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doi:10.1016/j.jacc.2009.02.013 2009;53;2201-2229; originally published online May 18, 2009;J. Am. Coll. Cardiol. Robert E. Henkin, Patricia A. Pellikka, Gerald M. Pohost, and Kim A. Williams Robert C. Hendel, Daniel S. Berman, Marcelo F. Di Carli, Paul A. Heidenreich, Endorsed by the American College of Emergency Physicians Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine Society of Cardiovascular Computed Tomography, the Society for American Heart Association, the American Society of Echocardiography, the Society of Nuclear Cardiology, the American College of Radiology, the of Cardiology Foundation Appropriate Use Criteria Task Force, the American Criteria for Cardiac Radionuclide Imaging: A Report of the American College ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use This information is current as of August 4, 2009 http://content.onlinejacc.org/cgi/content/full/53/23/2201 located on the World Wide Web at: The online version of this article, along with updated information and services, is by on August 4, 2009 content.onlinejacc.orgDownloaded from A C R I W T P M Jam An Gr Pe Leonie Gordon, MB, CHB¶ *Offi ficia Soc Em ¶O AC Soc Soc cial A U T Thi Boa T cite RE SCC a re Tas Rad raph Journal of the American College of Cardiology Vol. 53, No. 23, 2009 © 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00 Pub ppropriate se Criteria ask Force 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 §§Immediate past chair of the Appropriate Use Criteria Task Force during the development of this document s document was approved by the American College of Cardiology Foundation rd of Trustees in 2009. he American College of Cardiology Foundation requests that this document be d as follows: Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, Henkin , Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/ T/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: port of the American College of Cardiology Foundation Appropriate Use Criteria k Force, the American Society of Nuclear Cardiology, the American College of Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol 2009;53:2201–29. 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@elsevier.com. Permissions: Modification, alteration, enhancement and/or distribution of this document are not permitted without the express permission of the American College iology, the American Heart A y, the Society of Cardiova anuel D. Cerqueira, MD, FACC, FAHA, FASNC† es R. Corbett, MD, FACC‡ thony J. Dean, MD, FACEP§ egory J. Dehmer, MD, FACC, FAHA* ter Goldbach, MD, FACC� ssociation, the American Society of Echocardiog- scular Computed Tomography, the Society for of Cardiology F healthpermissions by on content.onlinejacc.orgDownloaded from cial American College of Cardiology Foundation representative; †Of- l American Society of Nuclear Cardiology representative; ‡Official iety of Nuclear Medicine representative; §Official American College of ergency Physicians representative; �Official Health Plan representative; fficial American College of Radiology representative; #Official CF/AHA Task Force on Practice Guidelines representative; **Official iety for Cardiovascular Magnetic Resonance representative; ††Official iety of Cardiovascular Computed Tomography representative; ‡‡Offi- American Society of Echocardiography representative PPROPRIATE USE CRITERIA 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 Endorsed by the American College of Emergency Physicians ardiac adionuclide maging riting Group Robert C. Hendel, MD, FACC, FAHA, FASNC, Chair Daniel S. Berman, MD, FACC, FAHA Marcelo F. Di Carli, MD, FACC, FAHA Paul A. Heidenreich, MD, FACC Robert E. Henkin, MD, FACR Patricia A. Pellikka, MD, FACC, FAHA, FASE Gerald M. Pohost, MD, FACC, FAHA, FSCMR Kim A. Williams, MD, FACC, FAHA, FASNC echnical anel Michael J. Wolk, MD, MACC, Moderator 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† 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* lished by Elsevier Inc. doi:10.1016/j.jacc.2009.02.013 oundation. Please contact Elsevier’s permission department @elsevier.com August 4, 2009 T Ab Pr 1. 2. 3. 4. 5. 6. 7. 8. 9. Ap Im Ap Ap Ca Ap SC Us Fo Wi (In Re Ab Th alo du na qu ori M ate refl to in me a f ap clin we tec use ass cor tes gen les fou pa sig for fut Pr In 2202 Hendel et al. JACC Vol. 53, No. 23, 2009 ABLE OF CONTENTS stract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2202 eface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2202 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2203 Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2203 General Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2204 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2205 Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2206 Results of Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2206 Cardiac Radionuclide Imaging Appropriate Use Criteria (By Indication) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2207 Table 1. Detection of Coronary Artery Disease: Symptomatic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2207 Table 2. Detection of Coronary Artery Disease/ Risk Assessment Without Ischemic Equivalent. . . . . .2208 Table 3. Risk Assessment With Prior Test Results and/or Known Chronic Stable Coronary Artery Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2208 Table 4. Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2209 Table 5. Risk Assessment: Within 3 Months of an Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . .2209 Table 6. Risk Assessment: Postrevascularization (Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting Surgery). . . . . . . . . . . . . . . . . . . . .2210 Table 7. Assessment of Viability/Ischemia . . . . . . . . . . .2210 Table 8. Evaluation of Ventricular Function . . . . . . . . . .2210 Cardiac Radionuclide Imaging Appropriate Use Criteria (By Appropriate Use Category) . . . . . . . . . . . . .2211 Table 9. Appropriate Indications (Median Score 7–9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2211 Table 10. Uncertain Indications (Median Score 4–6). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2213 Table 11. Inappropriate Indications (Median Score 1–3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2214 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2215 9.1. Radionuclide Imaging Appropriate Use Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2216 9.2. Application of Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2219 Appropriate Use Criteria for Cardiac Radionuclide Imaging pendix A: Additional Cardiac Radionuclide aging Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2220 im AC content.onlinejaccDownloaded from pendix B: Additional Methods. . . . . . . . . . . . . . . . . . . . . . . . .2222 Relationships With Industry . . . . . . . . . . . . . . . . . . . . . . . . . . .2222 Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2222 pendix C: ACCF Appropriate Use Criteria for rdiac Radionuclide Imaging Participants . . . . . . . . . . . .2222 pendix D: ACCF/ASNC/ACR/AHA/ASE/SCCT/ MR/SNM Cardiac Radionuclide Imaging Appropriate e Criteria Writing Group, Technical Panel, Task rce, and Indication Reviewers—Relationships th Industry And Other Entities Alphabetical Order) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2225 ferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2228 stract e American College of Cardiology Foundation (ACCF), ng with key specialty and subspecialty societies, con- cted an appropriate use review of common clinical sce- rios where cardiac radionuclide imaging (RNI) is fre- ently considered. This document is a revision of the ginal Single-Photon Emission Computed Tomography yocardial Perfusion Imaging (SPECT MPI) Appropri- ness Criteria (1), published 4 years earlier, written to ect changes in test utilization and new clinical data, and clarify RNI use where omissions or lack of clarity existed the original criteria. This is in keeping with the commit- nt to revise and refine appropriate use criteria (AUC) on requent basis. The indications for this review were drawn from common plications or anticipated uses, as well as from current ical practice guidelines. Sixty-seven clinical scenarios re developed by a writing group and scored by a separate hnical panel on a scale of 1 to 9 to designate appropriate , inappropriate use, or uncertain use. In general, use of cardiac RNI for diagnosis and risk essment in intermediate- and high-risk patients with onary artery disease (CAD) was viewed favorably, while ting in low-risk patients, routine repeat testing, and eral screening in certain clinical scenarios were viewed s favorably. Additionally, use for perioperative testing was nd to be inappropriate except for high selected groups of tients. It is anticipated that these results will have a nificant impact on physician decision making, test per- mance, and reimbursement policy, and will help guide ure research. eface an effort to respond to the need for the rational use of June 9, 2009:2201–29 aging services in the delivery of high quality care, the CF has undertaken a process to determine the appro- by on August 4, 2009 .org pri ind eff rev tes pa on the be ide con the the Di clin ran inf all Th an int de or sel use sou cur rat an SP sim ech car the ind dif ite ap tim com im ass clin gro tho car tha rev ind ind he Ke an com 1. Th Im its tio car tar inn pe co res As ing mo sta da co eff cat dia rec tim co do AU pro pu (SP int tan tia to sh a c an rat tes pre un be 2. 2203JACC Vol. 53, No. 23, 2009 Hendel et al. June ate use of cardiovascular imaging for selected patient ications. Appropriate use criteria publications reflect an ongoing ort by the ACCF to critically and systematically create, iew, and categorize clinical situations where diagnostic ts and procedures are utilized by physicians caring for tients with cardiovascular diseases. The process is based a current understanding of the technical capabilities of imaging modalities examined. Although not intended to entirely comprehensive, the indications are meant to ntify common scenarios encompassing the majority of temporary practice. Given the breadth of information y convey, the indications do not directly correspond to Ninth Revision of the International Classification of seases (ICD-9) system as these codes do not include ical information, such as symptom status. The ACCF believes that careful blending of a broad ge of clinical experiences and available evidence-based ormation will help guide a more efficient and equitable ocation of health care resources in cardiovascular imaging. e ultimate objective of AUC is to improve patient care d health outcomes in a cost-effective manner, but it is not ended to ignore ambiguity and nuance intrinsic to clinical cision making. Local parameters, such as the availability quality of equipment or personnel, may influence the ection of appropriate imaging procedures. Appropriate criteria thus should not be considered a substitute for nd clinical judgment and practice experience. The ACCF AUC process itself is also evolving. In the rent iteration, technical panel members were asked to e indications for cardiac RNI in a manner independent d irrespective of the prior published ACCF ratings for ECT MPI (1) as well as the prior ACCF ratings for ilar diagnostic stress imaging modalities, such as stress ocardiography (2), cardiac computed tomography, or diac magnetic resonance (3). Given the iterative nature of process, readers are counseled not to compare too closely ividual appropriate use ratings among modalities rated at ferent times over the past 2 years. Since this process is rative and evolving, readers are counseled that individual propriate use ratings among modalities rated at different es over the past 2 years may not be consistent. A parative evaluation of the appropriate use of multiple aging techniques will be undertaken in the near future to ess the relative strengths of each modality for various ical scenarios. We are grateful to the technical panel, a professional up with a wide range of skills and insights, for their ughtful and thorough deliberation on the merits of diac RNI for various indications. In addition to our nks to the technical panel for their dedicated work and iew, we would like to offer special thanks to the many ividuals who provided a careful review of the draft ications; to Peggy Christiansen, the ACCF librarian for 9, 2009:2201–29 r comprehensive literature searches; to Lindsey Law and nnedy Elliott, who continually drove the process forward; Th bro content.onlinejaccDownloaded from d to Robert Hendel, MD, the chair of the writing mittee, 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 Introduction is report addresses the appropriate use of cardiac RNI. provements in cardiovascular imaging technology and application, coupled with increasing therapeutic op- ns for cardiovascular disease, have led to an increase in diovascular imaging. At the same time, the armamen- ium of noninvasive diagnostic tools has expanded with ovations in new contrast agents, molecular RNI, rfusion echocardiography, computed tomography for ronary angiography and calcium score, and magnetic onance imaging for myocardial structure and viability. the field of cardiac radionuclide cardiovascular imag- continues to advance along with other imaging dalities, the health care community needs to under- nd how to best incorporate these technologies into ily clinical care. All prior AUC publications from the ACCF and llaborating organizations have reflected an ongoing ort to critically and systematically create, review, and egorize the appropriate use of certain cardiovascular gnostic tests. The American College of Cardiology ognizes the importance of revising these criteria in a ely manner in order to provide the cardiovascular mmunity with the most accurate indications. This cument presents the first attempt to update an existing C document, the 2005 published ACCF/ASNC Ap- priateness Criteria for Single-Photon Emission Com- ted Tomography Myocardial Perfusion Imaging ECT MPI) (1). Clinicians, payers, and patients are erested in the specific benefits of cardiac RNI. Impor- tly, inappropriate use of cardiac RNI may be poten- lly harmful to patients and generate unwarranted costs the healthcare system, whereas appropriate procedures ould likely improve patients’ clinical outcomes. This is ritical shift since the intent is for the potential benefits d risks of the treatment to be explicitly considered, her than just the potential usefulness of a diagnostic t as a prelude to further treatment. This document sents the results of this effort, but it is critical to derstand the background and scope of this document fore interpreting the rating tables. Methods Appropriate Use Criteria for Cardiac Radionuclide Imaging e indications included in this publication are purposefully ad, and comprise a wide array of cardiovascular signs and by on August 4, 2009 .org sym car the an en Ap thi tic mo do sev fur for cir rat ba pa tio de pa of pro pe we for inf the fac wa ind wa inc exc wi gen pro sco arb vie div Sc the sea sho res tha gen cri wa pa off ha spe tio inf tec RA pa as ou Di rat cat riz Ind dis 3. To ass tec the 1. 2. *Ne exp diag 2204 Hendel et al. JACC Vol. 53, No. 23, 2009 ptoms as well as clinical judgment as to the likelihood of diovascular findings. A detailed description of the methods used for ranking selected clinical indications is outlined in Appendix B d is also found more generally in a previous publication titled, “ACCF Proposed Method for Evaluating the propriateness of Cardiovascular Imaging” (4). Briefly, s process combines evidence-based medicine and prac- e experience by engaging a technical panel in a dified Delphi exercise. Since the original SPECT cument (1) and methods paper (4) were published, eral important processes have been put in place to ther enhance this process. They include convening a mal writing group with diverse expertise in imaging, culating the indications for external review prior to ing by the technical panel, and ensuring appropriate lance of the technical panel, a standardized rating ckage, and formal roles for facilitating panel interac- n at the face-to-face meeting. These changes are tailed in a separate manuscript, which is in preparation. The panel first rated indications independently. Then the nel was convened for a face-to-face meeting for discussion each indication. At this meeting, panel members were vided with their scores and a blinded summary of their ers’ scores. After the consensus meeting, panel members re then asked to independently provide their final scores each indication. While panel members were not provided explicit cost ormation to help determine their appropriate use ratings, y were asked to implicitly consider cost as an additional tor in their evaluation of appropriate use. In developing these criteria, the AUC Technical Panel s asked to assess whether the use of the test for each ication is appropriate, uncertain, or inappropriate, and s provided the following definition of appropriate use: An appropriate imaging study is one in which the expected remental information, combined with clinical judgment, eeds the expected negative consequences* by a sufficiently de margin for a specific indication that the procedure is erally considered acceptable care and a reasonable ap- ach for the indication. The technical panel scores each indication as follows