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P U B L I S H E D B Y E L S E V I E R

APPROPRIATE USE CRITERIA

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ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS2019 Appropriate Use Criteriafor Multimodality Imaging in theAssessment of Cardiac Structure and

Function in Nonvalvular Heart Disease

A Report of the American College of Cardiology Appropriate Use Criteria Task Force,American Association for Thoracic Surgery, American Heart Association, American Society ofEchocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society,Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular ComputedTomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons

Writing Group John U. Doherty, MD, FACC, FAHA, Chair*

Members

Smadar Kort, MD, FACC, FASE, FAHAyRoxana Mehran, MD, FACC, FSCAI, FAHAzPaul Schoenhagen, MD, FAHAxPrem Soman, MD, PHD, FACCk

0

This document was approved by the American College of Cardiology Clini

The American College of Cardiology requests that this document be cited

AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 appropriate use crite

function in nonvalvular heart disease: a report of the American College of

Thoracic Surgery, American Heart Association, American Society of Echocard

Society for Cardiovascular Angiography and Interventions, Society of Card

Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2019;73:488

This document has been reprinted in the Journal of the American Society o

Journal of Cardiovascular Computed Tomography, the Journal of Nuclear Car

Copies: This document is available on the World Wide Web site of the Am

please contact Elsevier Inc. Reprint Department via fax (212) 633-3820 or e-m

Permissions: Multiple copies, modification, alteration, enhancement, and

permission of the American College of Cardiology. Requests may be com

business/policies/copyright/permissions).

*American College of Cardiology Representative.

yAmerican Society of Echocardiography Representative.zSociety for Cardiovascular Angiography and Interventions Representative.xSociety of Cardiovascular Computed Tomography Representative.kAmerican Society of Nuclear Cardiology Representative.

Rating PanelMembers

Gregory J. Dehmer, MD, MACC, MSCAI, FACP,Moderator*

FAHA,

John U. Doherty, MD, FACC, FACP, FAHA,Writing Group Liaison*Paul Schoenhagen, MD, FAHA, Writing Group Liaisonx

Thomas M. Bashore, MD, FACC*

Nicole M. Bhave, MD, FACC*Dennis A. Calnon, MD, FACC, FASE, MASNC, FSCCTkBlase Carabello, MD, FACC*John Conte, MD{Timm Dickfeld, MD, FACC#Daniel Edmundowicz, MD, FACC*Victor A. Ferrari, MD, FACC**

https://doi.org/10.1016/j.jacc.2018.10.038

cal Policy Approval Committee in December 2019.

as follows: Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P. ACC/

ria for multimodality imaging in the assessment of cardiac structure and

Cardiology Appropriate Use Criteria Task Force, American Association for

iography, American Society of Nuclear Cardiology, Heart Rhythm Society,

iovascular Computed Tomography, Society for Cardiovascular Magnetic

–516.

f Echocardiography, Catheterization and Cardiovascular Interventions, the

diology, and the Journal of Thoracic and Cardiovascular Surgery.

erican College of Cardiology (www.acc.org). For copies of this document,

ail ([email protected]).

/or distribution of this document are not permitted without the express

pleted online via the Elsevier site (https://www.elsevier.com/about/our-

https://doi.org/10.1016/j.jacc.2018.10.038http://www.acc.orgmailto:[email protected]://www.elsevier.com/about/our-business/policies/copyright/permissionshttps://www.elsevier.com/about/our-business/policies/copyright/permissionshttp://crossmark.crossref.org/dialog/?doi=10.1016/j.jacc.2018.10.038&domain=pdf

J A C C V O L . 7 3 , N O . 4 , 2 0 1 9 Doherty et al.F E B R U A R Y 5 , 2 0 1 9 : 4 8 8 – 5 1 6 AUC for Multimodality Imaging in Non–VHD

489

Michael E. Hall, MD, FACC*Brian Ghoshhajra MD, MBAxPraveen Mehrotra, MD, FACC*Tasneem Z. Naqvi, MD, FACC, FASE*T. Brett Reece, MDyyRandall C. Starling, MD, FACC*Molly Szerlip, MD, MD, FACCz

Wendy S. Tzou, MD, FACC, FHRSzzJohn B. Wong, MD*

{Society of Thoracic Surgeons Representative.#Heart Rhythm Society Representative.

**Society for Cardiovascular Magnetic Resonance Representative.

yyAmerican Association for Thoracic Surgery Representative.zzAmerican Heart Association Representative.

AppropriateUse CriteriaTask Force

Gregory J. Dehmer, MD, MACC, MSCAI, FACo-Chair

John U. Doherty, MD, FACC, FAHA, FACP, Co-ChairHA,

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

Nicole M. Bhave, MD, FACCAlan S. Brown, MD, FACCxxStacie L. Daugherty, MD, FACCLarry S. Dean, MD, FACC, MSCAIMilind Y. Desai, MBBS, FACCClaire S. Duvernoy, MD, FACCLinda D. Gillam, MD, FACCRobert C. Hendel, MD, FACC, FAHAxx

Christopher M. Kramer, MD, FACC, FAHAkkBruce D. Lindsay, MD, FACCxxWarren J. Manning, MD, FACCManesh R. Patel, MD, FACC, FAHA{{Ritu Sachdeva, MBBS, FACCL. Samuel Wann, MD, MACCxxDavid E. Winchester, MD, FACCMichael J. Wolk, MD, MACCxx

xxFormer Task Force member; member during writing effort.kkFormer Task Force Co-chair; Co-Chair during writing effort.{{Former Task Force Chair; Chair during writing effort.

TABLE OF CONTENTS

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490

1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491

Table A. Stages of Valvular Heart Disease . . . . . . . . . . 491

Table B. Stages of Heart Failure . . . . . . . . . . . . . . . . . . 491

2. METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492

Indication Development . . . . . . . . . . . . . . . . . . . . . . . . 492

3. GENERAL ASSUMPTIONS . . . . . . . . . . . . . . . . . . . . . . 493

4. DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494

5. ABBREVIATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495

6. MULTIMODALITY IMAGING IN NONVALVULAR

HEART DISEASE: APPROPRIATE USE CRITERIA

(BY INDICATION) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

6.1. Initial Evaluation of Cardiac Structure andFunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

Table 1. Initial Evaluation of an AsymptomaticPatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496

Table 2. Initial Evaluation of a Patient WithClinical Signs and/or Symptoms ofHeart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497

6.2. Evaluation of Cardiac Structure and Function inPatients Who Had Prior Testing . . . . . . . . . . . . . 500

Table 3. Sequential or Follow-Up Testing toClarify Initial Diagnostic Testing . . . . . . . . . . . . . . 500

Table 4. Sequential or Follow-Up Testing:Asymptomatic or Stable Symptoms . . . . . . . . . . . 501

Table 5. Sequential or Follow-Up Testing: New orWorsening Symptoms or to Guide Therapy . . . . . 502

6.3. Evaluation of Cardiac Structure and Function inPatients Undergoing Transcatheter Interventionfor Structural Heart Disease . . . . . . . . . . . . . . . . . . 503

Table 6. Imaging for the Evaluation of TIA orIschemic Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . 503

6.3.1. Imaging for the Evaluation of Patent Foramen

Ovale or Atrial Septal Defect . . . . . . . . . . . . 504

Table 7a. Preprocedural Evaluation for Closureof PFO or Atrial Septal Defect . . . . . . . . . . . . . . . . 504

Table 7b. Intraprocedural Guidance for Closureof PFO or ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504

Table 7c. Assessment Following Closure ofPFO or ASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504

6.3.2. Imaging for the Evaluation of Left Atrial

Appendage Occlusion Device . . . . . . . . . . . . 505

Doherty et al. J A C C V O L . 7 3 , N O . 4 , 2 0 1 9

AUC for Multimodality Imaging in Non–VHD F E B R U A R Y 5 , 2 0 1 9 : 4 8 8 – 5 1 6490

Table 8a. Preprocedural Evaluation forLAA Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505

Table 8b. Intraprocedural Guidance forLAA Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505

Table 8c. Assessment Following LAA Occlusion . 505

7. DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 506

8. CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508

ACC PRESIDENT AND STAFF . . . . . . . . . . . . . . . . . . . . . 509

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509

APPENDIX A

Relationships With Industry and Other Entities . . . . . 511

ABSTRACT

This document is the second of 2 companion appropriateuse criteria (AUC) documents developed by the AmericanCollege of Cardiology, American Association for ThoracicSurgery, American Heart Association, American Society ofEchocardiography, American Society of Nuclear Cardiol-ogy, Heart Rhythm Society, Society for CardiovascularAngiography and Interventions, Society of CardiovascularComputed Tomography, Society for Cardiovascular Mag-netic Resonance, and Society of Thoracic Surgeons. Thefirst document (1) addresses the evaluation and use ofmultimodality imaging in the diagnosis and managementof valvular heart disease, whereas this document ad-dresses this topic with regard to structural (nonvalvular)heart disease. While dealing with different subjects, the 2documents do share a common structure and featuresome clinical overlap. The goal of the companion AUCdocuments is to provide a comprehensive resource formultimodality imaging in the context of structural andvalvular heart disease, encompassing multiple imagingmodalities.

Using standardized methodology, the clinical scenarios(indications) were developed by a diverse writing groupto represent patient presentations encountered ineveryday practice and included common applications andanticipated uses. Where appropriate, the scenarios weredeveloped on the basis of the most current AmericanCollege of Cardiology/American Heart Association ClinicalPractice Guidelines.

A separate, independent rating panel scored the 102clinical scenarios in this document on a scale of 1 to 9.Scores of 7 to 9 indicate that a modality is consideredappropriate for the clinical scenario presented. Midrangescores of 4 to 6 indicate that a modality may be appro-priate for the clinical scenario, and scores of 1 to 3 indicate

that a modality is considered rarely appropriate for theclinical scenario.

The primary objective of the AUC is to provide aframework for the assessment of these scenarios bypractices that will improve and standardize physiciandecision making. AUC publications reflect an ongoingeffort by the American College of Cardiology to criticallyand systematically create, review, and categorize clinicalsituations in which diagnostic tests and procedures areutilized by physicians caring for patients with cardiovas-cular diseases. The process is based on the current un-derstanding of the technical capabilities of the imagingmodalities examined.

PREFACE

Structural and valvular heart disease (VHD) encompass asignificant proportion of cardiovascular disease condi-tions. Initial diagnosis and subsequent follow-upfrequently rely on imaging with more than 1 imagingmodality. Rapidly evolving less-invasive and trans-catheter treatment options have fueled the need for pre-cise preprocedural and intraprocedural anatomic andfunctional imaging.

The publication of appropriate use criteria (AUC) re-flects 1 of several ongoing efforts by the American Collegeof Cardiology (ACC) and its partners to assist clinicianswho are caring for patients with cardiovascular diseasesand support high-quality cardiovascular care. The ACC/American Heart Association Clinical Practice Guidelinesprovide a foundation for summarizing evidence-basedcardiovascular care and, when evidence is lacking,expert consensus opinion that is approved in review bythe ACC and American Heart Association. However, inmany areas, variability remains in the use of cardiovas-cular imaging modalities, raising questions of overuse orunderuse. The AUC provide a practical standard uponwhich to assess and better understand variability.

We are grateful to the writing committee for thedevelopment of the overall structure of the document andclinical scenarios and to the rating panel—a professionalgroup with a wide range of skills and insights— for theirthoughtful deliberation of the merits of multimodalityimaging for various clinical scenarios. A special thanks toDr. Gregory J. Dehmer for serving as an expert moderatorat our in-person rating panel meeting. We would also liketo thank the AUC Task Force members, who providedinsight and guidance, and the ACC staff—especially MaríaVelásquez—for their skilled support in the generation ofthis document.

John U. Doherty, MD, FACC, FAHA, FACPChair, Multimodality Imaging in Nonvalvular Heart

Disease Writing GroupCo-Chair, Appropriate Use Criteria Task Force

TABLE A Stages of Valvular Heart Disease

Stage Definition Description

A At risk Patients with risk factors for development ofVHD

B Progressive Patients with progressive VHD (mild tomoderate severity and asymptomatic)

C Asymptomaticsevere

Asymptomatic patients who meet criteria forsevere VHD:

C1: Asymptomatic patients with severe VHDin whom the left or right ventricle remainscompensated

C2: Asymptomatic patients with severe VHDwith decompensation of the left or rightventricle

D Symptomaticsevere

Patients who have developed symptoms as aresult of severe VHD

Reproduced from Nishimura et al. (8).

VHD ¼ valvular heart disease.

TABLE B Stages of Heart Failure

Stage Definition

Stage A Patients with risk factors for heart failure butwithout structural disease or symptoms (e.g.,patient with hypertension but without leftventricular hypertrophy).

Stage B Patient with structural disease but no symptoms(e.g., asymptomatic left ventricularhypertrophy)

Stage C Current or prior symptoms of heart failure

Stage D Drug-refractory heart failure


491

1. INTRODUCTION

Improvements in noninvasive cardiovascular imagingtechnologies and their broader application to cardiovas-cular diagnosis and therapy have led to a dizzying array ofimaging options for the clinician. The strengths and lim-itations of various modalities are increasingly a body ofknowledge that may be unfamiliar to general clinicians,who are, at the same time, striving to be responsiblestewards of medical resources. The Appropriate Usemethodology has evolved from the evaluation of singlemodalities of imaging to a diagnosis-based and patient-centered approach evaluating multiple diagnostic op-tions in the assessment and care of our patients.

Through efforts to derive maximal value from imaging,the rate of imaging volume growth in Medicare has beenslowing. Still, the armamentarium of noninvasive diag-nostic tools has expanded greatly, offering a variety ofnew and more sophisticated imaging techniques. As im-aging technology and clinical applications continue toadvance, the healthcare community must understandhow best to incorporate these technologies into dailyclinical care and how to choose between new and estab-lished imaging technologies.

Proper diagnosis of structural heart disease has becomecritical as numerous catheter-based interventions arenow available as less-invasive therapeutic options. Forthe purpose of this document, structural disease is usedmore broadly and includes heart failure and diseases ofthe aorta and pericardium, in essence, any disorder inwhich there is an abnormality of cardiac structure orfunction, excluding valvular diseases.

Using standardized methodology, the clinical scenarios(indications) in this document were developed by adiverse writing group to represent patient presentationsencountered in everyday practice and were evaluated andrated by a separate, independent rating panel.

Because there is significant clinical overlap betweenstructural and valvular heart disease, separating the in-dications in the 2 AUC documents is somewhat arbitrary.The writing group therefore deliberately followed acommon structure in creating the companion documentson structural heart disease and VHD.

Specifically, this document is organized into 4 sectionsand 8 tables. Section 4 provides definitions of key con-cepts in structural heart disease, with Table A defining thestages of valvular heart disease and Table B defining thestages of heart failure. Section 6.1. describes scenarios ofinitial evaluation with no prior imaging. Table 1 lists sce-narios for the asymptomatic patient, whereas Table 2 listsscenarios for the symptomatic patient. Section 6.2. de-scribes scenarios in which prior imaging has been per-formed and sequential evaluation required. Table 3 ratesscenarios in which additional testing is used to clarify the

initial diagnosis. This is meant to span the period of initialevaluation, with further testing performed as needed toestablish the diagnosis and guide therapy. This may bemore detailed evaluation after the identification ofstructural heart disease by initial imaging that has notproved definitive either in diagnosis or prognosis or indirecting therapy. Table 4 describes scenarios in whichadditional testing is used in the context of clinical follow-up after initial diagnosis in the asymptomatic patient.This may be done to assess the response to therapy or thestability of the asymptomatic patient in whom structuralheart disease has been identified by initial imaging. Inthis case the imaging modality may be the same as that ofthe initial study and is used to assess stability and/orguide therapy. Table 5 describes scenarios in whichfollow-up testing is done in the symptomatic patient. Itencompasses follow-up imaging after the identification ofstructural heart disease in the face of new or worseningsymptoms. Section 6.3. evaluates transcatheter interven-tion for structural heart disease (Tables 6, 7a to 7c, and 8ato 8c). Table 6 and Tables 7a to 7c evaluate diagnosis andimaging support for transient ischemic cerebral attacksand identify patent foramen ovale preprocedural, intra-procedural, and postprocedural scenarios. Tables 8a to 8care further divided into preprocedural, intraprocedural,

*Negative consequences include the risks of the procedure (e.g., radiation or

contrast exposure) and the downstream impact of poor test performance such

as delay in diagnosis (false negatives) or inappropriate diagnosis (false

positives).



and postprocedural indications. For these indications,imaging support for left atrial appendage occlusionassumes the intervention’s clinical appropriateness.

2. METHODS

Indication Development

This document covers a wide array of methods for treatingstructural heart disease. A standardized approach was used tocreate different categories of indications, with the goal ofcapturing actual clinical scenarios, yet withoutmaking the listof indications excessively long. Indications were created torepresent most of the possible treatment approaches forstructural heart disease, rather than limiting the AUC to in-dications for which evidence was available.

To identify and categorize the indications, a writinggroup was formed that comprised structural heart diseaseexperts representing a variety of organizations and soci-eties. Wherever possible during the writing process, thegroup members would map the indications to relevantclinical practice guidelines and key publications or refer-ences (see Online Appendix). Once the indications wereformed, they were reviewed and critiqued by the parentAUC Task Force and by numerous external reviewers,including interventionalists, surgeons, radiologists, im-agers, and generalists. After the writing group incorpo-rated this initial feedback, the indications were sent to anindependent rating panel comprising additional expertsin the structural heart disease realm. The indications werethen sent back to the writing group for additional vetting.Imaging for each indication was then rated and classifiedas Appropriate (A), May Be Appropriate (M), or RarelyAppropriate (R) on the basis of these multiple rounds ofreview and revision.

A detailed description for the rating of imaging mo-dalities is found in a previous publication, ACCF ProposedMethod for Evaluating the Appropriateness of Cardio-vascular Imaging (2), as well as the updated version, ACCAppropriate Use Criteria Methodology: 2018 Update (3).Briefly, this process combines evidence-based medicineand practice experience, and engages a rating panel in amodified Delphi exercise. Other steps include convening aformal writing group with diverse expertise in structuralheart disease, circulating the indications for external re-view prior to sending them to the rating panel, ensuringan appropriate balance of expertise and practice area inthe rating panel, developing a standardized rating pack-age that includes relevant evidence, and establishment offormal roles for facilitating panel interaction at the face-to-face meeting.

The rating panel first evaluated the indications inde-pendently. Then the panel was convened for a face-to-face meeting to discuss each indication. At this meeting,panel members were given their scores and a blinded

summary of their peers’ scores. After the meeting, panelmembers were asked to provide their final scores for eachindication independently.

Although panel members were not provided explicitcost information to help determine their Appropriate Useratings, they were asked to implicitly consider cost as anadditional factor in their evaluation of Appropriate Use. Inrating these criteria, the AUC Rating Panel was asked toassess whether the use of the test for each indication isAppropriate, May Be Appropriate, or Rarely Appropriate,and was provided the following definition of AppropriateUse:

An appropriate imaging study is one in which theexpected incremental information, combined withclinical judgment, exceeds the expected negativeconsequences* by a sufficiently wide margin for aspecific indication that the procedure is generally

considered acceptable care and a reasonableapproach for the indication.

The rating panel scored each indication as follows:Median Score 7 to 9: Appropriate test for specific indi-

cation (test is generally acceptable and is a reasonableapproach for the indication).

An appropriate option for management of patients inthis population due to benefits generally outweighingrisks; an effective option for individual care plans,although not always necessary depending on physi-cian judgment and patient-specific preferences (i.e.,procedure is generally acceptable and is generally

reasonable for the indication).

Median Score 4 to 6: May Be Appropriate test for spe-cific indication (test may be generally acceptable and maybe a reasonable approach for the indication). May BeAppropriate also implies that more research and/or pa-tient information is needed to classify the indicationdefinitively.

At times an appropriate option for management ofpatients in this population due to variable evidence

or agreement regarding the benefit-risk ratio,potential benefit based on practice experience in the

absence of evidence, and/or variability in thepopulation; effectiveness for individual care must bedetermined by a patient’s physician in consultationwith the patient on the basis of additional clinical

variables and judgment along with patient

https://doi.org/10.1016/j.jacc.2018.10.038


493

preferences (i.e., procedure may be acceptable andmay be reasonable for the indication).

Median Score 1 to 3: Rarely Appropriate test for specificindication (test is not generally acceptable and is not areasonable approach for the indication).

Rarely an appropriate option for management ofpatients in this population due to the lack of a clearbenefit/risk advantage; rarely an effective option for

individual care plans; exceptions should havedocumentation of the clinical reasons for proceedingwith this care option (i.e., procedure is not generallyacceptable and is not generally reasonable for the

indication).

The division of the numerical scores into 3 levels ofappropriateness is somewhat arbitrary, and the numericdesignations should be viewed as a continuum. Further,clinical opinions may vary for particular clinical sce-narios, such that scores in the intermediate level ofappropriate use were labeled “May Be Appropriate,” ascritical patient or research data may be lacking ordiscordant. This designation should be a prompt to thefield to carry out definitive research investigationwhenever possible. It is anticipated that the AUC reportswill continue to be revised as further data are generatedand information from implementation of the criteria isaccumulated.

To prevent bias in the scoring process, the rating panelwas deliberately assembled to include a minority of spe-cialists in structural heart disease. While offering impor-tant clinical and technical insights, specialists might havea natural tendency to rate the indications within theirspecialty as more appropriate than would nonspecialists.In addition, care was taken in providing objective, unbi-ased information, including clinical practice guidelinesand key references, to the rating panel.

The level of agreement among panelists as defined byRAND (4) was analyzed on the basis of the BIOMED rulefor a panel of 14 to 16 members. As such, agreement wasdefined as an indication where 4 or fewer panelists’ rat-ings fell outside the 3-point region containing the medianscore.

Disagreement was defined as when at least 5 panelists’ratings fell in both the Appropriate and the RarelyAppropriate categories. Any indication having disagree-ment was categorized as May Be Appropriate regardless ofthe final median score.

3. GENERAL ASSUMPTIONS

1. This document will address the use of multimodalityimaging for evaluation of cardiac structure and

function focusing on nonvalvular structural diseaseand interventions. The companion document evalu-ates valvular diseases as well as percutaneous in-terventions used for their treatment.

2. Indication ratings contained herein supersede theratings of similar indications contained in previousAUC documents.

3. Evaluation of all indications pertains only to nonur-gent clinical circumstances.

4. A qualified clinician has obtained a complete clinicalhistory and performed a physical examination so thatthe clinical status of the patient can be assumed to bevalid as stated in the indication. Example: Anasymptomatic patient is truly asymptomatic and suf-ficient questioning has been undertaken for the con-dition in question.

5. All patients are receiving optimal standard care,including clinical practice guideline-based risk factormodification, primary and secondary prevention ofischemic heart disease, or treatment of heart failure,unless it is specifically noted.

6. The indications are, at times, purposely broad to coveran array of cardiovascular signs and symptoms and toaccount for the ordering physician’s best judgmentregarding the presence of cardiovascular abnormal-ities. Additionally, there are likely clinical scenariosthat are not covered in this document.

7. If the reason for a test can be assigned to more than 1indication, the reason is classified under the mostclinically significant indication.

8. Testing modalities are rated for their level of appro-priateness specific to clinical scenarios rather than aforced rank-order comparison against other testingmodalities. The goal of this document is to identifyany and all tests that are considered reasonable for agiven clinical indication. The goal of this document isthe determination of the range of modalities that

may or may not be reasonable for specific indications

rather than determination of a single best test for

each indication or a rank order. As such, more than 1test type may be considered Appropriate, May BeAppropriate, or Rarely Appropriate for any givenclinical indication.

9. If more than one modality falls into the same Appro-priate Use category, physician judgment and availablelocal expertise should be used to determine choice oftest.

10. The appropriate use of testing has the potential toimpact clinical decision making and to direct thera-peutic interventions.

11. Patients are suitable candidates for the procedure af-ter consideration of procedural risk. Unless explicitlystated, it is presumed that patients presenting for a



specific clinical indication are potential candidates forall of the tests to be rated and do not present withstrong contraindications that preclude them frombeing tested (e.g., renal dysfunction, presence of animplanted device).

12. Risk benefit: Overall patients’ representation asdescribed by age and other clinical factors was used inthe risk/benefit estimate. Each modality considered inthis document has inherent risks that may include butare not limited to radiation exposure, contrast sensi-tivity, other bodily injury, and interpretation errors.For any test, there may be certain patient populationswho are more susceptible to its known risks who arenot specifically captured in the indications butdeserve consideration when rating. Such risks shouldbe viewed “on balance” and not used as justificationto systematically reduce the level of appropriatenessof a particular test relative to other tests. (e.g., teststhat expose the patient to ionizing radiation shouldnot necessarily receive a lower score than those thatdo not). Thus, a given modality should be weighedspecifically in the context of the clinical scenario, withthe potential harm considered relative to the potentialbenefit gained.

13. Radiation safety: No clinical evidence to date un-equivocally supports the notion that low-doseionizing radiation at the levels used in medical im-aging is associated with increased long-term risk ofmalignancy. In a conservative approach, many ex-perts in the field have adopted the linear no-thresholdhypothesis, which assumes a linear relationship be-tween radiation dose and risk of malignancy irre-spective of radiation dose magnitude. Accordingly,the following radiation safety principles should beapplied to all testing involving ionizing radiation:

a. Clinical benefit should be As High As Reasonably

Achievable, embracing the guiding principle thattesting should be performed on cohorts that aremost likely to experience a net benefit.

b. Radiation exposure should be As Low As Reason-ably Achievable (ALARA). ALARA should be used toguide test choice and the imaging protocol. Implicitin the ALARA principle is that the use of testsinvolving ionizing radiation should be minimizedin vulnerable populations such as younger pa-tients, and that optimal test procedures are utilizedto perform the test at the lowest possible radiationdose while preserving image quality and informa-tion output.

c. Consider a patient’s exposure to ionizing radiationfor noncardiac diseases. These principles and theirimplications for care have recently been evaluatedin the 2018 ACC/HRS/NASCI/SCAI/SCCT Expert

Consensus Document on Optimal Use of IonizingRadiation in Cardiovascular Imaging (5).

14. Selection of patients for and monitoring of patientsduring and after contrast administration are assumedto be in accord with published standards whenavailable.

15. Cost: Clinical benefit should always be consideredfirst, and cost should be considered in relationshipto these benefits when determining net value. Forexample, a procedure with moderate clinical effi-cacy for a given AUC indication should not bescored as more appropriate than a procedure with ahigh clinical efficacy solely because of lower cost.Value may be informed by multiple measures ofpotential economic impact such as: a) induceddownstream or layered testing rates; b) comparativecost savings or minimization for diagnostic or near-term follow-up, c) cost to reduce adverse outcomes(e.g., cost for hospitalization averted); d) cost forlife years gained.

16. All tests and procedures are presumed to be per-formed and interpreted by qualified individuals in afacility that is in compliance with national standardsfor performing such imaging studies or procedures.Therefore, the level of appropriateness does notconsider issues of local availability or skill in the rat-ing of any modality.

17. Time biases in available data: Newer technologiesshould not be considered necessarily more or lessappropriate than older technologies. Apparent differ-ences in diagnostic accuracy and risk stratificationbetween older and newer techniques may not be ac-curate, especially when the techniques are notcompared directly or when historical data are utilized.As treatment paradigms evolve, diagnosis may occurat earlier stages of disease, posing unique challengesfor comparison of the performance of diagnostic mo-dalities used at different stages of the disease processowing to time lag bias.

18. Patients are suitable candidates for the procedure,with suitable procedural risk.

4. DEFINITIONS

1. Family History

In this document, the term “family history” refers tofirst-degree relatives only.

2. Symptomatic

A patient is deemed to be symptomatic when he/sheexhibits typical signs and/or symptoms (e.g., forcongestive heart failure, symptoms such as dyspnea,rales, edema, and limited exercise capacity).


495

3. Asymptomatic

Patient is deemed asymptomatic when he/she ex-hibits none of the typical symptoms.

4. Low, Moderate, and High Pretest Probability

As defined by the “2013 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diag-nosis and Management of Patients with StableIschemic Heart Disease” (6). Low pretest probabilityindicates 90% likelihood of the presenceof the disease entity under question prior to anytesting.

5. Clinically Significant

An abnormality that, if left untreated, can or will leadto functional impairment or death.

6. Mild, Moderate, and Severe Valvular Disease

As defined by the “2017 AHA/ACC Focused Update ofthe 2014 AHA/ACC Guideline for the Management ofPatients with Valvular Heart Disease” (7,8).

7. Stages of VHD

VHD as defined by the “2017 AHA/ACC Focused Up-date of the 2014 AHA/ACC Guideline for the Manage-ment of Patients with Valvular Heart Disease” (7,8)(Table A).

8. Uninterpretable or Technically Limited Images

Images that are not of diagnostic quality despite per-formance of the study by a skilled sonographer,technician, or other provider using appropriateequipment. This may be due to patient-related factorssuch as body habitus or motion artifact.

9. Concomitant Coronary Artery Disease

Term used when coronary artery disease does notexplain most of the clinical symptomology of the pa-tient but does occur in conjunction with another dis-ease entity.

10. Frequent Ventricular Premature Contractions

Ventricular premature contractions occurring morefrequently than 30 times per hour or occurring in apattern of bigeminy, trigeminy, or runs of ventriculartachycardia.

11. Infrequent Atrial Premature Complexes

Atrial premature complexes occurring less than 30times per hour or less than once per minute.

12. Nonsustained Ventricular Tachycardia

Ventricular arrhythmia of 3 or more consecutivecomplexes but lasting 100 bpm.

13. Sustained Ventricular Tachycardia

Ventricular tachycardia lasting more than 30 secondsor requiring therapy because of hemodynamiccompromise in



6. MULTIMODALITY IMAGING IN NONVALVULAR

HEART DISEASE: APPROPRIATE USE CRITERIA

(BY INDICATION)

6.1. Initial Evaluation of Cardiac Structure and Function

TABLE 1 Initial Evaluation of an Asymptomatic Patient

Indication

TTE (With orWithout 3D;With Contrastas Needed)

TEE(With or

Without 3D)StressEcho*

Strain/StrainRate Imaging bySpeckle or Tissue

Doppler RVG

MPI(SPECT/PET) CMR CT

1. Initial cardiac evaluation of a known systemic,congenital, or acquired disease that could beassociated with structural heart disease

9 (A) 2 (R) 2 (R) 5 (M) 1 (R) 2 (R) 5 (M) 2 (R)

2. Screening evaluation for structure and function infirst-degree relatives of a patient with aninherited cardiomyopathy

9 (A) 1 (R) 2 (R) 4 (M) 1 (R) 1 (R) 5 (M) 2 (R)

3. Initial evaluation prior to exposure tomedications/radiation that could result incardiotoxicity/heart failure

9 (A) 2 (R) 2 (R) 7 (A) 7 (A) 2 (R) 5 (M) 2 (R)

4. Evaluation of the ascending aorta in the settingof a known or suspected connective tissuedisease or genetic condition that predisposes toaortic aneurysm or dissection (e.g., Marfansyndrome)

8 (A) 5 (M) 1 (R) 1 (R) 1 (R) 1 (R) 8 (A) 8 (A)

5. Screening evaluation in relatives of a patient withknown aortic aneurysm or dissection

8 (A) 3 (R) 1 (R) 1 (R) 1 (R) 1 (R) 7 (A) 7 (A)

6. Preparticipation athlete assessment in a patientwith no symptoms, normal examination, and nofamily history of inheritable heart disease

3 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

7. Preparticipation assessment of an asymptomaticathlete with $1 of the following: abnormalexamination, abnormal ECG, or definite (or highsuspicion for) family history of inheritable heartdisease

9 (A) 2 (R) 4 (M) 4 (M) 1 (R) 2 (R) 5 (M) 4 (M)

8. Evaluation of suspected pulmonary arterialhypertension, including evaluation of rightventricular function and estimated pulmonaryartery pressure in a patient at risk for developingpulmonary arterial hypertension

9 (A) 2 (R) 3 (R) 2 (R) 1 (R) 1 (R) 4 (M) 4 (M)

*Stress echo comprises exercise stress echocardiography and dobutamine stress echocardiography.

3D ¼ 3-dimensional; A ¼ appropriate; CMR ¼ cardiovascular magnetic resonance imaging; CT ¼ computed tomography; ECG ¼ electrocardiogram; Echo ¼ echocardiography; M ¼may be appropriate; MPI ¼ myocardial perfusion imaging; PET ¼ positron emission tomography; R ¼ rarely appropriate; RVG ¼ radionuclide ventriculography; SPECT ¼ single-photonemission computed tomography; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.

TABLE 2 Initial Evaluation of a Patient With Clinical Signs and/or Symptoms of Heart Disease

Indication

TTE (With orWithout 3D;

With Contrast asNeeded)

TEE(With or


Strain/StrainRate Imagingby Speckle orTissue Doppler

F-18 FDGPET

Tc-99mPYP

MPI(SPECT/PET) CMR CT† ANG RVG

9. Initial evaluation whensymptoms or signssuggest heart disease

9 (A) 3 (R) 5 (M) 5 (M) 2 (R) 2 (R) 5 (M) 5 (M) 4 (M) 3 (R) 4 (M)

Arrhythmias or Conduction Disorders

10. Newly diagnosed LBBB 7 (A) 2 (R) 4 (M) 4 (M) 1 (R) 1 (R) 5 (M) 4 (M) 3 (R) 2 (R) 3 (R)

11. Newly diagnosed RBBB 5 (M) 1 (R) 3 (R) 2 (R) 1 (R) 1 (R) 2 (R) 2 (R) 2 (R) 1 (R) 2 (R)

12. Frequent VPCs withoutother evidence of heartdisease

7 (A) 2 (R) 3 (R) 2 (R) 1 (R) 1 (R) 3 (R) 4 (M) 3 (R) 2 (R) 2 (R)

13. Nonsustained VT 8 (A) 2 (R) 5 (M) 4 (M) 2 (R) 1 (R) 5 (M) 5 (M) 3 (R) 3 (R) 3 (R)

14. Sustained VT or VF 9 (A) 2 (R) 6 (M) 3 (R) 2 (R) 2 (R) 6 (M) 6 (M) 6 (M) 7 (A) 4 (M)

15. Evaluation of the patientwith episodes of SVTwithout other evidence ofheart disease

6 (M) 2 (R) 2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 2 (R) 1 (R) 1 (R) 1 (R)

16. Atrial fibrillation/flutter(not for purposes ofprecardioversionevaluation)

8 (A) 2 (R) 6 (M) 3 (R) 1 (R) 1 (R) 4 (M) 3 (R) 3 (R) 2 (R) 2 (R)

Palpitations/Presyncope/Syncope

17. Clinical symptoms or signsconsistent with a cardiacdiagnosis known to causepresyncope/syncope(including but not limitedto hypertrophiccardiomyopathy and HF)

9 (A) 3 (R) 5 (M) 4 (M) 2 (R) 1 (R) 5 (M) 7 (A) 5 (M) 3 (R) 3 (R)

18. Palpitations without othersymptoms or signs ofcardiovascular disease

6 (M) 1 (R) 2 (R) 2 (R) 1 (R) 1 (R) 2 (R) 2 (R) 1 (R) 1 (R) 1 (R)

19. Presyncope without othersymptoms or signs ofcardiovascular disease

7 (A) 1 (R) 1 (R) 2 (R) 1 (R) 1 (R) 1 (R) 2 (R) 1 (R) 1 (R) 1 (R)

20. Syncope without othersymptoms or signs ofcardiovascular disease

8 (A) 2 (R) 4 (M) 2 (R) 1 (R) 1 (R) 4 (M) 3 (R) 2 (R) 2 (R) 2 (R)

Hypotension or Hemodynamic Instability

21. Hypotension orhemodynamic instabilityof uncertain or suspectedcardiac etiology

8 (A) 4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 4 (M) 4 (M) 1 (R)

22. Assessment of volumestatus in a critically illpatient

7 (A) 2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

Hypertensive Heart Disease

23. Initial evaluation ofsuspected hypertensiveheart disease

8 (A) 2 (R) 2 (R) 3 (R) 1 (R) 1 (R) 1 (R) 3 (R) 2 (R) 1 (R) 1 (R)

24. Routine evaluation ofsystemic hypertensionwithout symptoms orsigns of hypertensiveheart disease

5 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

Continued on the next page


497

TABLE 2 Continued

Indication



TEE(With or



F-18 FDGPET

Tc-99mPYP


ACS

25. Evaluation of LV functionduring initial presentationwith acute coronarysyndrome

8 (A) 2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 3 (R) 1 (R) 7 (A) 1 (R)

26. Suspected complication ofmyocardial ischemia/infarction, including butnot limited to acute mitralregurgitation, ventricularseptal defect, free-wallrupture/tamponade,shock, right ventricularinvolvement, HF, orintraventricular thrombus

9 (A) 7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 6 (M) 6 (M) 6 (M) 2 (R)

Respiratory Failure/Exertional Shortness of Breath

27. Exertional shortness ofbreath/dyspnea orhypoxemia of uncertainetiology

8 (A) 3 (R) 7 (A) 4 (M) 1 (R) 1 (R) 6 (M) 5 (M) 5 (M) 3 (R) 3 (R)

28. Exertional shortness ofbreath /dyspnea orhypoxemia when a non-cardiac etiology ofdyspnea has beenestablished

4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 2 (R) 1 (R) 1 (R)

Heart Failure/Cardiomyopathy

29. Initial evaluation of knownor suspected HF (systolicor diastolic) based onsymptoms, signs, orabnormal test results toassess systolic or diastolicfunction and to assess forpossible etiology (CAD,valvular disease)

9 (A) 4 (M) 7 (A) 6 (M) 3 (R) 1 (R) 7 (A) 7 (A) 6 (M) 6 (M) 4 (M)

30. Suspected inherited oracquired cardiomyopathy(e.g., restrictive,infiltrative, dilated,hypertrophic)

9 (A) 3 (R) 3 (R) 6 (M) 4 (M) 4 (M) 2 (R) 7 (A) 4 (M) 3 (R) 4 (M)

31. Evaluation of LV functionin patients who arescheduled for or who havereceived chemotherapy

9 (A) 1 (R) 2 (R) 6 (M) 1 (R) 1 (R) 1 (R) 6 (M) 4 (M) 1 (R) 7 (A)

Pulmonary Hypertension

32. Evaluation of suspectedpulmonary hypertensionincluding evaluation ofright ventricular functionand estimated pulmonaryartery pressure

9 (A) 3 (R) 3 (R) 3 (R) 1 (R) 1 (R) 1 (R) 6 (M) 5 (M) 3 (R) 3 (R)




TABLE 2 Continued

Indication



TEE(With or



F-18 FDGPET

Tc-99mPYP


Device Therapy

33. Evaluation afterappropriate time intervalfollowingrevascularization and/oroptimal medical therapyto determine candidacy forICD/CRT and/or todetermine optimal choiceof device

9 (A) 2 (R) 1 (R) 2 (R) 1 (R) 1 (R) 1 (R) 7 (A) 5 (M) 1 (R) 7 (A)

34. Initial evaluation for CRTdevice optimization afterimplantation

7 (A) 1 (R) 1 (R) 3 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

35. Known implanted pacing/ICD/CRT device withsymptoms possibly due tosuboptimal device settings

8 (A) 2 (R) 1 (R) 4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

36. To determine candidacyfor ventricular assistdevice

9 (A) 3 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 6 (M) 5 (M) 5 (M) 3 (R)

37. Optimization of ventricularassist device settings

8 (A) 4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

Cardiac Transplantation

38. Monitoring for rejection orcoronary arteriopathy in acardiac transplantrecipient

8 (A) 2 (R) 3 (R) 4 (M) 2 (R) 1 (R) 4 (M) 5 (M) 3 (R) 5 (M) 3 (R)

39. Cardiac structure andfunction evaluation in apotential heart donor

9 (A) 4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 2 (R) 3 (R) 6 (M) 2 (R)

Other

40. Suspected pericardialdiseases

9 (A) 4 (M) 1 (R) 5 (M) 1 (R) 1 (R) 1 (R) 7 (A) 7 (A) 1 (R) 1 (R)

41. Initial evaluation of cardiacmass, suspected tumor orthrombus, or potentialcardiac source of emboli

9 (A) 7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 7 (A) 7 (A) 1 (R) 1 (R)

42. Suspected acute aorticpathology including acuteaortic syndrome

7 (A) 8 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 8 (A) 9 (A) 3 (R) 1 (R)

*Stress echo comprises exercise stress echocardiography and dobutamine stress echocardiography.†Could include CT angiography of the coronaries or any other vessel.

3D ¼ 3-dimensional; A ¼ appropriate; ACS ¼ acute coronary syndrome; ANG ¼ angiography/ventriculography/aortography; CAD ¼ coronary artery disease; CMR ¼ cardiovascularmagnetic resonance imaging; CRT ¼ cardiac resynchronization therapy; CT ¼ computed tomography; F-18 FDG ¼ fluorodeoxyglucose F18; HF ¼ heart failure; ICD ¼ implantablecardioverter-defibrillator; LBBB ¼ left bundle branch block; LV ¼ left ventricular; M ¼ may be appropriate; MPI ¼myocardial perfusion imaging; PET ¼ positron emission tomography;R ¼ rarely appropriate; RBBB ¼ right bundle branch block; RVG ¼ radionuclide ventriculography; SPECT ¼ single-photon emission computed tomography; Tc-99m PYP ¼ technetium-99m pyrophosphate; SVT ¼ supraventricular tachycardia; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography; VF ¼ ventricular fibrillation; VPC ¼ventricular premature contraction; VT ¼ ventricular tachycardia.


499



6.2. Evaluation of Cardiac Structure and Function in PatientsWho Had Prior Testing

TABLE 3 Sequential or Follow-Up Testing to Clarify Initial Diagnostic Testing


TEE(With or

Without 3D


ExerciseSE/DSE

F-18FDG-PET

Tc-99mPYP

MPI(SPECT/PET) CMR CT ANG

43. Left ventricular systolic dysfunction inthe absence of severe valvular disease

3 (R) 3 (R) 7 (A) 4 (M) 3 (R) 7 (A) 7 (A) 7 (A) 7 (A)

44. Pulmonary hypertension in the absenceof severe valvular disease

6 (M) 4 (M) 4 (M) 1 (R) 1 (R) 1 (R) 7 (A) 7 (A) 3 (R)

45. Excluding CAD in patients with HF andLV systolic dysfunction without angina

1 (R) 1 (R) 7 (A) 3 (R) 1 (R) 7 (A) 7 (A) 7 (A) 8 (A)

46. New or increasing HF symptomsdespite adherence to medical therapy

4 (M) 3 (R) 6 (M) 3 (R) 2 (R) 6 (M) 6 (M) 5 (M) 6 (M)

47. Comprehensive further evaluation ofundefined cardiomyopathy

3 (R) 5 (M) 5 (M) 5 (M) 4 (M) 6 (M) 8 (A) 6 (M) 7 (A)

48. Evaluation of suspected cardiacsarcoidosis

2 (R) 3 (R) 1 (R) 7 (A) 2 (R) 3 (R) 8 (A) 3 (R) 1 (R)

49. Evaluation of suspected cardiacamyloidosis

1 (R) 6 (M) 1 (R) 2 (R) 7 (A) 2 (R) 8 (A) 2 (R) 1 (R)

50. Evaluation of suspected hypertrophiccardiomyopathy

4 (M) 7 (A) 7 (A) 1 (R) 1 (R) 1 (R) 8 (A) 5 (M) 2 (R)

51. Further characterization of a known orsuspected, incidentally noted, smallcardiovascular implantable electronicdevice-related thrombus identified byTTE in an asymptomatic patient

2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

52. Comprehensive further evaluation ofdilated aortic sinuses or ascending aortaidentified by TTE

7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 8 (A) 8 (A) 3 (R)

53. Evaluation of the aortic sinuses,sinotubular junction, or ascending aortain patients with bicuspid aortic valvewhen morphology cannot be assessedaccurately or fully by TTE

7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 8 (A) 8 (A) 3 (R)

54. Further anatomic characterization ofanomalous coronary arteries identifiedby invasive coronary angiography

2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 7 (A) 9 (A)

*For more specific scenarios, please refer to the Heart Failure AUC.†Modalities grayed out assumes modality has been performed.

3D ¼ 3-dimensional; A ¼ appropriate; ANG ¼ angiography/ventriculography/aortography; AUC ¼ Appropriate Use Criteria; CAD ¼ coronary artery disease; CMR ¼ cardiovascularmagnetic resonance imaging; CT ¼ computed tomography; DSE ¼ dobutamine stress echocardiography; F-18 FDG ¼ fluorodeoxyglucose F18; HF ¼ heart failure; M ¼ may beappropriate; MPI ¼ myocardial perfusion imaging; PET ¼ positron emission tomography; R ¼ rarely appropriate; SE ¼ stress echocardiography; SPECT ¼ single-photon emissioncomputed tomography; Tc-99m PYP ¼ technetium-99m pyrophosphate; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.

TABLE 4 Sequential or Follow-Up Testing: Asymptomatic or Stable Symptoms

Indication


TEE(With or

Without 3D)

Strain/StrainRate Imagingby Speckleor TissueDoppler

F-18FDG-PET

Tc-99mPYP CMR CT RVG

55. Re-evaluation (

TABLE 5 Sequential or Follow-Up Testing: New or Worsening Symptoms or to Guide Therapy

Indication

TTE (Withor Without 3D;With Contrastas Needed)

TEE(With or

Without 3D) Ex.-SE DSE


F-18FDG-PET

Tc-99mPYP

MPI(SPECT/PET) CMR CT ANG RVG

68. Re-evaluation of known structuralheart disease with change inclinical status or cardiacexamination or to guide therapy(assume ischemic work-up hasbeen performed and remains valid)

8 (A) 5 (M) 4 (M) 4 (M) 4 (M) 2 (R) 1 (R) 2 (R) 6 (M) 5 (M) 1 (R) 4 (M)

69. Re-evaluation of prior TEE findingsfor interval change (e.g., reductionor resolution of atrial thrombusafter anticoagulation orintracardiac evaluation of cardiacmass when a change in therapy isanticipated

5 (M) 7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 7 (A) 7 (A) 1 (R) 1 (R)

70. Re-evaluation of knowncardiomyopathy with a change inclinical status or cardiacexamination or to guide therapy(assume ischemic work-up hasbeen done, performed, and remainsvalid)

8 (A) 3 (R) 3 (R) 3 (R) 5 (M) 3 (R) 2 (R) 2 (R) 6 (M) 5 (M) 3 (R) 4 (M)

71. Re-evaluation of known HF(systolic or diastolic) with a changein clinical status or cardiacexamination without a clearprecipitating change in medicationor diet

8 (A) 3 (R) 5 (M) 5 (M) 4 (M) 2 (R) 2 (R) 5 (M) 5 (M) 5 (M) 4 (M) 4 (M)

72. Re-evaluation of known HF(systolic or diastolic) with a changein clinical status or cardiacexamination with a clearprecipitating change in medicationor diet

4 (M) 2 (R) 2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

73. Periodic re-evaluation in a patientundergoing therapy withcardiotoxic agents and worseningsymptoms

9 (A) 2 (R) 1 (R) 1 (R) 7 (A) 1 (R) 1 (R) 1 (R) 6 (M) 4 (M) 1 (R) 7 (A)

74. Re-evaluation afterrevascularization and/or optimalmedical therapy to determinecandidacy for device therapy and/or to determine optimal choice ofdevice

8 (A) 2 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 6 (M) 4 (M) 1 (R) 5 (M)

75. Re-evaluation for CRT deviceoptimization in a patient withworsening HF (*Gated-SPECT forthis indication only)

8 (A) 1 (R) 1 (R) 1 (R) 4 (M) 1 (R) 1 (R) 2 (R) 1 (R) 1 (R) 1 (R) 1 (R)

76. Re-evaluation for ventricular assistdevice-related complication orinfection is suspected (*FDG PET inthis indication is for infectiondetection)

8 (A) 7 (A) 1 (R) 1 (R) 1 (R) 5 (M) 1 (R) 1 (R) 6 (M) 4 (M) 1 (R)

77. Re-evaluation for progression ofpericardial effusion size ordevelopment of tamponade

9 (A) 5 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 6 (M) 6 (M) 1 (R) 1 (R)

78. Re-evaluation for progression ofpericardial constriction

8 (A) 4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 7 (A) 6 (M) 1 (R) 1 (R)

79. Evaluation of patient withpericardial mass and symptomssuggestive of expansion

8 (A) 6 (M) 1 (R) 1 (R) 1 (R) 3 (R) 1 (R) 1 (R) 8 (A) 8 (A) 1 (R) 1 (R)




TABLE 5 Continued

Indication

TTE (Withor Without 3D;With Contrastas Needed)

TEE(With or

Without 3D) Ex.-SE DSE


F-18FDG-PET

Tc-99mPYP

MPI(SPECT/PET) CMR CT ANG RVG

80. Re-evaluation of known ascendingaortic dilatation or history of aorticdissection with a change in clinicalstatus (excluding acute coronarysyndrome) or cardiac examinationor when findings may altermanagement or therapy

8 (A) 7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 8 (A) 8 (A) 2 (R) 1 (R)

81. Re-evaluation of known pulmonaryhypertension with change inclinical status or cardiacexamination or to guide therapy

8 (A) 4 (M) 4 (M) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 5 (M) 6 (M) 3 (R) 1 (R)

3D ¼ 3-dimensional; A ¼ appropriate; ANG ¼ angiography/ventriculography/aortography; CMR ¼ cardiovascular magnetic resonance imaging; CRT ¼ cardiac resynchronizationtherapy; CT ¼ computed tomography; DSE ¼ dobutamine stress echocardiography; Ex.-SE ¼ exercise stress echocardiography; F-18 FDG ¼ fluorodeoxyglucose F18; HF ¼ heart failure;M ¼ may be appropriate; MPI ¼ myocardial perfusion imaging; PET ¼ positron emission tomography; R ¼ rarely appropriate; RVG ¼ radionuclide ventriculography; SPECT ¼ single-photon emission computed tomography; Tc-99m PYP ¼ technetium-99m pyrophosphate; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.


503

6.3. Evaluation of Cardiac Structure and Function inPatients Undergoing Transcatheter Intervention forStructural Heart Disease

TABLE 6 Imaging for the Evaluation of TIA or Ischemic Stroke

TTE (withagitated saline

injection; with orwithout 3D; with

contrast asneeded)

TEE (withagitated saline

injection;with or without 3D) TCD

MRAH/N

CTAH/N

CardiacMR

CardiacCT ANG

CarotidDoppler

82. Initial evaluation of patient to excludecardiac origin of TIA or ischemic stroke:

n Intracardiac masses (thrombus,vegetation)

n Valvular pathology

8 (A) 7 (A) 6 (M) 6 (M) 6 (M) 5 (M) 5 (M) 3 (R) 7 (A)

83. Assessment of intracranial arteries 6 (M) 8 (A) 8 (A) 5 (M)

84. Assessment of extracranial arteries(evaluation of the carotid and vertebralarteries)

8 (A) 8 (A) 5 (M) 8 (A)

85. Provocative maneuvers (Valsalva,cough) to assess for the presence of:

n Right-to-left intracardiac shunt

8 (A) 7 (A) 7 (A) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R) 1 (R)

3D ¼ 3-dimensional; A ¼ appropriate; ANG ¼ angiography/ventriculography/aortography; CT ¼ computed tomography; CTA ¼ computed tomography angiography; H/N ¼ head andneck; M ¼ may be appropriate; MR ¼ magnetic resonance; MRA ¼ magnetic resonance angiography; R ¼ rarely appropriate; TCD ¼ transcranial Doppler; TEE ¼ transesophagealechocardiography; TTE ¼ transthoracic echocardiography; TIA ¼ transient ischemic attack.



6.3.1. Imaging for the Evaluation of Patent Foramen Ovale or

Atrial Septal Defect

TABLE 7a Preprocedural Evaluation for Closure of PFO or Atrial Septal Defect

Indication

TTE (With AgitatedSaline Injection; Withor Without 3D; WithContrast as Needed)

TEE (WithAgitated SalineInjection; Withor Without 3D) 3D-TEE CMR CTA ANG

86. Preprocedure assessment for PFO:n Atrial appendage thrombusn Spontaneous echo contrast (slow blood flow)n Aortic atheroman Cardiac massesn Vegetations

7 (A) 8 (A) 5 (M) 1 (R) 1 (R) 1 (R)

87. Preprocedure assessment for:n Atrial septum anatomyn Atrial septum aneurysmn Suitability for percutaneous device closure

7 (A) 8 (A) 8 (A) 7 (A) 7 (A) 1 (R)

3D ¼ 3-dimensional; A ¼ appropriate; ANG ¼ angiography/ventriculography/aortography; CMR ¼ cardiovascular magnetic resonance imaging; CTA ¼ computed tomographyangiography; M ¼ may be appropriate; PFO ¼ patent foramen ovale; R ¼ rarely appropriate; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.

TABLE 7b Intra-Procedural Guidance for Closure of PFO or ASD

Indication


TEE (With AgitatedSaline Injection)

3D-TEE (WithAgitated Saline

Injection)ICE (With orWithout 3D) TCD Fluoro

88. Intraprocedural guidance in patient with either:n ASD of simple anatomyn No aneurysmal atrial septumn PFO with short tunnel

3 (R) 7 (A) 7 (A) 8 (A) 1 (R) 7 (A)

89. Intraprocedural guidance in patient with either:n ASD with complex anatomyn Aneurysmal interatrial septumn PFO with long tunnel

3 (R) 8 (A) 7 (A) 8 (A) 1 (R) 7 (A)

3D ¼ 3-dimensional; A ¼ appropriate; ASD ¼ atrial septal defect; Fluoro ¼ fluoroscopy; ICE ¼ intracardiac echocardiography; PFO ¼ patent foramen ovale; R ¼ rarely appropriate;TCD ¼ transcranial Doppler; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.

TABLE 7c Assessment Following Closure of PFO or ASD

Indication


TEE (With orWithout 3D Agitated

Saline Injection) CMR CT

90. 6-month routine scheduled follow-up ASD/PFO deviceclosure for position of device and integrity of device

n PFO patencyn Thrombus formation

7 (A) 4 (M) 3 (R) 2 (R)

91. Nonroutine follow up of ASD/PFO device closure and clinicalconcern for infection, malposition, embolization or persistentshunt.

8 (A) 8 (A) 4 (M) 4 (M)

3D ¼ 3-dimensional; A ¼ appropriate; ASD ¼ atrial septal defect; CMR ¼ cardiac magnetic resonance; CT ¼ computed tomography; M ¼ may be appropriate; PFO ¼ patent foramenovale; R ¼ rarely appropriate; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.


505

6.3.2. Imaging for the Evaluation of Left Atrial Appendage

Occlusion Device

TABLE 8a Pre-Procedural Evaluation for LAA Occlusion

IndicationTTE (With or Without 3D;With Contrast as Needed) TEE (With or Without 3D) CTA CMR

92. Evaluate for:n All cardiac chambersn LV functionn Interatrial septumn Valve function

8 (A) 8 (A) 7 (A) 5 (M)

93. Evaluate for:n LA/LAA thrombusn Spontaneous echo contrast/slow blood flow

5 (M) 9 (A) 7 (A) 5 (M)

94. Assess:n LAA morphologyn Baseline LAA dimensionsn Ostial morphology and dimensionn Maximum length of dominant lobe

6 (M) 9 (A) 7 (A) 5 (M)

3D ¼ 3-dimensional; A ¼ appropriate; CMR ¼ cardiac magnetic resonance; CTA ¼ computed tomography angiography; LA ¼ left atrial; LAA ¼ left atrial appendage; LV ¼ leftventricular; M ¼ may be appropriate; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.

TABLE 8b Intraprocedural Guidance for LAA Occlusion

IndicationTTE (With or Without 3D;With Contrast as Needed) TEE (With or Without 3D) ICE Fluoro

95. Reassess for LAA thrombus 9 (A) 6 (M) 4 (M)

96. Assess LAA size and morphology: select device size 9 (A) 6 (M) 5 (M)

97. Guide delivery and deployment of the device 9 (A) 6 (M) 8 (A)

98. Check for:n Leaks around devicen Disruption of mitral inflown Disruption of pulmonary vein flow

9 (A) 6 (M) 7 (A)

99. Assess adequacy of LAA occlusion 9 (A) 6 (M) 7 (A)

100. Screen for procedural complications 7 (A) 9 (A) 7 (A) 7 (A)

3D ¼ 3-dimensional; A ¼ appropriate; Fluoro ¼ fluoroscopy; ICE ¼ intracardiac echo; LAA ¼ left atrial appendage; M ¼ may be appropriate; TEE ¼ transesophageal echocardiography;TTE ¼ transthoracic echocardiography.

TABLE 8c Assessment Following LAA Occlusion

TTE (With or Without 3D) TEE (With or Without 3D) CTA CMR Fluoro

101. Prior to discharge to assess:n Device positionn Presence of pericardial effusionn Presence of thrombus around the devicen Mitral valve functionn LV function

6 (M) 3 (R) 2 (R) 1 (R) 1 (R)

102. Surveillance at 45 days or FDA guidance/guidelines for follow-up:n Assess device stabilityn Exclude migration, displacement, or erosionn Assess device leak

4 (M) 8 (A) 3 (R) 2 (R) 1 (R)

103. Long-term follow-up (assume device integrity) 5 (M) 4 (M) 2 (R) 2 (R) 1 (R)

3D ¼ 3-dimensional; A ¼ appropriate; CMR ¼ cardiac magnetic resonance; CTA ¼ computed tomography angiography; FDA ¼ Food and Drug Administration; Fluoro ¼ fluoroscopy;LV ¼ left ventricular; M ¼ may be appropriate; R ¼ rarely appropriate; TEE ¼ transesophageal echocardiography; TTE ¼ transthoracic echocardiography.



7. DISCUSSION

AUC are intended to inform clinicians, patients, andhealth policy makers about the reasonable use of tech-nologies to help improve patient symptoms and healthoutcomes. Since 2005, the ACC, along with its profes-sional partners, has worked to provide criteria for bothinvasive and noninvasive testing and selected treat-ments, further expanding the AUC portfolio (2,3,10–14).

The 2019 Appropriate Use Criteria for MultimodalityImaging in the Assessment of Cardiac Structure andFunction in Nonvalvular Heart Disease is the culminationof the analysis of various modalities used in the evalua-tion and treatment of patients with nonvalvular heartdisease. The document signals a shift from documentsevaluating a single modality in various disease states todocuments evaluating multiple imaging modalities andfocusing on evidence and clinical experience within agiven disease category. We believe that this approachbetter reflects clinical decision making in real-world sce-narios and offers the diagnostic choices available to theclinician.

Because a given modality may address diverse diseasestates, indications previously compiled in a single docu-ment may be spread over several AUC documents. Theprevious nonvalvular heart disease–related indicationsthat the current paper supplants are contained in theechocardiography (echo) (14), radionuclide imaging (13),and computed tomography/magnetic resonance imagingAUC documents (11,12). Other indications in these docu-ments remain in force until these scenarios are evaluatedin subsequent documents.

The tables in this paper are organized to reflect thespectrum of patients with nonvalvular heart disease—from patients with no symptoms suspected of havingnonvalvular heart disease to patients with signs andsymptoms ranging from mild to severe. The first 2 tablesare for initial evaluation when no prior imaging has beendone. As noted, the diagnostic choices vary among thetables and reflect the options that would be considered inthe initial evaluation by most clinicians. If a diagnostictest would seldom or never be considered, it was notincluded as an option for the rating panel.

Table 1 addresses the initial evaluation of an asymp-tomatic patient (15). This encompasses a variety of clinicalscenarios, including the evaluation of patients with aknown disease state that could be associated with struc-tural heart disease, evaluation for structural heart diseasein first-degree relatives of a patient with inherited car-diomyopathy (16), initial evaluation prior to exposure topotentially cardiotoxic medications (17,18), and partici-pation for asymptomatic athletes with and without afamily history of heart disease (19). Imaging of the

thoracic aorta is evaluated in patients with a known orsuspected connective tissue or genetic condition thatpredisposes patients to aortic aneurysm or in patientswhose relatives have a known aortic aneurysm ordissection (20,21). Finally, suspected pulmonary arterialhypertension (including the evaluation of right ventricu-lar function) is evaluated in patients at risk for developingpulmonary hypertension (22).

As might be expected, transthoracic echo is ratedAppropriate in all of these scenarios. Strain rate imagingby speckle tracking is also rated May Be Appropriate forspecific indications. Cardiac MR and cardiac computedtomography (CT) are rated May Be Appropriate for specificcardiac indications and are rated Appropriate for theevaluation of the thoracic aorta.

Table 2 addresses initial evaluation of a patient withclinical signs and or symptoms of cardiac disease (18).This is further subdivided into the categories of arrhyth-mias or conduction disorders; palpitations/presyncope/syncope (16,23–26); hypotension or hemodynamic insta-bility; hypertensive heart disease; acute coronary syn-dromes; respiratory failure; heart failure; pulmonaryhypertension (27–29); device therapy (30,31); and cardiactransplantation, including monitoring for rejection in arecipient and evaluation of structure and function in apotential heart donor (22,32). In addition, evaluation forsuspected pericardial disease or suspected acute aorticpathology and initial evaluation of cardiac mass or po-tential cardiac source of embolism are examined. Asmight be expected, the modality chosen depends uponthe disease state for which the clinician wishes to eval-uate. That being said, transthoracic echo is the modalityrecognized as Appropriate in most of the scenarios. Cor-onary angiography is also included and is found to beAppropriate in the evaluation of the patient with sus-tained ventricular tachycardia or ventricular fibrillationbut is not an initial testing modality across other sce-narios. The presence of atrial fibrillation in whichischemia may be a trigger resulted in a May Be Appro-priate rating for single-photon emission computed to-mography imaging and stress echo. Scenarios such as anewly diagnosed right bundle branch block, supraven-tricular tachycardia, and palpitations without othersymptoms or signs of heart disease resulted in a May BeAppropriate rating for transthoracic echo and a RarelyAppropriate rating for all other modalities. Mechanicalcomplications of myocardial infarction are evaluated withan Appropriate rating for both transthoracic and trans-esophageal echo, but cardiac MR and cardiac CT as well ascoronary angiography with ventriculography received aMay Be Appropriate rating. F-18 fluorodeoxyglucose-positron emission tomography and technetium 99m py-rophosphate injection are also evaluated and received a


507

May Be Appropriate rating for the evaluation of cardiacsarcoid and amyloid, respectively.

Section 6.2 evaluates cardiac structure and function inpatients who have undergone prior testing. As examinedin Table 3, this sequential testing is done to clarify theinitial diagnosis. These are instances in which the initialimaging modality—commonly transthoracic echo—has notyielded a definitive diagnosis. Scenarios included here areleft ventricular dysfunction not explained by the presenceof severe valvular disease, pulmonary hypertension in theabsence of severe valvular disease, and left ventricularsystolic dysfunction in which myocardial ischemia hasnot been excluded (33,16). Specific testing modalities forcertain cardiac diagnoses such as sarcoidosis, amyloid-osis, and hypertrophic cardiomyopathy are included (32).Although certain modalities are very specific for di-agnoses such as sarcoidosis or amyloidosis (34–37), car-diac MR was ranked Appropriate and of significantdiagnostic utility across a variety of disease states. Theevaluation of the aortic sinuses and ascending aorta arewell-delineated by cardiac MR, cardiac CT, and trans-esophageal echocardiography when transthoracic echohas not proven definitive (20,21). All 3 modalities wereranked Appropriate. Likewise, cardiac MR and cardiac CTare useful beyond coronary angiography for furtheranatomic characterization of anomalous coronaryarteries.

Table 4 evaluates sequential or follow-up testing toassess for clinical stability when a diagnosis has beenestablished and the patient is asymptomatic or exhibitsstable symptoms. All modalities were found to be RarelyAppropriate when used for repeat imaging in less than 1year in patients at risk of heart failure without structuralheart disease, with known hypertension without a changein their clinical status, or with systolic or diastolic heartfailure without a change in clinical status (18).Conversely, in patients who are imaged after having un-dergone therapy with potentially cardiotoxic agents,repeat imaging in less than a year was deemed Appro-priate for transthoracic echo, strain imaging, and radio-nuclide ventriculography, and May Be Appropriate forcardiovascular magnetic resonance imaging (38,39). Inpatients with a bicuspid aortic valve with an initial aorticdilatation of greater than 4.5 centimeters, family historyof dissection or rapid rate of change in the aortic diam-eter, re-evaluation in less than 1 year by cardiovascularmagnetic resonance imaging or CT is rated May BeAppropriate. There was discussion among writing groupmembers that evaluation by transthoracic echo may beconsidered in a specific subset of patients in which theinvolved segment of the aorta is well-visualized by echoand/or in which repeated exposure to radiation is unde-sirable, such as in young women.

In patients without these concerning features, imagingin less than 1 year is considered Rarely Appropriate for allmodalities (20). Evaluation of known moderate or greaterpulmonary hypertension by transthoracic echo in an in-terval of less than 1 year was rated May Be Appropriate,whereas re-evaluation after 1 year or longer was deemedAppropriate. Serial imaging of a chronic asymptomaticpericardial effusion in instances in which findings wouldpotentially alter therapy was rated Appropriate fortransthoracic echo and May Be Appropriate for cardiacMR. In a similar fashion, re-evaluation of an intracardiacmass when findings would potentially alter therapy wasdeemed Appropriate for transthoracic and trans-esophageal echocardiography, cardiac MR, and cardiacCT. It is not recommended to re-evaluate for resolution ofleft atrial thrombus after anticoagulation unless a changein therapy is warranted. In this instance, all modalitieswere rated Rarely Appropriate.

Table 5 evaluates sequential or follow-up testing inwhich a diagnosis has been established in the setting ofnew or worsening symptoms or to guide therapy. Thistable encompasses a variety of clinical diagnoses. It in-cludes patients with heart failure with a deterioration intheir clinical status and re-evaluation after revasculari-zation or optimal medical therapy to determine devicecandidacy. It also includes re-evaluation for cardiacresynchronization therapy device optimization. Serialimaging was also used to evaluate the progression of apericardial effusion with the development of tamponadeor the progression of constrictive pericarditis. Serial im-aging was also use to evaluate patients with known aorticdilatation with a change in clinical status. In this table, avariety of imaging modalities showed utility. Althoughtransthoracic echo was generally ranked Appropriate formost of these scenarios, there was a significant role fortransesophageal echo in specific indications such asevaluation of the thoracic aorta and resolution of intra-cardiac thrombus. Cardiac MR and CT were also useful fora variety of indications. Cardiac CT was rated Appropriatefor evaluation of pericardial mass and the thoracic aortaas was cardiac MR, whereas cardiac MR was found to beAppropriate for re-evaluation of the progression ofconstriction. Radionuclide ventriculography was Appro-priate for serial evaluation of patients undergoing car-diotoxic therapy, where it was ranked Appropriate. It wasranked May Be Appropriate for serial imaging in patientswith known cardiomyopathy with a change in their clin-ical status.

Section 6.3. evaluates cardiac structure and function inpatients undergoing transcatheter interventions forstructural heart disease. Table 6 evaluates imaging for theevaluation of transient ischemic attacks or ischemicstroke (40). This table is included as a prelude to the



subsequent tables on evaluation of closure of a patentforamen ovale or atrial septal defect or structural inter-vention to place a left atrial appendage occlusion device.Depending upon the clinical suspicion of the source of thestroke or TIA, different modalities are evaluated. Assess-ment of the intracranial arteries is most appropriatelydone with MR angiography or CT angiography of the headand neck, whereas assessment of the extracranial arteriesis most appropriate with carotid Doppler in addition tothese 2 modalities.

The evaluation for closure of a patent foramen ovale oratrial septal defect is divided into preprocedural evalua-tion (41), intraprocedural guidance, and assessmentfollowing closure of PFO or atrial septal defect (Tables 7ato 7c). For preprocedural guidance, both transthoracicand transesophageal echo are rated Appropriate, and theaddition of 3-dimensional (3D) transesophageal echo im-aging as an adjunct is rated May Be Appropriate. Forassessment of atrial septal anatomy, transthoracic echo,transesophageal echo, 3D transesophageal echo imaging,CT, and MR are rated Appropriate. For intraproceduralguidance, the same imaging tools are deemed appropriateregardless of whether the patient appears to have com-plex or simple anatomy. In cases requiring intra-procedural guidance, transesophageal echo with orwithout 3D imaging, intracardiac echo, and fluoroscopyare all rated Appropriate. Routine assessment followingclosure of a patent foramen ovale is accomplished withtransthoracic echo with the occasional use of trans-esophageal echo, which was rated May Be Appropriate(42). Nonroutine assessment of such patients when thereis clinical concern for infection, malposition, emboliza-tion, or persistent shunt involves utilizing trans-esophageal echo as a first-line technique where it isranked Appropriate.

Tables 8a to 8c evaluate the preprocedural (43,44),intraprocedural (45), and postprocedural assessment ofpatients undergoing left atrial appendage occlusion de-vice placement. Evaluation involves the use of bothtransthoracic and transesophageal echocardiography(with or without 3D), CT angiography, and, to a lesserextent, cardiac MR angiography. Intraprocedural evalua-tion involves the use of transesophageal echocardiogra-phy (with or without 3D), fluoroscopy, intracardiac echo,and transthoracic echo to screen for early proceduralcomplications. Assessment after deployment of the de-vice involves a transthoracic echo, which may be doneprior to discharge. U.S. Food and Drug Administration–mandated surveillance at 45 days includes transthoracicechocardiography, which is rated as May Be Appropriate,and transesophageal echocardiography, which is rated as

Appropriate. In long-term follow-up, both transthoracicecho (with or without 3D) and transesophageal echo (withor without 3D) are rated May Be Appropriate.

8. CONCLUSION

This document assesses a wide array of imaging modal-ities available to the clinician in the evaluation of patientswith non-VHD. Presented here is a broad spectrum ofclinical scenarios in such patients. Some of these sce-narios replicate those of prior documents, but many arenew, specifically structural interventions that were not inthe armamentarium of clinicians when prior, single-modality documents were published. The writing groupespecially wants to thank the rating panel, which helpedus clarify the language of many scenarios and which, withfocused rerating of a handful of indications, helped us tocreate a document that is consistent with and supportedby medical evidence and helps guide clinicians whereevidence is incomplete.

We believe the multimodality approach more closelyreplicates clinical decision making and will be useful.Future documents will not provide single-source guid-ance for appropriateness of a single imaging modality inall disease states. Echocardiography indications, forexample, will be spread across complimentary documentssuch as the multimodality stable ischemic heart diseaseAUC, the valvular heart disease multimodality document,the current document, and the multimodality imaging inpre-operative evaluation document, which is underdevelopment.

As with prior documents, the evaluation is a product ofcurrent ACC/AHA clinical practice guidelines whereavailable, subspecialty societal guidelines, consensusdocuments, single-center studies, and expert consensus.ACC/AHA guidelines are considered the highest level ofevidence for the purpose of these efforts but are notavailable for all scenarios. The modalities are not to beconsidered in a rank order and may be used relative toindividual patient circumstances and the balance of riskversus benefit. Accordingly, a study rated May BeAppropriate should not be denied reimbursement in lieuof one rated Appropriate. In some circumstances, a studyranked Rarely Appropriate may be clinically useful ifproperly documented.

The American College of Cardiology is recognized as aQualified Provider-Led Entity in the crafting of thesedocuments and is so recognized by the Center for Medi-care and Medicaid Services (CMS). This process demandsa rigorous evidentiary review and a commitment to peri-odic updates.


509

.ACC PRESIDENT AND STAFF

C. Michael Valentine, MD, FACC, PresidentTimothy W. Attebery, Chief Executive Officer,

MBA, FACHEWilliam J. Oetgen, MD, FACC, Executive Vice President,

Science, Education, Quality, and Publishing

JosephM. Allen, MA, Team Leader, Clinical Policy and PathwaysAmy Dearborn, Team Leader, Pathways and Appropriate

Use CriteriaMarίa Velásquez, Senior Research Specialist, Appropriate

Use CriteriaAmelia Scholtz, PhD, Publications Manager, Science,

Education, Quality, and Publishing

RE F E RENCE S

1. Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 appro-priate use criteria for multimodality imaging in valvularheart disease: a report of the American College ofCardiology Appropriate Use Criteria Task Force,American Association for Thoracic Surgery, AmericanHeart Association, American Society of Echocardiog-raphy, American Society of Nuclear Cardiology, HeartRhythm Society, Society for Cardiovascular Angiog-raphy and Interventions, Society of CardiovascularComputed Tomography, Society for CardiovascularMagnetic Resonance, and Society of Thoracic Sur-geons. J Am Coll Cardiol. 2017;70:1647–72.

2. Patel MR, Spertus JA, Brindis RG, et al. ACCF pro-posed method for evaluating the appropriateness ofcardiovascular imaging. J Am Coll Cardiol. 2005;46:1606–13.

3. Hendel RC, Lindsay BD, Allen JM, et al. ACC appro-priate use criteria methodology: 2018 update. J AmColl Cardiol. 2018;71:935–48.

4. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method User’s Manual. Arling-ton, Va: RAND, 2001.

5. Hirshfeld JW Jr., Ferrari VA, Bengel FM, et al. 2018ACC/HRS/NASCI/SCAI/SCCT expert consensus docu-ment on optimal use of ionizing radiation in cardio-vascular imaging: best practices for safety andeffectiveness: a report of the American College ofCardiology Task Force on Clinical Expert ConsensusDocuments. J Am Coll Cardiol. 2018;71:e283–351.

6. Fihn SD, Blankenship JC, Alexander KP, et al. 2014ACC/AHA/AATS/PCNA/SCAI/STS focused update of theGuideline for the Diagnosis and Management of Pa-tients With Stable Ischemic Heart Disease: a report ofthe American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines, and theAmerican Association for Thoracic Surgery, PreventiveCardiovascular Nurses Association, Society for Cardio-vascular Angiography and Interventions, and Societyof Thoracic Surgeons. J Am Coll Cardiol. 2014;64:1929–49.

7. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients withvalvular heart disease: a report of the American Col-lege of Cardiology/American Heart Association TaskForce on Practice Guidelines. J Am Coll Cardiol. 2014;63:e57–185.

8. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC Guidelinefor the Management of Patients With Valvular HeartDisease: a report of the American College ofCardiology/American Heart Association Task Force onClinical Practice Guidelines. J Am Coll Cardiol. 2017;70:252–89.

9. Hunt SA, Abraham WT, Chin MH, et al. 2009focused update incorporated into the ACC/AHA 2005Guidelines for the Diagnosis and Management of HeartFailure in Adults: a report of the American College ofCardiology Foundation/American Heart AssociationTask Force on Practice Guidelines developed incollaboration with the International Society for Heartand Lung Transplantation. J Am Coll Cardiol. 2009;53:e1–90.

10. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013multimodality appropriate use criteria for the detectionand risk assessment of stable ischemic heart disease: areport of the American College of Cardiology Foun-dation Appropriate Use Criteria Task Force, AmericanHeart Association, American Society of Echocardiog-raphy, American Society of Nuclear Cardiology, HeartFailure Society of America, Heart Rhythm Society, So-ciety for Cardiovascular Angiography and In-terventions, Society of Cardiovascular ComputedTomography, Society for Cardiovascular MagneticResonance, and Society of Thoracic Surgeons. J AmColl Cardiol. 2013;63:380–406.

11. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriate-ness criteria for cardiac computed tomography andcardiac magnetic resonance imaging of cardiovascularimaging: a report of the American College of Cardiol-ogy Foundation Quality Strategic Directions CommitteeAppropriateness Criteria Working Group, AmericanCollege of Radiology, Society of CardiovascularComputed Tomography, Society for CardiovascularMagnetic Resonance, American Society of NuclearCardiology, North American Society for Cardiac Imag-ing, Society for Cardiovascular Angiography and In-terventions, and Society of Interventional Radiology.J Am Coll Cardiol. 2006;48:1475–97.

12. Taylor AJ, Cequeira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010appropriate use criteria for cardiac computed tomog-raphy: a report of the American College of CardiologyFoundation Appropriate Use Criteria Task Force, theSociety of Cardiovascular Computed Tomography, theAmerican College of Radiology, the American HeartAssociation, the American Society of Echocardiogra-phy, the American Society of Nuclear Cardiology, theSociety for Cardiovascular Angiography and In-terventions, and the Society for Cardiovascular Mag-netic Resonance. J Am Coll Cardiol. 2010;56:1864–94.

13. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/ SCCT/SCMR/SNM 2009 appro-priate use criteria for cardiac radionuclide imaging: areport of the American College of Cardiology Foun-dation Appropriate Use Criteria Task Force, the Amer-ican Society of Nuclear Cardiology, the American

College of Radiology, the American Heart Association,the American Society of Echocardiography, the Societyof Cardiovascular Computed Tomography, the Societyfor Cardiovascular Magnetic Resonance, and the Soci-ety of Nuclear Medicine. J Am Coll Cardiol. 2009;53:2201–29.

14. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/ HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011appropriate use criteria for echocardiography: a reportof the American College of Cardiology FoundationAppropriate Use Criteria Task Force, American Societyof Echocardiography, American Heart Association,American Society of Nuclear Cardiology, Heart FailureSociety of America, Heart Rhythm Society, Society forCardiovascular Angiography and Interventions, Societyof Critical Care Medicine, Society of CardiovascularComputed Tomography, and Society for CardiovascularMagnetic Resonance. J Am Coll Cardiol. 2011;57:1126–66.

15. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk inasymptomatic adults: a report of the American Collegeof Cardiology Foundation/American Heart AssociationTask Force on Practice Guidelines. J Am Coll Cardiol.2010;56:e50–103.

16. Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA guideline for the diagnosis and treatment of hy-pertrophic cardiomyopathy: a report of the AmericanCollege of Cardiology Foundation/American Heart As-sociation Task Force on Practice Guidelines. J Am CollCardiol. 2011;58:e212–60.

17. Plana JC, Galderisi M, Barac A, et al. Expertconsensus for multimodality imaging evaluation ofadult patients during and after cancer therapy: a reportfrom the American Society of Echocardiography andthe European Association of Ca

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