is a revision of the original SPECT MPI Appropriateness Criteria (1) published 4 years earlier, written to reflect changes in test utilization, to add insight provided by interim clinical data, and to clarify cardiac RNI use where omissions or lack of clarity existed in the original criteria. This is consistent with the commitment to revise and refine AUC on a frequent basis. Published trials and a societal review have highlighted a significant number of clinical scenarios that were either uncertain or could not be categorized with the original criteria and warranted reconsideration (15–17). Additionally, trials and reviews have suggested new clinical indications to consider for this update of AUC for RNI.

In addition to adding new clinical indications and clarifying existing indications from the original SPECT MPI Appropriateness Criteria (1) document, the writing group, technical panel, and/or external reviewers of the RNI document also revised specific definitions and assumptions. Four additional assumptions were added. The first addressed accordance with best practice standards as delineated in the imaging guidelines for nuclear cardiology procedures (6) as well as ensuring that procedures are performed in an accredited facility. The second new assumption addressed the use of pharmacologic stress testing versus exercise stress testing in the setting of an ACS. The third new assumption emphasized that in the perioperative setting, the use of RNI would have the potential to impact clinical decision making and to direct therapeutic interventions. This assumption was added to enhance consistency with the updated 2007 ACC/AHA Guideline for Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (18). The fourth new assumption addressed the category of uncertain indications and clarified the relationship between such a rating and grounds for reimbursement.

The writing group also revised the definition of "chest pain syndrome" that had caused confusion when applying the original SPECT MPI document. The original definition of chest pain syndrome focused only on symptoms and excluded other clinical findings, such as new ECG changes that suggest the presence of obstructive CAD and may warrant RNI testing. Therefore, a new term "ischemic equivalent" was developed to encompass chest pain syndromes as well as other symptoms and signs that the clinician believes may be due to obstructive CAD. This revision was supported by the writing group, technical panel, and external reviewers.

The AUC in this report provide an estimate of whether it is reasonable to use cardiac RNI for a particular clinical scenario, such as those 67 indications listed in this document. These criteria are expected to be useful for clinicians, health care facilities, and third-party payers engaged in the delivery of cardiovascular imaging. Experience with already published AUC (1–3) has shown their value across a broad range of situations, guiding care of individual patients, educating caregivers, and informing policy decisions regarding reimbursement for cardiovascular imaging.

Appropriate use criteria represent the first component of the chain of quality recommendations for cardiovascular imaging (19). After ensuring proper test selection, the achievement of quality in imaging includes adherence to best practices in image acquisition, image interpretation and results communication, as well as incorporation of findings into clinical care. All components are important for optimal patient care, although not addressed in this report. The development of AUC and their ranking by the technical panel assumes that other quality standards have been met.

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 AUC 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 cardiac RNI 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 cardiac RNI. 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 cardiac radionuclide 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.

Panelists were asked specifically to rate each indication according to the definition of appropriateness use (see Section 2, Methods) and to not necessarily consider comparisons to other imaging procedures or other AUC documents while completing their ratings, However, panelists were also provided with links to relevant guideline recommendations as well as previously published AUC documents to ensure they were adequately educated on all relevant medical literature when rating the indications. Whereas the newer modalities of CCTA and CMR perfusion are not as well studied, RNI and stress echocardiography have robust bodies of evidence to support their use. The overwhelming majority of final ratings of cardiac RNI and stress echocardiography were concordant for similar clinical indications. However, a few of the final scores and rating categories reported in this document differ from those previously published for stress echocardiography (2). Readers should note, however, that the categorical summaries tend to accentuate differences that sometimes are slight. For example, small fluctuations in a median rating (e.g., 4 versus 3) will cause an indication to switch appropriate use categories (from uncertain to inappropriate). There are several potential reasons for these discordant occurrences. The most likely reason for this is a simple variation in the ratings by the different panel members, whether due to different backgrounds levels and types of clinical experience or interpretations of data. The RAND process has documented that the interpretation of the literature by different sets of experts can yield slightly different final ratings (5). Inconsistency in wording of indications for the cardiac RNI and stress echocardiography panels has also likely contributed to differences in the ratings of some scenarios. Finally, true differences in the data reported in the literature regarding the modalities might explain some of the discordance.

9.1 Cardiac Radionuclide Imaging Appropriate Use Criteria.   The clinical scenarios included in this report were designed to reflect the most common and important potential applications for cardiac RNI. After thepreparation of a draft manuscript by the writing group and extensive review from external editors and then by the technical panel itself, the result is a set of scenarios that clearly define patient-specific applications.

The primary objective of this report is to provide guidance regarding the suitability of cardiac RNI for diverse clinical scenarios. As with previous AUC documents, consensus among the raters was desirable, but an attempt to achieve complete agreement within this diverse panel would have been artificial and was not the goal of the process. Two rounds of ratings with substantial discussion among the technical panelists concerning the ratings did lead to some consensus among panelists. However, further attempts to drive consensus would have diluted true differences in opinion among panelists and therefore was not undertaken.

Among the 67 indications, 33 were classified as appropriate, while uncertain and inappropriate designations were assigned for 9 and 25 indications, respectively.

To facilitate implementation of these AUC, an algorithm is presented in Figure 1, which presents a hierarchy of potential test ordering based on clinical presentation. The purpose of this algorithm is to help avoid situations in which the AUC failed to follow the true clinical reasons for test ordering, such as using an indication designed for assessment of chest pain even when a patient may have already undergone revascularization or a prior imaging procedure.

View larger version (33K): [in this window] [in a new window] [Download PPT slide]   Figure 1 Hierarchy of Potential Test Ordering Based on Clinical Presentation For those patients who may be classified into more than 1 of the clinical indication tables and/or algorithms, this flow chart places clinical conditions into a hierarchy to aid in assessing appropriateness for radionuclide imaging. *Symptomatic patients who are being considered for a preoperative evaluation for noncardiac surgery should begin down the algorithm as if "No."

View larger version (13K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Potential Applications for Chest Pain Patients with an ischemic equivalent, consisting of symptoms associated with CAD or ECG findings, were divided based on the likelihood of CAD. If patients had an intermediate or high likelihood for CAD, RNI was appropriate. RNI was also appropriate for patients at low likelihood if they were unable to exercise or had an uninterpretable ECG. For patients with a suspected ACS, RNI was appropriate irrespective of the TIMI score or whether or not their troponin levels were elevated.

View larger version (8K): [in this window] [in a new window] [Download PPT slide]   Figure 3 Potential Applications for Asymptomatic* Patients Only in high CHD risk patients was RNI felt to be appropriate, although those with intermediate CHD risk with an uninterpretable ECG were uncertain. The presence of syncope did not alter the appropriateness of patients separate from their CHD risk, with low-risk patients being inappropriate and high-risk patients being appropriate. *Asymptomatic patients exhibiting the following clinical indications are appropriate (or uncertain) for RNI and do not require risk assessment by either step: 1) new-onset or newly diagnosed heart failure with LV systolic dysfunction without ischemic equivalent who have not had a prior CAD evaluation AND have no planned coronary angiography (Appropriate); 2) ventricular tachycardia (Appropriate); 3) elevated troponin without additional evidence of acute coronary syndrome (Appropriate); 4) new-onset atrial fibrillation (Uncertain). Includes diabetes mellitus or the presence of other clinical atherosclerotic disease, including peripheral arterial disease, abdominal aortic aneurysm, carotid artery disease, and other likely forms of clinical disease (e.g., renal artery disease).

View larger version (14K): [in this window] [in a new window] [Download PPT slide]   Figure 4 Prior Test Results* When new or worsening symptoms were present, RNI was appropriate if prior abnormal results were present, but was uncertain if the prior study was normal. RNI was inappropriate when no or stable symptoms were present if prior test results were known, except when performed more than 2 years later, and only if an abnormal study was previously present or if the patient was at intermediate or greater CHD risk. In those circumstances, RNI use was "uncertain." *RNI is appropriate if prior test results were uncertain in the following 2 scenarios: 1) Coronary Angiography: coronary stenosis or anatomic abnormality of uncertain significance; OR 2) Prior Noninvasive Evaluation: equivocal, borderline, or discordant stress testing where obstructive CAD remains a concern.

View larger version (10K): [in this window] [in a new window] [Download PPT slide]   Figure 5 Perioperative Evaluation RNI was felt to be inappropriate for preoperative risk assessment except in the setting of intermediate risk or vascular surgery when at least 1 risk factor is present and the patient has poor or unknown functional capacity. Additionally, patients who are asymptomatic up to 1 year postnormal catheterization, noninvasive test, or previous revascularization in the setting of intermediate risk or vascular surgery were also rated as inappropriate for RNI. *History of ischemic heart disease, compensated or prior heart failure, cerebrovascular disease, diabetes mellitus (requiring insulin), or renal insufficiency (creatinine >2.0).

View larger version (18K): [in this window] [in a new window] [Download PPT slide]   Figure 6 Postrevascularization Following revascularization with PCI or CABG in a more chronic (>3 months) setting, recurrence of symptoms or the presence of suspected incomplete revascularization were felt to be appropriate indications for RNI. For asymptomatic patients less than 2 years after a PCI, RNI was rated inappropriate. For asymptomatic patients at less than 5 years after CABG or those at greater than or equal to 2 years after PCI, RNI was rated uncertain. If CABG was performed more than 5 years ago, RNI is appropriate. *Assumes that additional revascularization is feasible.

Several changes were present when comparing the original SPECT MPI criteria to the new RNI AUC. Specifically, indications 26 and 28 are now "uncertain" compared with the previous designation of "appropriate"—these changes likely reflect increased knowledge and/or differing technical panel composition. Additionally, indication 32 has changed from uncertain to appropriate.

9.2 Application of Criteria.   There are many potential applications for AUC. Clinicians could use the ratings for decision support or an educational tool when considering the need for cardiac RNI. Moreover, these criteria could be used to facilitate discussion with patients and/or referring physicians about the need for cardiac RNI. Facilities and payers may choose to use these criteria either prospectively in the design of protocols or preauthorization procedures or retrospectively for quality reports. It is hoped that payers would use these criteria as the basis for the development of rational payment management strategies.

It is expected that services performed for appropriate indications will be considered reimbursable. In contrast, services performed for inappropriate indications should likely require additional documentation to justify reimbursement because of the unique circumstances or the clinical profile that must exist in such a patient. It is critical to emphasize that the writing group, technical panel, AUC Working Group, and clinical community do not believe an uncertain rating is grounds to deny reimbursement for cardiac RNI. Rather, uncertain ratings are those where the available data vary and many other factors exist that may affect the decision to perform or not perform cardiac RNI. The opinions of the technical panel often varied for these indications, reflecting that additional research is needed. Indications with high clinical volume that are rated as uncertain identify important areas for further research.

In conclusion, this document represents the current understanding of the clinical benefit of cardiac RNI with respect to health outcomes and survival. It is intended to provide a practical guide to clinicians and patients when considering cardiac RNI. As with other AUC documents, some of these ratings will require research and further evaluation to provide the greatest information and benefit to clinical decision making. Finally, it will be necessary to periodically assess and update the indications and criteria as technology evolves and new data and field experience becomes available.

	Appendix A: Additional Cardiac Radionuclide Imaging Definitions

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
Angina: as defined by the ACC/AHA Guidelines on Exercise Testing (7)

• Typical Angina (Definite):1. Substernal chest pain or discomfort that is2. provoked by exertion or emotional stress and3. relieved by rest and/or nitroglycerin (22).

• Atypical Angina (Probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina (22).

• Nonanginal Chest Pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

Evaluating Perioperative Risk for Noncardiac Surgery.   METHOD FOR DETERMINING PERIOPERATIVE RISK
See Figure A1, "Stepwise Approach to Perioperative Cardiac Assessment," from the ACC/AHA 2007 Perioperative Guidelines (18). Based on 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 A1) and/or perioperative risk predictor (see Table A2). If any active cardiac conditions and/or major risk predictors are present (see Tables A1 and A2), Figure A1 suggests consideration of coronary angiography and postponing or canceling noncardiac surgery. Once perioperative risk predictors are assessed based on the algorithm, then the surgical risk and patient's functional status should be used to establish the need for noninvasive testing.

View larger version (22K): [in this window] [in a new window] [Download PPT slide]   Figure A1 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 or greater. *See Table A1 for active clinical conditions. Please note that the 2007 ACC/AHA Guidelines for Perioperative Cardiac Assessment recommend that noninvasive testing is not useful for patients with no clinical risk factors undergoing intermediate-risk noncardiac surgery (Level of Evidence: C) and that noninvasive testing is not useful for patients undergoing low-risk noncardiac surgery (Level of Evidence: C). See Table A2 for list of clinical risk factors. Noninvasive testing may be considered before surgery in specific patients with risk factors if it will change management. Clinical risk factors include ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal insufficiency, and cerebrovascular disease. ¶Consider perioperative beta blockade for populations in which this has been shown to reduce cardiac morbidity/mortality. Reprinted from the recommendations from the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (18).

Low-Risk TIMI Score: TIMI score less than 2

High-Risk TIMI Score: TIMI score greater than or equal to 2

ECG—Uninterpretable

Refers to ECGs with resting ST-segment depression (greater than or equal to 0.10 mV), complete LBBB, pre-excitation (Wolf-Parkinson-White Syndrome), or paced rhythm.

	Appendix B: Additional Methods

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
See Section 2, Methods, for a description of panel selection, indication development, scope of indications, and rating process.

Relationships With Industry.   The ACCF and its partnering organizations rigorously avoid any actual, perceived, or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the technical panel. Specifically, all panelists are asked to provide disclosure statements of all relationships that might be perceived as real or potential conflicts of interest. These statements were reviewed by the AUC Working Group, discussed with all members of the technical panel at the face-to-face meeting, and updated and reviewed as necessary. A table of disclosures by the technical panel and oversight working group members can be found in Appendix C.

Literature Review.   The technical panel members were asked to refer to the relevant guidelines for a summary of the relevant literature, guideline recommendation tables, and reference lists provided for each indication table when completing their ratings (Online Appendix at http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.02.013).

	Appendix C: ACCF Appropriate Use Criteria for Cardiac Radionuclide Imaging Participants

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
Cardiac Radionuclide Imaging Writing Group.   Robert C. Hendel, MD, FACC, FAHA, FASNC—Chair, Appropriate Use Criteria for Radionuclide Imaging Writing Group–Midwest Heart Specialists, Winfield, IL

Daniel S. Berman, MD, FACC, FAHA—Director, Cardiac Imaging, Cedars-Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA

Marcelo F. Di Carli, MD, FACC, FAHA—Division of Nuclear Medicine and Molecular Imaging and Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Associate Professor of Radiology and Medicine, Harvard Medical School, Boston, MA

Paul A. Heidenreich, MD, MS, FACC—Associate Professor of Medicine, Stanford University, VA Palo Alto Health Care System, Palo Alto, CA

Robert E. Henkin, MD, FACR—Professor Emeritus of Radiology, Loyola University Stritch School of Medicine, Maywood, IL

Patricia A. Pellikka, MD, FACC, FAHA, FASE—Professor of Medicine, Co-Director, Echocardiography Laboratory, Mayo Clinic College of Medicine, Rochester, MN

Gerald M. Pohost, MD, FACC, FAHA—Professor of Radiology, Keck School of Medicine, Professor of Electrical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA; Professor of Medicine, Loma Linda College of Medicine, Loma Linda, CA; and Director of Research, Hollywood Heart and Vascular Institute, Los Angeles, CA

Kim A. Williams, MD, FACC, FAHA, FASNC—Professor of Medicine and Radiology; Director of Nuclear Cardiology, University of Chicago Sections of Cardiology and Nuclear Medicine, Chicago, IL

Cardiac Radionuclide Imaging Technical Panel.   Michael J. Wolk, MD, MACC—Moderator, Appropriate Use Criteria for Cardiac Radionuclide Imaging Technical Panel—Past President, American College of Cardiology Foundation; Clinical Professor of Medicine, Weill-Cornell Medical School, New York, NY

Robert C. Hendel, MD, FACC, FAHA, FASNC—Methodology/Writing Group Liaison Appropriate Use Criteria for Cardiac Radionuclide Imaging Technical Panel—Midwest Heart Specialists, Winfield, IL

Patricia A. Pellikka, MD, FACC, FAHA, FASE—Writing Group Liaison Appropriate Use Criteria for Cardiac Radionuclide Imaging Technical Panel—Professor of Medicine, Co-Director, Echocardiography Laboratory, Mayo Clinic College of Medicine, Rochester, MN

Peter Alagona, Jr., MD, FACC—Program Director General Cardiology Penn State Heart and Vascular Institute Associate Professor of Medicine and Radiology, Penn State College of Medicine, Hershey, PA

Timothy M. Bateman, MD, FACC—Co-Director, Cardiovascular Radiologic Imaging, Cardiovascular Consultants, PC, Kansas City, MO

Manuel D. Cerqueira, MD, FACC, FAHA, FASNC—Professor of Radiology and Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Chairman, Department of Nuclear Medicine, Imaging Institute and Staff Cardiologist, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH

James R. Corbett, MD, FACC—Professor of Radiology and Internal Medicine, Nuclear Medicine and Cardiology Divisions, University of Michigan Medical Center, Ann Arbor, MI

Anthony J. Dean, MD, FACEP—Assistant Professor of Emergency Medicine and Assistant Professor of Emergency Medicine in Radiology; Director, Division of Emergency Ultrasonography, Department of Emergency Medicine, University of Pennsylvania Medical Center, Philadelphia, PA

Gregory J. Dehmer, MD, FACC, FAHA—Professor of Medicine, Texas A&M College of Medicine, Scott & White Healthcare, Cardiology Division, Temple, TX

Peter Goldbach, MD, FACCP—Medical Director, Blue Cross Blue Shield of Massachusetts, Boston, MA (former); CEO, MedVantage, Inc., San Francisco, CA

Leonie Gordon, MB ChB—Professor of Radiology, Medical University of South Carolina, Charleston, SC

Frederick G. Kushner, MD, FACC—Medical Director, Heart Clinic of Louisiana, Clinical Professor, Tulane University Medical Center, Merrero, LA

Raymond Y. K. Kwong, MD, MPH, FACC—Director of Cardiac Magnetic Resonance Imaging, Cardiovascular Division of Department of Medicine, Brigham & Women's Hospital; Assistant Professor of Medicine, Harvard Medical School, Boston, MA

James K. Min, MD, FACC—Assistant Professor of Medicine and Radiology, Weill Cornell University Medical College, New York Presbyterian Hospital, New York, NY

Miguel A. Quinones, MD, FACC—Chair, Department of Cardiology, Methodist DeBakey Heart and Vascular Center, Houston, TX

R. Parker Ward, MD, FACC—Associate Professor of Medicine, University of Chicago Medical Center, Chicago, IL

Scott H. Yang, MD, PhD, FACC—Kaiser Permanente Santa Rosa, Santa Rosa, CA

External Reviewers of the Appropriate Use Criteria Indications.   James Arrighi, MD, FACC, FASNC—Director, Nuclear Cardiology, Rhode Island Hospital and Program Director, Cardiology Fellowship, Brown University, Associate Professor of Medicine, Brown University, Providence, RI

Robert O. Bonow, MD, MACC, FAHA—Goldberg Distinguished Professor; Chief, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL

Lee A. Fleisher, MD, FACC, FAHA—Robert D. Dripps Professor and Chair of Anesthesiology and Critical Care, Professor of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA

Julius M. Gardin, MD, FACC, FAHA, FASE—Professor and Chairman, Department of Internal Medicine, Hackensack University Medical Center and Touro University College of Medicine, Hackensack, NJ

Raymond J. Gibbons, MD, FACC, FAHA—Arthur M. and Gladys D. Gray Professor of Medicine; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN

John A. Gillespie, MD, FACC—Chief Medical Officer, Independent Health Corporation, Buffalo, NY

Bennett S. Greenspan, MD, MS, FACNP, FACR, FACNM—Assistant Professor, Radiology, Associate Program Director, Nuclear Medicine, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO

Rory Hachamovitch, MD, FACC—Independent consultant, Los Angeles, CA

Warren R. Janowitz, MD, FACC, FAHA—Director of Molecular Imaging, Baptist Hospital of Miami, Miami, FL

Christopher M. Kramer, MD, FACC, FAHA—Professor of Medicine and Radiology, Director, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, VA

Michael H. Picard, MD, FACC, FASE, FAHA—Associate Professor of Medicine, Harvard Medical School, Director, Echocardiography, Massachusetts General Hospital, Boston, MA

Michael Poon, MD, FACC—Past President, Society of Cardiac Computed Tomography, New York, NY

Miguel A. Quinones, MD, FACC—Chair, Department of Cardiology, Methodist DeBakey Heart and Vascular Center, Houston, TX

Raymond F. Stainback, MD, FACC, FASE—Medical Director, Noninvasive Cardiac Imaging, Texas Heart Institute at St. Luke's Episcopal Hospital; Clinical Assistant Professor of Medicine, Baylor College of Medicine; Partner, Hall-Garcia Cardiology Associates, Houston, TX

Mark I. Travin, MD, FACC, FASNC—Director of Cardiovascular Nuclear Medicine, Montefiore Medical Center, Professor of Clinical Nuclear Medicine and Clinical Medicine, Albert Einstein College of Medicine, Bronx, NY

Samuel Wann, MD, MACC—Clinical Professor of Medicine, University of Wisconin–Madison and Medical College of Wisconsin–Milwaukee, Chairman, Department of Cardiovascular Medicine, Wisconsin Heart Hospital, Milwaukee, WI

R. Parker Ward, MD, FACC—Associate Professor of Medicine, University of Chicago Medical Center, Chicago, IL

Neil J. Weissman, MD, FACC, FASE—Professor of Medicine, Georgetown University, and President, MedStar Research Institute, Washington, DC

Jack A. Ziffer, MD, FACC—Medical Director, Nuclear Cardiology, Miami Cardiac and Vascular Institute, Miami, FL

William A. Zoghbi, MD, FACC, FAHA, FASE—Professor of Medicine, Director, Cardiovascular Imaging Institute; William L. Winters Endowed Chair in Cardiovascular Imaging, Methodist DeBakey Heart and Vascular Center, Houston, TX

ACCF Appropriate Use Criteria Task Force.   Ralph G. Brindis, MD, MPH, FACC—Chair, Task Force–Regional Senior Advisor for Cardiovascular Disease, Northern California Kaiser Permanente, Oakland, CA; Clinical Professor of Medicine, University of California at San Francisco, San Francisco, CA; Chief Medical Officer & Chairman, NCDR Management Board, American College of Cardiology Foundation, Washington, DC

Pamela S. Douglas, MD, MACC, FAHA, FASE—Past President, American College of Cardiology Foundation; Past President American Society of Echocardiography; and Ursula Geller Professor of Research in Cardiovascular Diseases and Chief, Cardiovascular Disease, Duke University Medical Center, Durham, NC

Robert C. Hendel, MD, FACC, FAHA, FASNC—Chair, Appropriate Use Criteria for Radionuclide Imaging Writing Group–Midwest Heart Specialists, Winfield, IL

Manesh R. Patel, MD—Assistant Professor of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC

Eric D. Peterson, MD, MPH, FACC, FAHA—Professor of Medicine and Director, Cardiovascular Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC

Michael J. Wolk, MD, MACC—Past President, American College of Cardiology Foundation and Clinical Professor of Medicine, Weill-Cornell Medical School, New York, NY

Joseph M. Allen, MA—Director, TRIP (Translating Research into Practice), American College of Cardiology Foundation, Washington, DC

	Staff

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
American College of Cardiology Foundation

John C. Lewin, MD, Chief Executive Officer

Thomas E. Arend, Jr., Esq., Chief Operating Officer

Joseph M. Allen, MA, Director, TRIP (Translating Research Into Practice)

Kennedy Elliott, Specialist, Appropriate Use Criteria

Lindsey Law, MHS, Senior Specialist, Appropriate Use Criteria

Erin A. Barrett, Senior Specialist, Science and Clinical Policy

	APPENDIX D. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM CARDIAC RADIONUCLIDE IMAGING APPROPRIATE USE CRITERIA WRITING GROUP, TECHNICAL PANEL, TASK FORCE, AND INDICATION REVIEWERS—RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (IN ALPHABETICAL ORDER)

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 

Committee Member Consultant Speaker Ownership/Partnership/Principal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Cardiac Radionuclide Imaging Appropriate Use Criteria Writing Group Dr. Robert C. Hendel Astellas • GE Healthcare • PGx Health • Astellas None • GE Healthcare None None Dr. Daniel S. Berman • Astellas • Floura Pharma • Tyco Mallinckrodt Healthcare None • Cedars Sinai Medical Center • Spectrum Dynamics • Astellas • Bristol-Myers Squibb Medical Imaging • Siemens • Tyco Mallinckrodt Healthcare None None Dr. Marcelo F. Di Carli None None None None None None Dr. Paul A. Heidenreich None None None • Siemens None None Dr. Robert E. Henkin • Philips Medical Systems None None None None None Dr. Patricia A. Pellikka None None None None None None Dr. Gerald M. Pohost None None None None None None Dr. Kim A. Williams • Bracco • GE Healthcare • King Pharmaceuticals • Astellas None • GE Healthcare • Molecular Insight Pharmaceuticals None None Cardiac Radionuclide Imaging Appropriate Use Criteria Technical Panel Dr. Peter Alagona, Jr. • Digirad None None None None None Dr. Timothy M. Bateman • Astellas/CV Therapeutics • Bracco DiagnosticsCovidien • Lantheus • Molecular Insights Pharmaceuticals • Spectrum Dynamics None • CVIT • Bracco Diagnostics • Philips Medical Systems None None Dr. Manuel D. Cerqueira • Astellas • CV Therapeutics • GE Healthcare • Siemens • Astellas • CardiArc • Covidien • GE Healthcare None • CardiArc • Perceptive Informatics None • Intellectual property rights Dr. James R. Corbett None None None None None None Dr. Anthony J. Dean None None None • In-kind support with institutional loan of ultrasound equipment None None Dr. Gregory J. Dehmer None None None None None • Evaluation of PCI program • Fair hearing related to physician privileges at hospital • Need for open heart surgery for facility Dr. Peter Goldbach None • MedVantange, Inc. None None • Blue Cross Blue Shield of Massachusetts (Medical Director, former) • MedVantange, Inc. (Chief Executive Officer) None Dr. Leonie Gordon None None None None None • PET brain scan Dr. Frederick G. Kushner None None None • AstraZeneca • Novartis • Pfizer None None Dr. Raymond Y. Kwong None None None None None None Dr. James Min • GE Healthcare • GE Healthcare None None None None Dr. Miguel A. Quinones None None None None None • Diet pills and valve disease Dr. R. Parker Ward None None None • Pfizer None None Dr. Michael J. Wolk None None None None None None Dr. Scott H. Yang None None None None None None Cardiac Radionuclide Imaging Appropriate Use Criteria Task Force Mr. Joseph M. Allen None None None None None None Dr. Ralph G. Brindis None None None None None None Dr. Pamela S. Douglas • BG Medicine • Expression Analysis • Genentech • GlaxoSmithKline Foundation • Northpoint Domain • Ortho Diagnostics • Pappas Ventures • Visen Medicad • Xceed Molecular None • CardioDX • Millennium • Northpoint Domain • Atritech • Edwards Lifesciences • Lab Corp • Reata • United Health Care None None Dr. Robert C. Hendel • Astellas • GE Healthcare • PGx Health • Astellas None • GE Healthcare None None Dr. Manesh R. Patel None None None None None None Dr. Eric D. Peterson None None None • Bristol-Myers Squibb/Sanofi Aventis • Merck • Schering-Plough • St. Jude None None Dr. Michael J. Wolk None None None None None None Cardiac Radionuclide Imaging Appropriate Use Criteria Indication Reviewers Dr. James Arrighi None None None None None None Dr. Robert O. Bonow • Bristol-Myers Squibb Medical Imaging • Edwards Lifesciences None None None None None Dr. Lee A. Fleisher None None None None None • Preoperative potassium • Preoperative potassium level Dr. Julius M. Gardin None • CV Therapeutics • Pfizer • Takeda None • Merck None None Dr. Raymond J. Gibbons • Cardiovascular Clinical Studies (WOMEN study) • Consumers Union • TIMI 37A None None • Kai Pharmaceuticals • King Pharmaceuticals • Radiant Medical • TargeGen • Ther Ox None None Dr. John A. Gillespie None None None None None None Dr. Bennett S. Greenspan None None None None None None Dr. Rory Hachamovitch • Bristol-Myers Squibb Medical Imaging • GE Healthcare None • Astellas • Bracco Diagnostics • GE Healthcare • Siemens None None Dr. Warren R. Janowitz None None None None None None Dr. Christopher M. Kramer • Siemens None None • Astellas • GlaxoSmithKline • Merck • Siemens None None Dr. Michael H. Picard • Acusphere None None • Edwards Lifesciences None None Dr. Michael Poon None None None None None None Dr. Miguel A. Quinones None None None None None • Diet pills and valve disease Dr. Raymond F. Stainback None None None None None None Dr. Mark I. Travin None None None None None • Adding exercise to pharmacologic stress • ECG stress testing and ordering nuclear studies Dr. Samuel Wann None None None None None None Dr. R. Parker Ward None None None • Pfizer None None Dr. Neil J. Weissman • Takeda • Wyeth None None • Acusphere • Arena Pharmaceutical • ATS • Biotronik • Boston Scientific • Edwards Lifesciences • Lipid Science • Point Biomedical • Sorin Carbomedics • Spectranetics • St. Jude • Zilver None • Anorexic agents Dr. Jack A. Ziffer • Tyco Healthcare None • CV Therapeutics • Spectrum Dynamics • Bristol-Myers Squibb • CV Therapeutics None None Dr. William A. Zoghbi None None None None None None

This table represents the relevant relationships of committee members with industry and other entities that were reported orally at the initial writing committee meeting and updated in conjunction with all meetings and conference calls of the writing committee during the document development process. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10 000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted.

	Appendix

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
Supplementary materials cited in this article are available online.

	Footnotes

 
This document was approved by the American College of Cardiology Foundation Board of Trustees in 2009.

The American College of Cardiology Foundation requests that this document be cited as follows: Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:xxx–xxx.

This article has been copublished in the June 9, 2009, issue of Circulation.

Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints{at}elsevier.com.

Permissions: Modification, alteration, enhancement and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier's permission department healthpermissions{at}elsevier.com

^_* Official American College of Cardiology Foundation representative;

Official American Society of Nuclear Cardiology representative;

Official Society of Nuclear Medicine representative;

Official American College of Emergency Physicians representative;

^|| Official Health Plan representative;

^¶ Official American College of Radiology representative;

^# Official ACCF/AHA Task Force on Practice Guidelines representative;

^_** Official Society for Cardiovascular Magnetic Resonance representative;

Official Society of Cardiovascular Computed Tomography representative;

Official American Society of Echocardiography representative

Immediate past chair of the Appropriate Use Criteria Task Force during the development of this document

^_* Negative consequences include the risks of the procedure radiation or contrast exposure and the downstream impact of poor test performance such as delay in diagnosis (false negatives) or inappropriate diagnosis (false positives).

Grundy et al. (9) cites Framingham when assigning patients with diabetes mellitus to a category of high short-term risk because these patients typically have multiple risk factors and have poor prognoses if they develop CHD.

The use of TIMI score of 2 as a cut-point was arbitrary, but the technical panel felt the need to establish a threshold.

	References

Top Technical Panel Appropriate Use Criteria Task... Table of contents Abstract Preface 1. Introduction 2. Methods 3. General Assumptions 4. Definitions 5. Abbreviations 6. Results of Ratings 7. Cardiac Radionuclide Imaging... 8. Cardiac Radionuclide Imaging... 9. Discussion Appendix A: Additional Cardiac... Appendix B: Additional Methods Appendix C: ACCF Appropriate... Staff APPENDIX D.... Appendix References

 
1 Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Strategic Direction Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology J Am Coll Cardiol 2005;46:1587-1605.[Free Full Text]

2 Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography J Am Coll Cardiol 2008;51:1127-1147.[Free Full Text]

3 Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging J Am Coll Cardiol 2006;48:1475-1497.[Free Full Text]

4 Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging J Am Coll Cardiol 2005;46:1606-1613.[Free Full Text]

5 Fitch K, Bernstein SJ, Aguilar, MD, et al. The RAND/UCLA Appropriateness Method User's ManualArlington, Va: RAND; 2001.

6 Ficaro E. Imaging guidelines for nuclear cardiology procedures. J Nucl Cardiol. 2006;13(6): doi: 10.1016/j.nuclcard.2006.10.006.

7 Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) J Am Coll Cardiol 2002;40:1531-1540.[Free Full Text]

8 National Institutes of Health: National Heart, Lung, and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). NIH Publication No. 02-5215. September 2002.

9 Grundy SM, Pasternak R, Greenland P, et al. AHA/ACC scientific statement: assessment of cardiovascular risk by use of multiple-risk factor assessment equations: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology J Am Coll Cardiol 1999;34:1348-1359.[Free Full Text]

10 Morise AP, Haddad WJ, Beckner D. Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease Am J Med 1997;102:350-356.[CrossRef][Web of Science][Medline]

11 Pryor DB, Shaw L, McCants CB, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease Ann Intern Med 1993;118:81-90.[Abstract/Free Full Text]

12 Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee on the Management of Patients With Chronic Stable Angina) J Am Coll Cardiol 2003;41:159-168.[Free Full Text]

13 Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease N Engl J Med 1979;300:1350-1358.[Web of Science][Medline]

14 Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) J Am Coll Cardiol 2002;40:1531-1540.[Free Full Text]

15 Mehta R, Agarwal S, Chandra S, Ward RP, Williams KA. Evaluation of the American College of Cardiology Foundation/American Society of Nuclear Cardiology Appropriateness Criteria for SPECT Myocardial Perfusion Imaging J Nucl Cardiol 2008;15:337-344.[CrossRef][Web of Science][Medline]

16 Gibbons RJ, Miller TD, Hodge D, et al. Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center J Am Coll Cardiol 2008;51:1283-1289.[Abstract/Free Full Text]

17 Ward RP, Al-Mallah MH, Grossman GB, et al. American Society of Nuclear Cardiology review of the ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) J Nucl Cardiol 2007;14:e26-e38.[CrossRef][Medline]

18 Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) J Am Coll Cardiol 2007;23;:50:e159–241.

19 Douglas P, Iskandrian AE, Krumholz HM, et al. Achieving quality in cardiovascular imaging: proceedings from the American College of Cardiology-Duke University Medical Center Think Tank on Quality in Cardiovascular Imaging J Am Coll Cardiol 2006;48:2141-2151.[Free Full Text]

20 Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making JAMA 2000;284:835-842.[Abstract/Free Full Text]

21 Askew JW, Miller TD, Hodge DO, Gibbons RJ. The value of myocardial perfusion single-photon emission computed tomography in screening asymptomatic patients with atrial fibrillation for coronary artery disease J Am Coll Cardiol 2007;50:1080-1085.[Abstract/Free Full Text]

22 Bierig SM, Ehler D, Knoll ML, Waggoner AD. American Society of Echocardiography minimum standards for the cardiac sonographer: a position paper J Am Soc Echocardiogr 2006;19:471-474.[CrossRef][Web of Science][Medline]

23 Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction) J Am Coll Cardiol 2004;44:671-719.[Free Full Text]

24 Campeau L. Letter: grading of angina pectoris Circulation 1976;54:522-523.

25 Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction) J Am Coll Cardiol 2007;50:e1-e157.[Free Full Text]

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