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Journal of the American College of Cardiology Vol. 53, No. 23, 2009© 2009 by the American College of Cardiology Foundation ISSN 0735-1097/09/$36.00P

APPROPRIATE USE CRITERIA

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009Appropriate Use Criteria for Cardiac Radionuclide ImagingA 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 HeartAssociation, the American Society of Echocardiography, the Society of Cardiovascular ComputedTomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine

Endorsed by the American College of Emergency Physicians

ublished by Elsevier Inc. doi:10.1016/j.jacc.2009.02.013

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CardiacRadionuclideImagingWriting Group

adiology, the American Heaaphy, the Society of Card

obert C. Hendel, MD, FACC, FAHA,FASNC, Chair

aniel S. Berman, MD, FACC, FAHAarcelo F. Di Carli, MD, FACC, FAHA

rt Association, the American Society of Echocardiog-iovascular Computed Tomography, the Society for

of Cardiologhealthpermissi

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obert E. Henkin, MD, FACRatricia A. Pellikka, MD, FACC, FAHA, FASEerald M. Pohost, MD, FACC, FAHA,FSCMR

im A. Williams, MD, FACC, FAHA, FASNC
Paul A. Heidenreich, MD, FACC
TechnicalPanel

Michael J. Wolk, MD, MACC, ModeratorRobert C. Hendel, MD, FACC, FAHA,

FASNC, Methodology/Writing Group LiaisonPatricia A. Pellikka, MD, FACC, FAHA,

FASE, Writing Group Liaison

Peter Alagona, JR, MD, FACC*Timothy M. Bateman, MD, FACC†Manuel D. Cerqueira, MD, FACC, FAHA,

FASNC†James R. Corbett, MD, FACC‡Anthony J. Dean, MD, FACEP§Gregory J. Dehmer, MD, FACC, FAHA*Peter Goldbach, MD, FACC�Leonie Gordon, MB, CHB¶

Frederick G. Kushner, MD, FACC#Raymond Y. Kwong, MD, MPH, FACC**James Min, MD, FACC††Miguel A. Quinones, MD, FACC‡‡R. Parker Ward, MD, FACC†Michael J. Wolk, MD, MACC*Scott H. Yang, MD, PHD, FACC*

*Official American College of Cardiology Foundation representative; †Of-ficial American Society of Nuclear Cardiology representative; ‡OfficialSociety of Nuclear Medicine representative; §Official American College ofEmergency Physicians representative; �Official Health Plan representative;¶Official American College of Radiology representative; #OfficialACCF/AHA Task Force on Practice Guidelines representative; **OfficialSociety for Cardiovascular Magnetic Resonance representative; ††OfficialSociety of Cardiovascular Computed Tomography representative; ‡‡Offi-cial American Society of Echocardiography representative

AppropriateUse CriteriaTask Force

Michael J. Wolk, MD, MACC, Chair

Joseph Allen, MARalph G. Brindis, MD, MPH, FACC§§Pamela S. Douglas, MD, MACC, FAHA,

FASE

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

Manesh Patel, MDEric Peterson, MD, MPH, FACC, FAHA

§§Immediate past chair of the Appropriate Use Criteria Task Forceduring the development of this document

his document was approved by the American College of Cardiology Foundationoard of Trustees in 2009.The American College of Cardiology Foundation requests that this document be

ited as follows: Hendel RC, Berman DS, Di Carli MF, Heidenreich PA, HenkinE, Pellikka PA, Pohost GM, Williams KA. ACCF/ASNC/ACR/AHA/ASE/CCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging:report of the American College of Cardiology Foundation Appropriate Use Criteriaask Force, the American Society of Nuclear Cardiology, the American College of

Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am CollCardiol 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 contactElsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected].

Permissions: Modification, alteration, enhancement and/or distribution of thisdocument are not permitted without the express permission of the American College

y Foundation. Please contact Elsevier’s permission [email protected]

February 25, 2010

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2202 Hendel et al. JACC Vol. 53, No. 23, 2009Appropriate Use Criteria for Cardiac Radionuclide Imaging June 9, 2009:2201–29

TABLE OF CONTENTS

bstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2202

reface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2202

. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2203

. Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2203

. General Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2204

. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2205

. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2206

. Results of Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2206

. Cardiac Radionuclide Imaging Appropriate UseCriteria (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 Resultsand/or Known Chronic Stable CoronaryArtery Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2208

Table 4. Risk Assessment: Preoperative Evaluationfor Noncardiac Surgery Without ActiveCardiac Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2209

Table 5. Risk Assessment: Within 3 Monthsof an Acute Coronary Syndrome . . . . . . . . . . . . . . . . . . . . .2209

Table 6. Risk Assessment: Postrevascularization(Percutaneous Coronary Intervention or CoronaryArtery Bypass Grafting Surgery). . . . . . . . . . . . . . . . . . . . .2210

Table 7. Assessment of Viability/Ischemia . . . . . . . . . . .2210

Table 8. Evaluation of Ventricular Function . . . . . . . . . .2210

. Cardiac Radionuclide Imaging Appropriate UseCriteria (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 AppropriateUse Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2216

9.2. Application of Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2219

ppendix A: Additional Cardiac Radionuclide
maging Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2220
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ppendix B: Additional Methods. . . . . . . . . . . . . . . . . . . . . . . . .2222

Relationships With Industry . . . . . . . . . . . . . . . . . . . . . . . . . . .2222

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2222

ppendix C: ACCF Appropriate Use Criteria forardiac Radionuclide Imaging Participants . . . . . . . . . . . .2222

ppendix D: ACCF/ASNC/ACR/AHA/ASE/SCCT/CMR/SNM Cardiac Radionuclide Imaging Appropriatese Criteria Writing Group, Technical Panel, Taskorce, and Indication Reviewers—Relationshipsith Industry And Other Entities

In Alphabetical Order) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2225

eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2228

bstract

he American College of Cardiology Foundation (ACCF),long with key specialty and subspecialty societies, con-ucted an appropriate use review of common clinical sce-arios where cardiac radionuclide imaging (RNI) is fre-uently considered. This document is a revision of theriginal Single-Photon Emission Computed Tomographyyocardial Perfusion Imaging (SPECT MPI) Appropri-

teness Criteria (1), published 4 years earlier, written toeflect changes in test utilization and new clinical data, ando clarify RNI use where omissions or lack of clarity existedn the original criteria. This is in keeping with the commit-

ent to revise and refine appropriate use criteria (AUC) onfrequent basis.The indications for this review were drawn from common

pplications or anticipated uses, as well as from currentlinical practice guidelines. Sixty-seven clinical scenariosere developed by a writing group and scored by a separate

echnical panel on a scale of 1 to 9 to designate appropriatese, inappropriate use, or uncertain use.In general, use of cardiac RNI for diagnosis and risk

ssessment in intermediate- and high-risk patients withoronary artery disease (CAD) was viewed favorably, whileesting in low-risk patients, routine repeat testing, andeneral screening in certain clinical scenarios were viewedess favorably. Additionally, use for perioperative testing wasound to be inappropriate except for high selected groups ofatients. It is anticipated that these results will have aignificant impact on physician decision making, test per-ormance, and reimbursement policy, and will help guideuture research.

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2203JACC Vol. 53, No. 23, 2009 Hendel et al.June 9, 2009:2201–29 Appropriate Use Criteria for Cardiac Radionuclide Imaging

riate use of cardiovascular imaging for selected patientndications.

Appropriate use criteria publications reflect an ongoingffort by the ACCF to critically and systematically create,eview, and categorize clinical situations where diagnosticests and procedures are utilized by physicians caring foratients with cardiovascular diseases. The process is basedn a current understanding of the technical capabilities ofhe imaging modalities examined. Although not intended toe entirely comprehensive, the indications are meant todentify common scenarios encompassing the majority ofontemporary practice. Given the breadth of informationhey convey, the indications do not directly correspond tohe Ninth Revision of the International Classification ofiseases (ICD-9) system as these codes do not include

linical information, such as symptom status.The ACCF believes that careful blending of a broad

ange of clinical experiences and available evidence-basednformation will help guide a more efficient and equitablellocation of health care resources in cardiovascular imaging.he ultimate objective of AUC is to improve patient care

nd health outcomes in a cost-effective manner, but it is notntended to ignore ambiguity and nuance intrinsic to clinicalecision making. Local parameters, such as the availabilityr quality of equipment or personnel, may influence theelection of appropriate imaging procedures. Appropriatese criteria thus should not be considered a substitute foround clinical judgment and practice experience.

The ACCF AUC process itself is also evolving. In theurrent iteration, technical panel members were asked toate indications for cardiac RNI in a manner independentnd irrespective of the prior published ACCF ratings forPECT MPI (1) as well as the prior ACCF ratings forimilar diagnostic stress imaging modalities, such as stresschocardiography (2), cardiac computed tomography, orardiac magnetic resonance (3). Given the iterative nature ofhe process, readers are counseled not to compare too closelyndividual appropriate use ratings among modalities rated atifferent times over the past 2 years. Since this process is

terative and evolving, readers are counseled that individualppropriate use ratings among modalities rated at differentimes over the past 2 years may not be consistent. Aomparative evaluation of the appropriate use of multiplemaging techniques will be undertaken in the near future tossess the relative strengths of each modality for variouslinical scenarios.

We are grateful to the technical panel, a professionalroup with a wide range of skills and insights, for theirhoughtful and thorough deliberation on the merits ofardiac RNI for various indications. In addition to ourhanks to the technical panel for their dedicated work andeview, we would like to offer special thanks to the manyndividuals who provided a careful review of the draftndications; to Peggy Christiansen, the ACCF librarian forer comprehensive literature searches; to Lindsey Law and
ennedy Elliott, who continually drove the process forward; b
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nd to Robert Hendel, MD, the chair of the writingommittee, for his dedication, insight, and leadership.

Michael J. Wolk, MD, MACCModerator, Cardiac Radionuclide Imaging Technical Panel

Ralph G. Brindis, MD, MPH, FACC, FSCAIChair, Appropriate Use Criteria Task Force

. Introduction

his report addresses the appropriate use of cardiac RNI.mprovements in cardiovascular imaging technology andts application, coupled with increasing therapeutic op-ions for cardiovascular disease, have led to an increase inardiovascular imaging. At the same time, the armamen-arium of noninvasive diagnostic tools has expanded withnnovations in new contrast agents, molecular RNI,erfusion echocardiography, computed tomography fororonary angiography and calcium score, and magneticesonance imaging for myocardial structure and viability.s the field of cardiac radionuclide cardiovascular imag-

ng continues to advance along with other imagingodalities, the health care community needs to under-

tand how to best incorporate these technologies intoaily clinical care.All prior AUC publications from the ACCF and

ollaborating organizations have reflected an ongoingffort to critically and systematically create, review, andategorize the appropriate use of certain cardiovasculariagnostic tests. The American College of Cardiologyecognizes the importance of revising these criteria in aimely manner in order to provide the cardiovascularommunity with the most accurate indications. Thisocument presents the first attempt to update an existingUC document, the 2005 published ACCF/ASNC Ap-ropriateness Criteria for Single-Photon Emission Com-uted Tomography Myocardial Perfusion ImagingSPECT MPI) (1). Clinicians, payers, and patients arenterested in the specific benefits of cardiac RNI. Impor-antly, inappropriate use of cardiac RNI may be poten-ially harmful to patients and generate unwarranted costso the healthcare system, whereas appropriate procedureshould likely improve patients’ clinical outcomes. This iscritical shift since the intent is for the potential benefits

nd risks of the treatment to be explicitly considered,ather than just the potential usefulness of a diagnosticest as a prelude to further treatment. This documentresents the results of this effort, but it is critical tonderstand the background and scope of this documentefore interpreting the rating tables.

. Methods

he indications included in this publication are purposefully
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ymptoms as well as clinical judgment as to the likelihood ofardiovascular findings.

A detailed description of the methods used for rankinghe selected clinical indications is outlined in Appendix Bnd is also found more generally in a previous publicationntitled, “ACCF Proposed Method for Evaluating theppropriateness of Cardiovascular Imaging” (4). Briefly,

his process combines evidence-based medicine and prac-ice experience by engaging a technical panel in aodified Delphi exercise. Since the original SPECT

ocument (1) and methods paper (4) were published,everal important processes have been put in place tourther enhance this process. They include convening aormal writing group with diverse expertise in imaging,irculating the indications for external review prior toating by the technical panel, and ensuring appropriatealance of the technical panel, a standardized ratingackage, and formal roles for facilitating panel interac-ion at the face-to-face meeting. These changes areetailed in a separate manuscript, which is in preparation.The panel first rated indications independently. Then the

anel was convened for a face-to-face meeting for discussionf each indication. At this meeting, panel members wererovided with their scores and a blinded summary of theireers’ scores. After the consensus meeting, panel membersere then asked to independently provide their final scores

or each indication.While panel members were not provided explicit cost

nformation to help determine their appropriate use ratings,hey were asked to implicitly consider cost as an additionalactor in their evaluation of appropriate use.

In developing these criteria, the AUC Technical Panelas asked to assess whether the use of the test for each

ndication is appropriate, uncertain, or inappropriate, andas provided the following definition of appropriate use:An appropriate imaging study is one in which the expected

ncremental information, combined with clinical judgment,xceeds the expected negative consequences* by a sufficientlyide margin for a specific indication that the procedure is

enerally considered acceptable care and a reasonable ap-roach for the indication.The technical panel scores each indication as follows:

Score 7–9

Appropriate test for specific indication (test is generallyacceptable and is a reasonable approach for theindication).

Score 4–6

Uncertain for specific indication (test may be generallyacceptable and may be a reasonable approach for theindication). (Uncertainty also implies that more re-

Negative consequences include the risks of the procedure radiation or contrast
xposure and the downstream impact of poor test performance such as delay iniagnosis (false negatives) or inappropriate diagnosis (false positives).

search and/or patient information is needed to classifythe indication definitively.)

Score 1–3Inappropriate test for that indication (test is not gener-

ally acceptable and is not a reasonable approach forthe indication).

The contributors acknowledge that the division of thesecores into 3 categories of appropriate use is somewhatrbitrary and that the numeric designations should beiewed as a continuum. The contributors also recognizeiversity in clinical opinion for particular clinical scenarios.cores in the intermediate level of appropriate use shouldherefore be labeled “uncertain,” as critical patient or re-earch data may be lacking or discordant. This designationhould be a prompt to the field to carry out definitiveesearch investigation whenever possible. It is anticipatedhat the AUC reports will require updates as further data areenerated and information from the implementation of theriteria is accumulated.

To prevent bias in the scoring process, the technical panelas deliberately not comprised solely of specialists in thearticular procedure under evaluation. Specialists, whileffering important clinical and technical insights, mightave a natural tendency to rate the indications within theirpecialty as more appropriate than nonspecialists. In addi-ion, care was taken in providing objective, nonbiasednformation, including guidelines and key references, to theechnical panel.

The level of agreement among panelists as defined byAND (5) was analyzed based on the BIOMED rule for aanel of 14 to 16 members. As such, agreement was defineds an indication where 4 or fewer panelists’ ratings fellutside the 3-point region containing the median score.isagreement was defined as where at least 5 panelists’

atings fell in both the appropriate and the inappropriateategories. Any indication having disagreement was catego-ized as uncertain regardless of the final median score.ndications which met neither definition for agreement orisagreement are in a third, unlabeled category.

. General Assumptions

o prevent any inconsistencies in interpretation, specificssumptions are provided that were considered by theechnical panel in rating the relevant clinical indications forhe appropriate use of RNI:

. Panel members were to assume that all radionuclidetechniques with different radiopharmaceuticals and im-aging protocols were available for each indication andthat each was performed in a manner similar to thatfound in the published literature.

. Radionuclide imaging is performed in accordance withbest practice standards as delineated in the imaging
guidelines for nuclear cardiology procedures (6). It is also


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assumed that procedures are performed in an accreditedfacility with appropriately credentialed physicians.

. Unless otherwise noted, all indications referred toSPECT MPI and positron emission tomography myo-cardial perfusion imaging. All radionuclide perfusionimaging indications also assume the use of electrocardio-gram (ECG) gating, whenever possible, with determi-nation of global ventricular function (i.e., left ventricularejection fraction) and regional wall motion as part of theevaluation.

. For all stress imaging, the mode of stress testing wasassumed to be exercise for patients able to exercise. Forpatients unable to exercise, pharmacologic stress testingwas assumed to be used. Further background on therationale for the assumption of exercise testing is avail-able in the ACC/AHA 2002 Guideline Update forExercise Testing (7).

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

. The use of testing in the perioperative setting is assumedto have the potential to impact clinical decision makingand to direct therapeutic interventions.

. The category of “uncertain” should be used when insuf-ficient clinical data is available for a definitive categori-zation or there is substantial disagreement regarding theappropriateness of that indication. The designation of“uncertain” is assumed to not provide grounds for denialof reimbursement.

. Definitions

complete set of definitions of terms used throughout thendication set are listed in Appendix A. These definitionsere provided and discussed with the technical panel prior

o ratings of indications.Ischemic Equivalent: Chest Pain Syndrome, Anginal

quivalent, or Ischemic ECG Abnormalities: Any con-tellation of clinical findings that the physician feels isonsistent with obstructive CAD. Examples of such find-ngs include, but are not exclusive to, chest pain, chestightness, burning, shoulder pain, palpitations, jaw pain,nd new ECG abnormalities suggestive of ischemic heartisease. Non-chest pain symptoms, such as dyspnea ororsening effort tolerance, that are felt to be consistent withAD may also be considered to be an anginal equivalent.

etermining Pretest Risk Assessment forisk Stratification

isk Assessment for Asymptomatic PatientsThe indications on risk assessment include asymptomatic

atients with suspected CAD. It is assumed that cliniciansill use RNI studies in addition to standard methods of risk

ssessment as presented in the National Heart, Lung, and
lood Institute report on “Detection, Evaluation, and
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reatment of High Blood Cholesterol in Adults (Adultreatment Panel III)” (ATP III) (8).oronary Heart Disease (CHD) Risk (Based on the ACC/AHAcientific Statement on Cardiovascular Risk Assessment [9])bsolute risk is defined as the probability of developingHD, including myocardial infarction or CHD deathver a given time period. The ATP III report specifiesbsolute risk for CHD over the next 10 years. CHD riskefers to 10-year risk for any hard cardiac event.

CHD Risk—LowDefined by the age-specific risk level that is below

average. In general, low risk will correlate with a 10-yearabsolute CHD risk less than 10%.CHD Risk—Moderate

Defined by the age-specific risk level that is average orabove average. In general, moderate risk will correlatewith a 10-year absolute CHD risk between 10% and20%.CHD Risk—High†

Defined as the presence of diabetes mellitus in apatient 40 years of age or older, peripheral arterial diseaseor other coronary risk equivalents, or a 10-year absoluteCHD risk of greater than 20%.

Pretest Probability of CAD for Symptomatic (Ischemicquivalent) Patients: Once the physician determines theresence of symptoms that may represent obstructive CADischemic equivalent present), the pretest probability ofAD should be assessed. There are a number of risk

lgorithms (10,11) available that can be used to calculatehis probability. Clinicians should become familiar withhose algorithms that pertain to the populations they en-ounter most often. In scoring the indications, the followingrobabilities, as calculated from any of the various availablelgorithms, should be applied.

Very low pretest probability: Less than 5% pretestprobability of CADLow pretest probability: Less than 10% pretest proba-bility of CADIntermediate pretest probability: Between 10% and90% pretest probability of CADHigh pretest probability: Greater than 90% pretestprobability of CAD

The method recommended by the ACC/AHA Guide-ines for Chronic Stable Angina (12) is provided below asne example of a method used to calculate pretest proba-ility and is a modification of a previously published

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

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iterature review (13). Please refer to definitions of anginand to Table A. Please note that Table A only predictsretest probability in patients without other complicatingistory or ECG findings. History and electrocardiographicvidence of prior infarction dramatically affect pretest prob-bility. While not incorporated into the algorithm, CADisk factors, discussed in the previous section, Determiningretest Risk Assessment for Risk Stratification, may alsoffect pretest likelihood of CAD. Detailed nomograms arevailable that incorporate the effects of a history of priornfarction, electrocardiographic Q waves, electrocardio-raphic ST- and T-wave changes, diabetes, smoking, andypercholesterolemia (14).

. Abbreviations

CS � acute coronary syndromeABG � coronary artery bypass grafting surgeryAD � coronary artery diseaseHD � coronary heart diseaseT � computed tomographyCG � electrocardiogramRNA � equilibrium radionuclide angiographyP � First PassF � heart failureBBB � left bundle-branch blockV � left ventricularET � estimated metabolic equivalents of exerciseI � myocardial infarctionPI � myocardial perfusion imaging

CI � percutaneous coronary interventionET � positron emission tomography

able A. Pretest Probability of CAD by Age, Gender, and Symp

Age(Years) Gender

Typical/DefiniteAngina Pectoris

�39 Men Intermediate

Women Intermediate

40–49 Men High

Women Intermediate

50–59 Men High

Women Intermediate

�60 Men High

Women High

igh: Greater than 90% pretest probability. Intermediate: Between 10% and 90% pretest probabilirom the ACC/AHA Exercise Testing Guidelines to reflect all age ranges (14).

NA � radionuclide angiography c


NI � radionuclide imagingPECT � single photon emission computed tomographyTEMI � ST-elevation myocardial infarctionA/NSTEMI � unstable angina (UA) and non–ST-

levation myocardial infarction (NSTEMI)

. Results of Ratings

he final ratings for cardiac RNI (Tables 1 to 8) are listedy indication sequentially as obtained from second-roundating sheets submitted by each panelist. The final scoreeflects the median score of the 15 panelists and has beenabeled according to the 3 appropriate use categories ofppropriate, uncertain, and inappropriate. Tables 9 to 11resent the indications by these categories.There was generally less variation in ratings for the

ndications labeled as either appropriate or inappropriate,ith 73% and 64%, respectively, showing agreement asefined in Section 2, Methods. There was, however,reater variability (less agreement) in the rating scores forndications defined as uncertain, with 11% showinggreement as defined above, suggesting greater variationn opinion. Two indications, 26 and 28, were distributednto each extreme such that the panel was classified aseing in disagreement. However, these indications werelready placed in the uncertain category so no changesere required to reflect disagreement. Across all catego-

ies, several indications failed to meet the definition ofgreement. In such cases, the final distribution of scorescross the panel contained a greater diversity of scoresmong panel members, but the scores were not soivergent (as defined by disagreement) as to necessitate a

*

typical/ProbableAngina Pectoris

NonanginalChest Pain Asymptomatic

Intermediate Low Very low

Very low Very low Very low

Intermediate Intermediate Low

Low Very low Very low


Intermediate Low Very low



Between 5% and 10% pretest probability. Very low: Less than 5% pretest probability. *Modified

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. Cardiac Radionuclide Imaging Appropriate Use Criteria (By Indication)

able 1. Detection of CAD: Symptomatic

IndicationAppropriate Use

Score (1–9)Evaluation of Ischemic Equivalent (Non-Acute)

1. ● Low pretest probability of CAD● ECG interpretable AND able to exercise

I (3)

2. ● Low pretest probability of CAD● ECG uninterpretable OR unable to exercise

A (7)

3. ● Intermediate pretest probability of CAD● ECG interpretable AND able to exercise

A (7)

4. ● Intermediate pretest probability of CAD● ECG uninterpretable OR unable to exercise

A (9)

5. ● High pretest probability of CAD● Regardless of ECG interpretability and ability to exercise

A (8)

Acute Chest Pain

6. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● Low-risk TIMI score● Peak troponin: borderline, equivocal, minimally elevated

A (8)

7. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● High-risk TIMI score● Peak troponin: borderline, equivocal, minimally elevated

A (7)

8. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● Low-risk TIMI score● Negative peak troponin levels

A (8)

9. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● High-risk TIMI score● Negative peak troponin levels

A (8)

10. ● Definite ACS* I (1)

Acute Chest Pain (Rest Imaging Only)

11. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● Initial troponin negative● Recent or ongoing chest pain

A (7)

See definition of ACS in Appendix A (based on ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction) (24).

by on February 25, 2010 content.onlinejacc.orgDownloaded from


T

T


able 2. Detection of CAD/Risk Assessment Without Ischemic Equivalent


Score (1–9)Asymptomatic

12. ● Low CHD risk (ATP III risk criteria) I (1)

13. ● Intermediate CHD risk (ATP III risk criteria)● ECG interpretable

I (3)

14. ● Intermediate CHD risk (ATP III risk criteria)● ECG uninterpretable

U (5)

15. ● High CHD risk (ATP III risk criteria) A (7)

New-Onset or Newly Diagnosed Heart Failure With LV Systolic Dysfunction Without Ischemic Equivalent

16. ● No prior CAD evaluation AND no planned coronary angiography A (8)

New-Onset Atrial Fibrillation

17. ● Part of evaluation when etiology unclear U (6)

Ventricular Tachycardia

18. ● Low CHD risk (ATP III risk criteria) A (7)

19. ● Intermediate or high CHD risk (ATP III risk criteria) A (8)

Syncope



Elevated Troponin

22. ● Troponin elevation without additional evidence of acute coronary syndrome A (7)

able 3. Risk Assessment With Prior Test Results and/or Known Chronic Stable CAD


Score (1–9)Asymptomatic OR Stable SymptomsNormal Prior Stress Imaging Study

23. ● Low CHD risk (ATP III risk criteria)● Last stress imaging study done less than 2 years ago

I (1)

24. ● Intermediate to high CHD risk (ATP III risk criteria)● Last stress imaging study done less than 2 years ago

I (3)

25. ● Low CHD risk (ATP III risk criteria)● Last stress imaging study done more than or equal to 2 years ago

I (3)

26. ● Intermediate to high CHD risk (ATP III risk criteria)● Last stress imaging study done more than or equal to 2 years ago

U (6)

Asymptomatic OR Stable SymptomsAbnormal Coronary Angiography OR Abnormal Prior Stress Imaging Study, No Prior Revascularization

27. ● Known CAD on coronary angiography OR prior abnormal stress imaging study● Last stress imaging study done less than 2 years ago

I (3)

28. ● Known CAD on coronary angiography OR prior abnormal stress imaging study● Last stress imaging study done more than or equal to 2 years ago

U (5)

Prior Noninvasive Evaluation

29. ● Equivocal, borderline, or discordant stress testing where obstructive CAD remains a concern A (8)

New or Worsening Symptoms

30. ● Abnormal coronary angiography OR abnormal prior stress imaging study A (9)

31. ● Normal coronary angiography OR normal prior stress imaging study U (6)

Coronary Angiography (Invasive or Noninvasive)

32. ● Coronary stenosis or anatomic abnormality of uncertain significance A (9)

AsymptomaticPrior Coronary Calcium Agatston Score

33. ● Agatston score less than 100 I (2)

34. ● Low to intermediate CHD risk● Agatston score between 100 and 400

U (5)

35. ● High CHD risk● Agatston score between 100 and 400

A (7)

36. ● Agatston score greater than 400 A (7)

Duke Treadmill Score

37. ● Low-risk Duke treadmill score I (2)

38. ● Intermediate-risk Duke treadmill score A (7)

39. ● High-risk Duke treadmill score A (8)



T

*

T


able 4. Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions*


Score (1–9)Low-Risk Surgery

40. ● Preoperative evaluation for noncardiac surgery risk assessment I (1)

Intermediate-Risk Surgery

41. ● Moderate to good functional capacity (greater than or equal to 4 METs) I (3)

42. ● No clinical risk factors† I (2)

43. ● Greater than or equal to 1 clinical risk factor● Poor or unknown functional capacity (less than 4 METs)

A (7)

44. ● Asymptomatic up to 1 year postnormal catheterization, noninvasive test, or previous revascularization I (2)

Vascular Surgery



47. ● Greater than or equal to 1 clinical risk factor● Poor or unknown functional capacity (less than 4 METS)

A (8)


Refer to Table A1. †Refer to Table A2.

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


Score (1–9)STEMI

49. ● Primary PCI with complete revascularization● No recurrent symptoms

I (2)

50. ● Hemodynamically stable, no recurrent chest pain symptoms or no signs of HF● To evaluate for inducible ischemia● No prior coronary angiography

A (8)

51. ● Hemodynamically unstable, signs of cardiogenic shock, or mechanical complications I (1)

UA/NSTEMI


A (9)

ACS–Asymptomatic Postrevascularization (PCI or CABG)

53. ● Evaluation prior to hospital discharge I (1)

Cardiac Rehabilitation

54. ● Prior to initiation of cardiac rehabilitation (as a stand-alone indication) I (3)



T

*

T

T

*


able 6. Risk Assessment: Postrevascularization (Percutaneous Coronary Intervention or Coronary Artery Bypass Graft)*


Score (1–9)Symptomatic

55. ● Evaluation of ischemic equivalent A (8)

Asymptomatic

56. ● Incomplete revascularization● Additional revascularization feasible

A (7)

57. ● Less than 5 years after CABG U (5)

58. ● Greater than or equal to 5 years after CABG A (7)

59. ● Less than 2 years after PCI I (3)

60. ● Greater than or equal to 2 years after PCI U (6)

Cardiac Rehabilitation

61. ● Prior to initiation of cardiac rehabilitation (as a stand-alone indication) I (3)

In patients who have had multiple coronary revascularization procedures, consider the most recent procedure.

able 7. Assessment of Viability/Ischemia


Score (1–9)Ischemic Cardiomyopathy/Assessment of Viability

62. ● Known severe LV dysfunction● Patient eligible for revascularization

A (9)

able 8. Evaluation of Ventricular Function


Score (1–9)Evaluation of LV Function

63. ● Assessment of LV function with radionuclide angiography (ERNA or FP RNA)● In absence of recent reliable diagnostic information regarding ventricular function obtained with

another imaging modality

A (8)

64. ● Routine* use of rest/stress ECG-gating with SPECT or PET MPI A (9)

65. ● Routine* use of stress FP RNA in conjunction with rest/stress gated SPECT MPI I (3)

66. ● Selective use of stress FP RNA in conjunction with rest/stress gated SPECT MPI● Borderline, mild, or moderate stenoses in 3 vessels OR moderate or equivocal left main stenosis in

left dominant system

U (6)

Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)

67. ● Serial assessment of LV function with radionuclide angiography (ERNA or FP RNA)● Baseline and serial measures after key therapeutic milestones or evidence of toxicity

A (9)

Performed under most clinical circumstances, except in cases with technical inability or clear-cut redundancy of information.



8

T


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

able 9. Appropriate Indications (Median Score 7–9)


Score (1–9)Detection of CAD: Symptomatic

Evaluation of Ischemic Equivalent (Nonacute)

2. ● Low pretest probability of CAD● ECG uninterpretable OR unable to exercise

A (7)

3. ● Intermediate pretest probability of CAD● ECG interpretable AND able to exercise

A (7)

4. ● Intermediate pretest probability of CAD● ECG uninterpretable OR unable to exercise

A (9)

5. ● High pretest probability of CAD● Regardless of ECG interpretability and ability to exercise

A (8)

Detection of CAD: SymptomaticAcute Chest Pain

6. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● Low-risk TIMI score● Peak troponin: borderline, equivocal, minimally elevated

A (8)

7. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● High-risk TIMI score● Peak troponin: borderline, equivocal, minimally elevated

A (7)

8. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● Low-risk TIMI score● Negative peak troponin levels

A (8)

9. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● High-risk TIMI score● Negative peak troponin levels

A (8)

Detection of CAD: SymptomaticAcute Chest Pain (Rest Imaging Only)

11. ● Possible ACS● ECG—no ischemic changes or with LBBB or electronically ventricular paced rhythm● Initial troponin negative● Recent or ongoing chest pain

A (7)

Detection of CAD/Risk Assessment: Without Ischemic EquivalentAsymptomatic

15. ● High CHD risk (ATP III risk criteria) A (7)

Detection of CAD/Risk Assessment: Without Ischemic EquivalentNew-Onset or Newly Diagnosed Heart Failure With LV Systolic Dysfunction Without Ischemic Equivalent

16. ● No prior CAD evaluation AND no planned coronary angiography A (8)

Detection of CAD/Risk Assessment: Without Ischemic EquivalentVentricular Tachycardia

18. ● Low CHD risk (ATP III risk criteria) A (7)


Detection of CAD/Risk Assessment: Without Ischemic EquivalentSyncope


Detection of CAD/Risk Assessment: Without Ischemic EquivalentElevated Troponin

22. ● Troponin elevation without additional evidence of acute coronary syndrome A (7)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADPrior Noninvasive Evaluation

29. ● Equivocal, borderline, or discordant stress testing where obstructive CAD remains a concern A (8)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADNew or Worsening Symptoms

30. ● Abnormal coronary angiography OR abnormal prior stress imaging study A (9)



T

*t


able 9. Continued


Score (1–9)Risk Assessment With Prior Test Results and/or Known Chronic Stable CAD

Coronary Angiography (Invasive or Noninvasive)

32. ● Coronary stenosis or anatomic abnormality of uncertain significance A (9)

Risk Assessment with Prior Test Results and/or Known Chronic Stable CADAsymptomatic

Prior Coronary Calcium Agatston Score

35. ● High CHD risk● Agatston score between 100 and 400

A (7)

36. ● Agatston score greater than 400 A (7)

Risk Assessment with Prior Test Results and/or Known Chronic Stable CADDuke Treadmill Score

38. ● Intermediate-risk Duke treadmill score A (7)

39. ● High-risk Duke treadmill score A (8)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions*Intermediate-Risk Surgery


A (7)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions*Vascular Surgery


A (8)

Risk Assessment: Within 3 Months of an ACSSTEMI


A (8)

Risk Assessment: Within 3 Months of an ACSUA/NSTEMI


A (9)

Risk Assessment: Postrevascularization (PCI or CABG)†Symptomatic

55. ● Evaluation of ischemic equivalent A (8)

Risk Assessment: Postrevascularization (PCI or CABG)†Asymptomatic

56. ● Incomplete revascularization● Additional revascularization feasible

A (7)

58. ● Greater than or equal to 5 years after CABG A (7)

Assessment of Viability/IschemiaIschemic Cardiomyopathy/Assessment of Viability

62. ● Known severe LV dysfunction● Patient eligible for revascularization

A (9)

Evaluation of Ventricular FunctionEvaluation of LV Function

63. ● Assessment of LV function with radionuclide angiography (ERNA or FP RNA)● In absence of recent reliable diagnostic information regarding ventricular function obtained with

another imaging modality

A (8)

64. ● Routine‡ use of rest/stress ECG-gating with SPECT or PET MPI A (9)

Evaluation of Ventricular FunctionUse of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)

67. ● Serial assessment of LV function with radionuclide angiogram (ERNA or FP RNA)● Baseline and serial measures after key therapeutic milestones or evidence of toxicity

A (9)

See Table A1. †In patients who have had multiple coronary revascularization procedures, consider the most recent procedure. ‡Performed under most clinical circumstances, except in cases withechnical inability, or clear-cut redundancy of information.



T

*


able 10. Uncertain Indications (Median Score 4–6)


Score (1–9)Detection of CAD/Risk Assessment Without Ischemic Equivalent

Asymptomatic

14. ● Intermediate CHD risk (ATP III risk criteria)● ECG uninterpretable

U (5)

Detection of CAD/Risk Assessment Without Ischemic EquivalentNew-Onset Atrial Fibrillation

17. ● Part of evaluation when etiology unclear U (6)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADAsymptomatic OR Stable SymptomsNormal Prior Stress Imaging Study

26. ● Intermediate to high CHD risk (ATP III risk criteria)● Last stress imaging study done more than or equal to 2 years ago

U (6)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADAsymptomatic OR Stable Symptoms

Abnormal Coronary Angiography OR Abnormal Prior Stress Imaging Study,No Prior Revascularization

28. ● Poor exercise tolerance (less than or equal to 4 METs)● Intermediate clinical risk predictors

U (5)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADNew or Worsening Symptoms

31. ● Normal coronary angiography OR normal prior stress imaging study U (6)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADAsymptomatic


34. ● Low to intermediate CHD risk● Agatston score between 100 and 400

U (5)

Risk Assessment: Postrevascularization (PCI or CABG)*Asymptomatic

57. ● Less than 5 years after CABG U (5)

60. ● Greater than or equal to 2 years after PCI U (6)

Evaluation of Ventricular FunctionEvaluation of Left Ventricular Function

66. ● Selective use of stress FP RNA in conjunction with rest/stress gated SPECT MPI● Borderline, mild, or moderate stenoses in 3 vessels OR moderate or equivocal left main stenosis in

left dominant system

U (6)

In patients who have had multiple coronary revascularization procedures, consider the most recent procedure.



T


able 11. Inappropriate Indications (Median Score 1–3)


Score (1–9)Detection of CAD: Symptomatic

Evaluation of Ischemic Equivalent (Nonacute)

1. ● Low pretest probability of CAD● ECG interpretable AND able to exercise

I (3)

Detection of CAD: SymptomaticAcute Chest Pain

10. ● Definite ACS* I (1)

Detection of CAD/Risk Assessment Without Ischemic EquivalentAsymptomatic


13. ● Intermediate CHD risk (ATP III risk criteria)● ECG interpretable

I (3)

Detection of CAD/Risk Assessment Without Ischemic EquivalentSyncope


Risk Assessment With Prior Test Results and/or Known Chronic Stable CADAsymptomatic OR Stable SymptomsNormal Prior Stress Imaging Study

23. ● Low CHD risk (ATP III risk criteria)● Last stress imaging study done less than 2 years ago

I (1)

24. ● Intermediate to high CHD risk (ATP III risk criteria)● Last stress imaging study done less than 2 years ago

I (3)

25. ● Low CHD risk (ATP III risk criteria)● Last stress imaging study done more than or equal to 2 years ago

I (3)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADAsymptomatic OR Stable Symptoms

Abnormal Coronary Angiography OR Abnormal Prior Stress Imaging Study,No Prior Revascularization

27. ● Known CAD on coronary angiography OR prior abnormal stress imaging study● Last stress imaging study done less than 2 years ago

I (3)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADAsymptomatic


33. ● Agatston score less than 100 I (2)

Risk Assessment With Prior Test Results and/or Known Chronic Stable CADDuke Treadmill Score

37. ● Low-risk Duke treadmill score I (2)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions*Low-Risk Surgery

40. ● Preoperative evaluation for noncardiac surgery risk assessment I (1)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions*Intermediate-Risk Surgery




Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions*Vascular Surgery




Risk Assessment: Within 3 Months of an ACSSTEMI

49. ● Primary PCI with complete revascularization● No recurrent symptoms

I (2)

51. ● Hemodynamically unstable, signs of cardiogenic shock, or mechanical complications I (1)

Risk Assessment: Within 3 Months of an ACSACS–Asymptomatic Postrevascularization (PCI or CABG)

53. ● Evaluation prior to hospital discharge I (1)



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. Discussion

his document is a revision of the original SPECT MPIppropriateness Criteria (1) published 4 years earlier, writ-

en to reflect changes in test utilization, to add insightrovided by interim clinical data, and to clarify cardiac RNIse where omissions or lack of clarity existed in the originalriteria. This is consistent with the commitment to revisend refine AUC on a frequent basis. Published trials and aocietal review have highlighted a significant number oflinical scenarios that were either uncertain or could not beategorized with the original criteria and warranted recon-ideration (15–17). Additionally, trials and reviews haveuggested new clinical indications to consider for thispdate of AUC for RNI.In addition to adding new clinical indications and clari-

ying existing indications from the original SPECT MPIppropriateness Criteria (1) document, the writing group,

echnical panel, and/or external reviewers of the RNIocument also revised specific definitions and assumptions.our additional assumptions were added. The first ad-ressed accordance with best practice standards as delin-ated in the imaging guidelines for nuclear cardiologyrocedures (6) as well as ensuring that procedures areerformed in an accredited facility. The second new as-umption addressed the use of pharmacologic stress testingersus exercise stress testing in the setting of an ACS. Thehird new assumption emphasized that in the perioperativeetting, the use of RNI would have the potential to impactlinical decision making and to direct therapeutic interven-ions. This assumption was added to enhance consistencyith the updated 2007 ACC/AHA Guideline for Periop-

rative Cardiovascular Evaluation and Care for Noncardiacurgery (18). The fourth new assumption addressed theategory of uncertain indications and clarified the relation-hip between such a rating and grounds for reimbursement.

The writing group also revised the definition of “chest

able 11. Continued

IndicationRisk Assessment: W

Cardiac R

54. ● Prior to initiation of cardiac rehabilitation (as a stan

Risk Assessment: PostrevAsym

59. ● Less than 2 years after PCI

Risk Assessment: PostrevCardiac R

61. ● Prior to initiation of cardiac rehabilitation (as a stan

Evaluation of VEvaluation

65. ● Routine§ use of stress FP RNA in conjunction with

Refer to Table A1. †Refer to Table A2. ‡In patients who have had multiple coronary revascularizxcept in cases with technical inability, or clear-cut redundancy of information.

ain syndrome” that had caused confusion when applying acontent.onlinejacDownloaded from

he original SPECT MPI document. The original defini-ion of chest pain syndrome focused only on symptoms andxcluded other clinical findings, such as new ECG changeshat suggest the presence of obstructive CAD and mayarrant RNI testing. Therefore, a new term “ischemic

quivalent” was developed to encompass chest pain syn-romes as well as other symptoms and signs that thelinician believes may be due to obstructive CAD. Thisevision was supported by the writing group, technicalanel, and external reviewers.The AUC in this report provide an estimate of whether

t is reasonable to use cardiac RNI for a particular clinicalcenario, such as those 67 indications listed in this docu-ent. These criteria are expected to be useful for clinicians,

ealth care facilities, and third-party payers engaged in theelivery of cardiovascular imaging. Experience with alreadyublished AUC (1–3) has shown their value across a broadange of situations, guiding care of individual patients,ducating caregivers, and informing policy decisions regard-ng reimbursement for cardiovascular imaging.

Appropriate use criteria represent the first component ofhe chain of quality recommendations for cardiovascularmaging (19). After ensuring proper test selection, thechievement of quality in imaging includes adherence toest practices in image acquisition, image interpretation andesults communication, as well as incorporation of findingsnto clinical care. All components are important for optimalatient care, although not addressed in this report. Theevelopment of AUC and their ranking by the technicalanel assumes that other quality standards have been met.Although these criteria are intended to provide guidance

or patients and clinicians, they are not intended to serve asubstitutes for sound clinical judgment and practice experi-nce. The writing group recognizes that many patientsncountered in clinical practice may not be represented inhese AUC or may have extenuating features when com-ared with the clinical scenarios presented. Although the

Appropriate UseScore (1–9)

Months of an ACSilitation

e indication) I (3)

arization (PCI or CABG)*atic

I (3)

arization (PCI or CABG)‡ilitation

e indication) I (3)

ular FunctionFunction

tress gated SPECT MPI I (3)

rocedures, consider the most recent procedure. §Performed under most clinical circumstances,

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ell as expert consensus, physicians and other stakeholdershould understand the role of clinical judgment in deter-ining whether to order a test for an individual patient.dditionally, uncertain indications often require individualhysician judgment and understanding of the patient toetter determine the usefulness of a test for a particularcenario. As such, the ranking of an indication as uncertain4 to 6) should not be viewed as limiting the use of cardiacNI for such patients. It should be emphasized that the

echnical panel was instructed that the “uncertain” designa-ion was still designed to be considered as a “reimbursable”ategory.

These ratings are intended to evaluate the appropriate usef specific patient scenarios to determine overall patterns ofare regarding cardiac RNI. In situations where there isubstantial variation between the appropriate use rating andhat the clinician believes is the best recommendation for

he patient, further considerations or actions, such as aecond opinion, may be appropriate. Moreover, it is notnticipated that all physicians or facilities will have 100% ofheir cardiac radionuclide procedures deemed appropriate.

owever, related to the overall patterns of care, if theational average of appropriate and uncertain ratings is 80%,or example, and a physician or facility has a 40% rate ofnappropriate procedures, further examination of the pat-erns of care may be warranted and helpful.

Panelists were asked specifically to rate each indicationccording to the definition of appropriate use (see Section 2,

ethods) and to not necessarily consider comparisons tother imaging procedures or other AUC documents whileompleting their ratings, However, panelists were alsorovided with links to relevant guideline recommendationss well as previously published AUC documents to ensurehey were adequately educated on all relevant medicaliterature when rating the indications. Whereas the newer

odalities of CCTA and CMR perfusion are not as welltudied, RNI and stress echocardiography have robustodies of evidence to support their use. The overwhelmingajority of final ratings of cardiac RNI and stress echocar-

iography were concordant for similar clinical indications.owever, a few of the final scores and rating categories

eported in this document differ from those previouslyublished for stress echocardiography (2). Readers shouldote, however, that the categorical summaries tend toccentuate differences that sometimes are slight. For exam-le, small fluctuations in a median rating (e.g., 4 versus 3)ill cause an indication to switch appropriate use categories

from uncertain to inappropriate). There are several poten-ial reasons for these discordant occurrences. The mostikely reason for this is a simple variation in the ratings byhe different panel members, whether due to differentackgrounds levels and types of clinical experience ornterpretations of data. The RAND process has docu-

ented that the interpretation of the literature by differentets of experts can yield slightly different final ratings (5).
nconsistency in wording of indications for the cardiac RNI t

nd stress echocardiography panels has also likely contrib-ted to differences in the ratings of some scenarios. Finally,rue differences in the data reported in the literature regard-ng the modalities might explain some of the discordance.

.1. Cardiac Radionuclide Imagingppropriate Use Criteria

he clinical scenarios included in this report were designedo reflect the most common and important potential appli-ations for cardiac RNI. After the preparation of a draftanuscript by the writing group and extensive review from

xternal editors and then by the technical panel itself, theesult is a set of scenarios that clearly define patient-specificpplications.

The primary objective of this report is to provide guid-nce regarding the suitability of cardiac RNI for diverselinical scenarios. As with previous AUC documents, con-ensus among the raters was desirable, but an attempt tochieve complete agreement within this diverse panel wouldave been artificial and was not the goal of the process. Twoounds of ratings with substantial discussion among theechnical panelists concerning the ratings did lead to someonsensus among panelists. However, further attempts torive consensus would have diluted true differences inpinion among panelists and therefore was not undertaken.Among the 67 indications, 33 were classified as appro-

riate, while uncertain and inappropriate designations weressigned for 9 and 25 indications, respectively.

To facilitate implementation of these AUC, an algorithms presented in Figure 1, which presents a hierarchy ofotential test ordering based on clinical presentation. Theurpose of this algorithm is to help avoid situations in whichhe AUC failed to follow the true clinical reasons for testrdering, such as using an indication designed for assess-ent of chest pain even when a patient may have already

ndergone revascularization or a prior imaging procedure.Table 1 focused on the diagnostic value of RNI. As

hown in Figure 2, patients with an ischemic equivalent,onsisting of symptoms associated with CAD or ECGndings, were divided based on the likelihood of ischemiceart disease. RNI was appropriate in patients with an

ntermediate or high likelihood of CAD, as it was inatients with a low likelihood if they were unable to exerciser had an uninterpretable ECG. The technical panel spe-ifically decided to incorporate Thrombolysis In Myocardialnfarction (TIMI) scores into the indications describingcute chest pain syndromes to provide a more comprehen-ive risk assessment model and one that was consistent withontemporary literature. The technical panel somewhatrbitrarily selected a TIMI score of 2 as a threshold value forow and high risk, as the actual value is currently not definedn guidelines (20). Regarding troponin values, “peak” tro-onin was used for the indication, implying more than 1ample was obtained, and serial testing was performed prioro a stress procedure. The technical panel felt it was best not
o provide a cutoff value for troponin elevation, but instead


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ecommended referring to the assay’s definition of the “bor-erline/equivocal/slightly elevated” category, as this wouldreserve the “possible ACS” definition. For patients with auspected ACS, RNI was considered appropriate irrespec-ive of the TIMI score or whether or not their troponinevels were elevated. These potential discriminators were

igure 2. Potential Applications for Chest Pain

atients with an ischemic equivalent, consisting of symptoms associated with CAD o

igure 1. Hierarchy of Potential Test Orderingased on Clinical Presentation

or those patients who may be classified into more than 1 of the clinical indicationables and/or algorithms, this flow chart places clinical conditions into a hierarchyo aid in assessing appropriateness for radionuclide imaging. *Symptomaticatients who are being considered for a preoperative evaluation for noncardiac sur-ery should begin down the algorithm as if “No.”

or patients with a suspected ACS, RNI was appropriate irrespective of the TIMI score or w


ncluded by the writing group, but were not felt to assistNI utilization by the technical panel.Table 2 primarily focused on the asymptomatic patient

nd is reflected in Figure 3. RNI was felt to be appropriatenly in high CHD risk patients, and in those with inter-ediate CHD risk with an uninterpretable ECG, RNI was

onsidered “uncertain.” The presence of unexplained tropo-in elevation, newly diagnosed heart failure, and ventricularachycardia were appropriate indications for RNI, but RNIas of uncertain appropriateness in the setting of atrialbrillation. This latter category was not divided by CHDisk per the technical panel’s request and was based onecent data (21). The appropriate use of RNI in the settingf syncope was dependent on CHD risk.The use of RNI in patients with prior test results was

resented in Table 3. As shown in Figure 4, RNI wasnappropriate if prior test results were known, except whenerformed more than 2 years later and only if an abnormaltudy was previously present or if the patient was atntermediate or greater CHD risk. In those circumstances,NI use was “uncertain.” When new or worsening symp-

oms were present, RNI was appropriate with prior abnor-al results, but was uncertain if the prior study was normal.egarding patients with prior coronary artery calcium

CAC) scoring, RNI was inappropriate in those with aAC score less than 100. However, RNI was appropriate in

hose with a CAC score greater than 400 or between 100nd 400 with intermediate CHD risk and was uncertain inhose with a CAC score between 100 and 400 and low-ntermediate CHD risk. Finally, a low-risk Duke treadmillcore derived from a prior exercise study was felt to be annappropriate indication for RNI.

findings, were divided based on the likelihood of CAD. If patients had an interme-
r ECGiate or high likelihood for CAD, RNI was appropriate. RNI was also appropriate for patients at low likelihood if they were unable to exercise or had an uninterpretable ECG.
hether or not their troponin levels were elevated.



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The new guidelines for perioperative risk stratification25) mandated a major revision of the original SPECT MPIriteria (1). Table 4 lists the clinical scenarios and theppropriate use ratings, with Figure 5 summarizing thesecores. Overall, RNI was felt to be inappropriate forreoperative risk assessment except in the setting of inter-

igure 3. Potential Applications for Asymptomatic* Patients

nly in high CHD risk patients was RNI felt to be appropriate, although those with inope did not alter the appropriateness of patients separate from their CHD risk, withomatic patients exhibiting the following clinical indications are appropriate (or unceriagnosed heart failure with LV systolic dysfunction without ischemic equivalent whoriate); 2) ventricular tachycardia (Appropriate); 3) elevated troponin without additionUncertain). †Includes diabetes mellitus or the presence of other clinical atherosclerrtery disease, and other likely forms of clinical disease (e.g., renal artery disease).

igure 4. Prior Test Results*

hen new or worsening symptoms were present, RNI was appropriate if prior abnormropriate when no or stable symptoms were present if prior test results were knowniously present or if the patient was at intermediate or greater CHD risk. In those cir
ncertain in the following 2 scenarios: 1) Coronary Angiography: coronary stenosis or anatoquivocal, borderline, or discordant stress testing where obstructive CAD remains a conce

ediate risk or vascular surgery when at least 1 risk factor isresent and the patient has a limited functional capacity.Following an acute ACS, it was felt that RNI was inappro-

riate within 3 months after ACS except in those patientshere a prior coronary angiogram had not been performed.ollowing revascularization with PCI or CABG in a more

iate CHD risk with an uninterpretable ECG were uncertain. The presence of syn-sk patients being inappropriate and high-risk patients being appropriate. *Asymp-or RNI and do not require risk assessment by either step: 1) new-onset or newlynot had a prior CAD evaluation AND have no planned coronary angiography (Appro-ence of acute coronary syndrome (Appropriate); 4) new-onset atrial fibrillationsease, including peripheral arterial disease, abdominal aortic aneurysm, carotid

ults were present, but was uncertain if the prior study was normal. RNI was inap-t when performed more than 2 years later, and only if an abnormal study was pre-

ances, RNI use was “uncertain.” *RNI is appropriate if prior test results were

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hronic setting, recurrence of symptoms or the presence ofuspected incomplete revascularization were felt to be appro-riate indications. The revascularization procedure and theime elapsed before considering RNI resulted in a variety ofppropriate use ratings, as depicted in Table 6 and Figure 6.oth the writing group and the technical panel spent a greateal of time deliberating the issue of whether to incorporate aistinction between the presence or absence of symptoms prioro revascularization into the indications, as patients may havendergone testing in the setting of silent ischemia. The writingroup initially elected to keep prerevascularization symptom-tology as a discrimination point within the indication, ineeping with the prior SPECT MPI criteria and those fortress echocardiography. However, the technical panel ulti-ately decided to remove the distinction due to the lack

ufficient evidence that this qualification was relevant.Table 8 focuses on ventricular function assessment, notPI, in an effort to delineate appropriateness of gated

PECT, first pass radionuclide angiography (FP RNA),nd equilibrium radionuclide angiography. The routine usef FP RNA imaging was deemed inappropriate but wasncertain when used in a selective fashion, such as for thoseatients with suspected multivessel coronary disease.Several changes were present when comparing the orig-

nal SPECT MPI criteria to the new RNI AUC. Specifi-ally, indications 26 and 28 are now “uncertain” comparedith the previous designation of “appropriate”—these

hanges likely reflect increased knowledge and/or differingechnical panel composition. Additionally, indication 32 has

igure 5. Perioperative Evaluation

NI was felt to be inappropriate for preoperative risk assessment except in the settiatient has poor or unknown functional capacity. Additionally, patients who are asym

arization in the setting of intermediate risk or vascular surgery were also rated as inre, cerebrovascular disease, diabetes mellitus (requiring insulin), or renal insufficien

hanged from uncertain to appropriate. rcontent.onlinejacDownloaded from

.2. Application of Criteria

here are many potential applications for AUC. Cliniciansould use the ratings for decision support or an educational toolhen considering the need for cardiac RNI. Moreover, these

riteria could be used to facilitate discussion with patientsnd/or referring physicians about the need for cardiac RNI.acilities and payers may choose to use these criteria eitherrospectively in the design of protocols or preauthorizationrocedures or retrospectively for quality reports. It is hopedhat payers would use these criteria as the basis for theevelopment of rational payment management strategies.It is expected that services performed for appropriate

ndications will be considered reimbursable. In contrast,ervices performed for inappropriate indications shouldikely require additional documentation to justify reimburse-

ent because of the unique circumstances or the clinicalrofile that must exist in such a patient. It is critical tomphasize that the writing group, technical panel, AUC

orking Group, and clinical community do not believe anncertain rating is grounds to deny reimbursement forardiac RNI. Rather, uncertain ratings are those where thevailable data vary and many other factors exist that mayffect the decision to perform or not perform cardiac RNI.he opinions of the technical panel often varied for these

ndications, reflecting that additional research is needed.ndications with high clinical volume that are rated asncertain identify important areas for further research.In conclusion, this document represents the current

nderstanding of the clinical benefit of cardiac RNI with

intermediate risk or vascular surgery when at least 1 risk factor is present and thetic up to 1 year postnormal catheterization, noninvasive test, or previous revascu-

priate for RNI. *History of ischemic heart disease, compensated or prior heart fail-eatinine �2.0).

ng ofptomaappro

espect to health outcomes and survival. It is intended to by on February 25, 2010 c.org


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rovide a practical guide to clinicians and patients whenonsidering cardiac RNI. As with other AUC documents,ome of these ratings will require research and furthervaluation to provide the greatest information and benefit tolinical decision making. Finally, it will be necessary toeriodically assess and update the indications and criteria asechnology evolves and new data and field experienceecomes available.

ppendix A: Additional Cardiac Radionuclidemaging Definitions

ngina: as defined by the ACC/AHA Guidelines onxercise Testing (7)

Typical Angina (Definite):1. Substernal chest pain or discomfort that is2. provoked by exertion or emotional stress and3. relieved by rest and/or nitroglycerin (22).Atypical Angina (Probable): Chest pain or discomfortthat lacks one of the characteristics of definite or typicalangina (22).Nonanginal Chest Pain: Chest pain or discomfort thatmeets one or none of the typical angina characteristics.

CS: As defined by the ACC/AHA Guidelines for theanagement of Patients With ST-Elevation Myocardial

igure 6. Postrevascularization

ollowing revascularization with PCI or CABG in a more chronic (�3 months) set-ing, recurrence of symptoms or the presence of suspected incomplete revascular-zation were felt to be appropriate indications for RNI. For asymptomatic patientsess than 2 years after a PCI, RNI was rated inappropriate. For asymptomaticatients at less than 5 years after CABG or those at greater than or equal to 2ears after PCI, RNI was rated uncertain. If CABG was performed more than 5 yearsgo, RNI is appropriate. *Assumes that additional revascularization is feasible.

nfarction: patients with an ACS include those whosemI


linical presentations cover the following range of diagnoses:nstable angina, myocardial infarction without ST elevationNSTEMI), and myocardial infarction with ST elevationSTEMI) (23).

valuating Perioperative Risk for Noncardiac Surgery

ETHOD FOR DETERMINING PERIOPERATIVE RISK

ee Figure A1, “Stepwise Approach to Perioperative Car-iac Assessment,” from the ACC/AHA 2007 Perioperativeuidelines (18). Based on the algorithm, once it is deter-ined that the patient does not require urgent surgery, the

linician should determine the patient’s active cardiac con-itions (see Table A1) and/or perioperative risk predictorsee Table A2). If any active cardiac conditions and/orajor risk predictors are present (see Tables A1 and A2),igure A1 suggests consideration of coronary angiographynd postponing or canceling noncardiac surgery. Onceerioperative risk predictors are assessed based on thelgorithm, then the surgical risk and patient’s functionaltatus should be used to establish the need for noninvasiveesting.

hrombolysis In Myocardial Infarction Risk Scores

he TIMI risk score (21) is a simple tool composed of 71-point) risk indicators rated on presentation (Table A3).he composite end points (all-cause mortality, new or

able A1. TIMI Risk Score for Unstable Angina/on–ST-Elevation Myocardial Infarction

Condition Examples

nstable coronary syndromes Unstable or severe angina* (CCS class IIIor IV)†

Recent MI‡

ecompensated HF(NYHA functional class IV;worsening or new-onset HF)

ignificant arrhythmias High-grade atrioventricular block

Mobitz II atrioventricular block

Third-degree atrioventricular heart block

Symptomatic ventricular arrhythmias

Supraventricular arrhythmias (includingatrial fibrillation) with uncontrolledventricular rate (HR greater than100 bpm at rest)

Symptomatic bradycardia

Newly recognized ventricular tachycardia

evere valvular disease Severe aortic stenosis (mean pressuregradient greater than 40 mm Hg,aortic valve area less than 1.0 cm2,or symptomatic)

Symptomatic mitral stenosis(progressive dyspnea on exertion,exertional presyncope, or HF)

According to Campeau (24). †May include “stable” angina in patients who are unusuallyedentary. ‡The American College of Cardiology National Database Library defines recent MI asore than 7 days but less than or equal to 1 month (within 30 days). Reprinted from Andersont al. (25).CCS indicates Canadian Cardiovascular Society; HF, heart failure, HR, heart rate; MI,
yocardial infarction; NYHA, New York Heart Association; and TIMI, Thrombolysis In Myocardial
nfarction.



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ecurrent MI, or severe recurrent ischemia prompting ur-ent revascularization within 14 days) increase as the TIMIisk score increases. The model remained a significantredictor of events and test sensitivity and was relativelynaffected/uncompromised by missing information, such asnowledge of previously documented coronary stenosis of0% or more. The model’s predictive ability remained intactith a cutoff of 65 years of age.The TIMI risk score is determined by the sum of the

resence of 7 variables at admission; 1 point is given for eachf the following variables: age 65 years or older; at least 3

able A2. Perioperative Clinical Risk Factors*

History of ischemic heart diseaseHistory of compensated or prior heart failureHistory of cerebrovascular diseaseDiabetes mellitus (requiring insulin)Renal insufficiency (creatinine greater than 2.0)

igure A1. Stepwise Approach to Perioperative Cardiac Assessme

ardiac evaluation and care algorithm for noncardiac surgery based on active clinicaf age or greater. *See Table A1 for active clinical conditions. †Please note that the

nvasive testing is not useful for patients with no clinical risk factors undergoing inteot useful for patients undergoing low-risk noncardiac surgery (Level of Evidence: C).efore surgery in specific patients with risk factors if it will change management. Clietes mellitus, renal insufficiency, and cerebrovascular disease. ¶Consider perioperaidity/mortality. Reprinted from the recommendations from the ACC/AHA 2007 Guid

As defined by the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation andare for Noncardiac Surgery (18). Note that these are not standard CAD risk factors.

RC


isk factors for CAD; prior coronary stenosis of 50% orore; ST-segment deviation on ECG presentation; at leastanginal events in prior 24 hours; use of aspirin in prior 7

ays; and elevated serum cardiac biomarkers. Prior coronary

able A3. Active Cardiac Conditions for Which the Patienthould Undergo Evaluation and Treatment Before Noncardiacurgery (Class I, Level of Evidence: B)

TIMI Risk Score

All-Cause Mortality, New or RecurrentMI, or Severe Recurrent Ischemia

Requiring Urgent RevascularizationThrough 14 Days After Randomization, %

0–1 4.7

2 8.3

3 13.2

4 19.9

5 26.2

6–7 40.9

itions, known cardiovascular disease, or cardiac risk factors for patients 50 yearsACC/AHA Guidelines for Perioperative Cardiac Assessment recommend that non-te-risk noncardiac surgery (Level of Evidence: C) and that noninvasive testing isTable A2 for list of clinical risk factors. §Noninvasive testing may be consideredsk factors include ischemic heart disease, compensated or prior heart failure, dia-eta blockade for populations in which this has been shown to reduce cardiac mor-on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery (18).

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eprinted from the recommendations from the ACC/AHA 2007 Guidelines on Perioperativeardiovascular Evaluation and Care for Noncardiac Surgery (18).



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tenosis of 50% or more was relatively unaffected/ncompromised by missing information and remained aignificant predictor of events.

Low-Risk TIMI Score: TIMI score less than 2‡High-Risk TIMI Score: TIMI score greater than or

equal to 2

CG—Uninterpretableefers to ECGs with resting ST-segment depression

greater than or equal to 0.10 mV), complete LBBB,reexcitation (Wolff-Parkinson-White Syndrome), oraced rhythm.

ppendix B: Additional Methods

ee Section 2, Methods, for a description of panel selection,ndication development, scope of indications, and ratingrocess.

elationships With Industry

he ACCF and its partnering organizations rigorouslyvoid any actual, perceived, or potential conflicts of interesthat might arise as a result of an outside relationship orersonal interest of a member of the technical panel.pecifically, all panelists are asked to provide disclosuretatements of all relationships that might be perceived aseal or potential conflicts of interest. These statements wereeviewed by the AUC Working Group, discussed with allembers of the technical panel at the face-to-face meeting,

nd updated and reviewed as necessary. A table of disclo-ures by the technical panel and oversight working groupembers can be found in Appendix C.

iterature Review

he technical panel members were asked to refer to theelevant guidelines for a summary of the relevant literature,uideline recommendation tables, and reference lists pro-ided for each indication table when completing theiratings (Online Appendix at http://content.onlinejacc.org/gi/content/full/j.jacc.2009.02.013).

ppendix C: ACCF Appropriate Useriteria for Cardiac Radionuclide Imagingarticipants

ardiac Radionuclide Imaging Writing Group

obert C. Hendel, MD, FACC, FAHA, FASNC—Chair,ppropriate Use Criteria for Radionuclide Imaging Writingroup–Midwest Heart Specialists, Winfield, ILDaniel S. Berman, MD, FACC, FAHA—Director,

ardiac Imaging, Cedars-Sinai Medical Center; Professor

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


f Medicine, David Geffen School of Medicine at UCLA,os Angeles, CAMarcelo F. Di Carli, MD, FACC, FAHA—Division ofuclear Medicine and Molecular Imaging and Noninvasiveardiovascular Imaging Program, Brigham and Women’sospital, Associate Professor of Radiology and Medicine,arvard Medical School, Boston, MAPaul A. Heidenreich, MD, MS, FACC—Associate Pro-

essor of Medicine, Stanford University, VA Palo Altoealth Care System, Palo Alto, CARobert E. Henkin, MD, FACR—Professor Emeritus of

adiology, Loyola University Stritch School of Medicine,aywood, ILPatricia A. Pellikka, MD, FACC, FAHA, FASE—

rofessor of Medicine, Co-Director, Echocardiography Lab-ratory, Mayo Clinic College of Medicine, Rochester, MN

Gerald M. Pohost, MD, FACC, FAHA—Professor ofadiology, Keck School of Medicine, Professor of Electricalngineering, Viterbi School of Engineering, University ofouthern California, Los Angeles, CA; Professor of Med-

cine, Loma Linda College of Medicine, Loma Linda, CA;nd Director of Research, Hollywood Heart and Vascularnstitute, Los Angeles, CA

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

nd Nuclear Medicine, Chicago, IL

ardiac Radionuclide Imaging Technical Panel

ichael J. Wolk, MD, MACC—Moderator, Appropriatese Criteria for Cardiac Radionuclide Imaging Technicalanel—Past President, American College of Cardiologyoundation; Clinical Professor of Medicine, Weill-Cornelledical School, New York, NYRobert C. Hendel, MD, FACC, FAHA, FASNC—ethodology/Writing Group Liaison Appropriate Useriteria for Cardiac Radionuclide Imaging Technicalanel—Midwest Heart Specialists, Winfield, ILPatricia A. Pellikka, MD, FACC, FAHA, FASE—riting Group Liaison Appropriate Use Criteria for Car-

iac Radionuclide Imaging Technical Panel—Professor ofedicine, Co-Director, Echocardiography Laboratory,ayo Clinic College of Medicine, Rochester, MNPeter Alagona, Jr., MD, FACC—Program Directoreneral Cardiology Penn State Heart and Vascular Insti-

ute Associate Professor of Medicine and Radiology, Penntate College of Medicine, Hershey, PATimothy M. Bateman, MD, FACC—Co-Director, Car-

iovascular Radiologic Imaging, Cardiovascular Consult-nts, PC, Kansas City, MO

Manuel D. Cerqueira, MD, FACC, FAHA, FASNC—rofessor of Radiology and Medicine, Cleveland Clinicerner College of Medicine of Case Western Reserve
niversity, Chairman, Department of Nuclear Medicine,

http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.02.013

http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.02.013


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maging Institute and Staff Cardiologist, Heart and Vascu-ar Institute, Cleveland Clinic, Cleveland, OH

James R. Corbett, MD, FACC—Professor of Radiologynd Internal Medicine, Nuclear Medicine and Cardiologyivisions, University of Michigan Medical Center, Annrbor, MIAnthony J. Dean, MD, FACEP—Assistant Professor

f Emergency Medicine and Assistant Professor ofmergency Medicine in Radiology; Director, Division ofmergency Ultrasonography, Department of Emergencyedicine, University of Pennsylvania Medical Center,

hiladelphia, PAGregory J. Dehmer, MD, FACC, FAHA—Professor ofedicine, Texas A&M College of Medicine, Scott &hite Healthcare, Cardiology Division, Temple, TXPeter Goldbach, MD, FACCP—Medical Director, Blue

ross Blue Shield of Massachusetts, Boston, MA (former);EO, MedVantage, Inc., San Francisco, CALeonie Gordon, MB ChB—Professor of Radiology, Med-

cal University of South Carolina, Charleston, SCFrederick G. Kushner, MD, FACC—Medical Director,eart Clinic of Louisiana, Clinical Professor, Tulane Uni-

ersity Medical Center, Merrero, LARaymond Y. K. Kwong, MD, MPH, FACC—Director

f Cardiac Magnetic Resonance Imaging, Cardiovascularivision of Department of Medicine, Brigham & Women’sospital; Assistant Professor of Medicine, Harvard Medical

chool, Boston, MAJames K. Min, MD, FACC—Assistant Professor ofedicine and Radiology, Weill Cornell University Medicalollege, New York Presbyterian Hospital, New York, NYMiguel A. Quinones, MD, FACC—Chair, Department

f Cardiology, Methodist DeBakey Heart and Vascularenter, Houston, TXR. Parker Ward, MD, FACC—Associate Professor ofedicine, University of Chicago Medical Center, Chicago, ILScott H. Yang, MD, PhD, FACC—Kaiser Permanente

anta Rosa, Santa Rosa, CA

xternal Reviewers of the Appropriate Useriteria Indications

ames Arrighi, MD, FACC, FASNC—Director, Nuclearardiology, Rhode Island Hospital and Program Director,ardiology Fellowship, Brown University, Associate Pro-

essor of Medicine, Brown University, Providence, RIRobert O. Bonow, MD, MACC, FAHA—Goldberg Dis-

inguished Professor; Chief, Division of Cardiology, North-estern University Feinberg School of Medicine, Chicago, ILLee A. Fleisher, MD, FACC, FAHA—Robert D.ripps Professor and Chair of Anesthesiology and Criticalare, Professor of Medicine, University of Pennsylvaniachool of Medicine, Philadelphia, PAJulius M. Gardin, MD, FACC, FAHA, FASE—

rofessor and Chairman, Department of Internal Medicine, Ccontent.onlinejacDownloaded from

ackensack University Medical Center and Touro Univer-ity College of Medicine, Hackensack, NJ

Raymond J. Gibbons, MD, FACC, FAHA—Arthur M.nd Gladys D. Gray Professor of Medicine; Division ofardiovascular Diseases, Mayo Clinic, Rochester, MNJohn A. Gillespie, MD, FACC—Chief Medical Officer,

ndependent Health Corporation, Buffalo, NYBennett S. Greenspan, MD, MS, FACNP, FACR,

ACNM—Assistant Professor, Radiology, Associate Pro-ram Director, Nuclear Medicine, Mallinckrodt Institute ofadiology, Washington University School of Medicine, St.ouis, MORory Hachamovitch, MD, FACC—Independent consul-

ant, Los Angeles, CAWarren R. Janowitz, MD, FACC, FAHA—Director ofolecular Imaging, Baptist Hospital of Miami, Miami, FLChristopher M. Kramer, MD, FACC, FAHA—

rofessor of Medicine and Radiology, Director, Cardiovas-ular Imaging Center, University of Virginia Health Sys-em, Charlottesville, VA

Michael H. Picard, MD, FACC, FASE, FAHA—ssociate Professor of Medicine, Harvard Medical School,irector, Echocardiography, Massachusetts General Hos-

ital, Boston, MAMichael Poon, MD, FACC—Past President, Society of

ardiac Computed Tomography, New York, NYMiguel A. Quinones, MD, FACC—Chair, Department

f Cardiology, Methodist DeBakey Heart and Vascularenter, Houston, TXRaymond F. Stainback, MD, FACC, FASE—Medicalirector, Noninvasive Cardiac Imaging, Texas Heart Insti-

ute at St. Luke’s Episcopal Hospital; Clinical Assistantrofessor of Medicine, Baylor College of Medicine; Part-er, Hall-Garcia Cardiology Associates, Houston, TXMark I. Travin, MD, FACC, FASNC—Director ofardiovascular Nuclear Medicine, Montefiore Medicalenter, Professor of Clinical Nuclear Medicine and Clinicaledicine, Albert Einstein College of Medicine, Bronx, NYSamuel Wann, MD, MACC—Clinical Professor ofedicine, University of Wisconin–Madison and Medicalollege of Wisconsin–Milwaukee, Chairman, Departmentf Cardiovascular Medicine, Wisconsin Heart Hospital,ilwaukee, WIR. Parker Ward, MD, FACC—Associate Professor ofedicine, University of Chicago Medical Center, Chicago, ILNeil J. Weissman, MD, FACC, FASE—Professor ofedicine, Georgetown University, and President, MedStar

esearch Institute, Washington, DCJack A. Ziffer, MD, FACC—Medical Director, Nuclear

ardiology, Miami Cardiac and Vascular Institute, Miami, FLWilliam A. Zoghbi, MD, FACC, FAHA, FASE—

rofessor of Medicine, Director, Cardiovascular Imagingnstitute; William L. Winters Endowed Chair in Cardio-ascular Imaging, Methodist DeBakey Heart and Vascular
enter, Houston, TX


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CCF Appropriate Use Criteria Task Force

alph G. Brindis, MD, MPH, FACC—Chair, Taskorce–Regional Senior Advisor for Cardiovascular Dis-ase, Northern California Kaiser Permanente, Oakland,A; Clinical Professor of Medicine, University of Cali-

ornia at San Francisco, San Francisco, CA; Chiefedical Officer & Chairman, NCDR Management

oard, American College of Cardiology Foundation,ashington, DCPamela S. Douglas, MD, MACC, FAHA, FASE—Past

resident, American College of Cardiology Foundation;ast President American Society of Echocardiography; andrsula Geller Professor of Research in Cardiovasculariseases and Chief, Cardiovascular Disease, Duke Univer-

ity Medical Center, Durham, NC F


Robert C. Hendel, MD, FACC, FAHA, FASNC—hair, Appropriate Use Criteria for Radionuclide Imagingriting Group–Midwest Heart Specialists, Winfield, ILManesh R. Patel, MD—Assistant Professor of Medicine,ivision of Cardiology, Duke University Medical Center,urham, NCEric D. Peterson, MD, MPH, FACC, FAHA—

rofessor of Medicine and Director, Cardiovascular Re-earch, Duke Clinical Research Institute, Duke University

edical Center, Durham, NCMichael J. Wolk, MD, MACC—Past President, American

ollege of Cardiology Foundation and Clinical Professor ofedicine, Weill-Cornell Medical School, New York, NYJoseph M. Allen, MA—Director, TRIP (Translating

esearch into Practice), American College of Cardiology
oundation, Washington, DC


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

CommitteeMember Consultant Speaker

Ownership/Partnership/

Principal Research

Institutional,Organizational, or

Other Financial Benefit Expert Witness

Cardiac Radionuclide Imaging Appropriate Use Criteria Writing Group

r. Robert C.Hendel

● Astellas● GE Healthcare● PGx Health

● Astellas None ● GE Healthcare None None

r. Daniel S.Berman

● Astellas● Floura Pharma● Tyco

MallinckrodtHealthcare

None ● Cedars SinaiMedicalCenter

● SpectrumDynamics

● Astellas● Bristol-Myers Squibb

Medical Imaging● Siemens● Tyco Mallinckrodt

Healthcare

None None

r. Marcelo F.Di Carli

None None None None None None

r. Paul A.Heidenreich

None None None ● Siemens None None

r. Robert E.Henkin

● Philips MedicalSystems

None None None None None

r. Patricia A.Pellikka


r. Gerald M.Pohost


r. Kim A.Williams

● Bracco● GE Healthcare● King

Pharmaceuticals

● Astellas None ● GE Healthcare● Molecular Insight

Pharmaceuticals

None None

Cardiac Radionuclide Imaging Appropriate Use Criteria Technical Panel

r. PeterAlagona, Jr.

● Digirad None None None None None

r. Timothy M.Bateman

● Astellas● Bracco

Diagnostics● CV Therapeutics● Lantheus● Molecular

InsightsPharmaceuticals


None ● CVIT ● Bracco Diagnostics● Philips Medical Systems

None None

r. Manuel D.Cerqueira

● Astellas● CV Therapeutics● GE Healthcare● Siemens

● Astellas● CardiArc● Covidien● GE Healthcare

None ● CardiArc● Perceptive Informatics

None ● Intellectual propertyrights

r. James R.Corbett


r. Anthony J.Dean

None None None ● In-kind support withinstitutional loan ofultrasound equipment

None None



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Principal Research



r. Gregory J.Dehmer

None None None None None ● Evaluation of PCIprogram

● Fair hearing relatedto physicianprivileges athospital

● Need for open heartsurgery for facility

r. PeterGoldbach

None ● MedVantange,Inc.

None None ● Blue Cross Blue Shieldof Massachusetts(Medical Director,former)

● MedVantange, Inc.(Chief ExecutiveOfficer)

None

r. LeonieGordon

None None None None None ● PET brain scan

r. Frederick G.Kushner

None None None ● AstraZeneca● Novartis● Pfizer

None None

r. Raymond Y.Kwong


r. James Min ● GE Healthcare ● GE Healthcare None None None None

r. Miguel A.Quinones

None None None None None ● Diet pills and valvedisease

r. R. ParkerWard

None None None ● Pfizer None None

r. Michael J.Wolk


r. Scott H.Yang


Cardiac Radionuclide Imaging Appropriate Use Criteria Task Force

r. Joseph M.Allen


r. Ralph G.Brindis


r. Pamela S.Douglas

● BG Medicine● Expression

Analysis● Genentech● GlaxoSmithKline

Foundation● Northpoint

Domain● Ortho

Diagnostics● Pappas Ventures● Visen Medicad● Xceed Molecular

None ● CardioDX● Millennium● Northpoint

Domain

● Atritech● Edwards Lifesciences● Lab Corp● Reata● United Health Care

None None

r. Robert C.Hendel

● Astellas● GE Healthcare● PGx Health

● Astellas None ● GE Healthcare None None

r. Manesh R.Patel




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Principal Research



r. Eric D.Peterson

None None None ● Bristol-Myers Squibb/Sanofi Aventis

● Merck● Schering-Plough● St. Jude

None None

r. Michael J.Wolk


Cardiac Radionuclide Imaging Appropriate Use Criteria Indication Reviewers

r. JamesArrighi


r. Robert O.Bonow

● Bristol-MyersSquibb MedicalImaging

● EdwardsLifesciences

None None None None None

r. Lee A.Fleisher

None None None None None ● Preoperativepotassium

● Preoperativepotassium level

r. Julius M.Gardin

None ● CVTherapeutics

● Pfizer● Takeda

None ● Merck None None

r. Raymond J.Gibbons

● CardiovascularClinical Studies(WOMEN study)

● ConsumersUnion

● TIMI 37A

None None ● Kai Pharmaceuticals● King Pharmaceuticals● Radiant Medical● TargeGen● Ther Ox

None None

r. John A.Gillespie


r. Bennett S.Greenspan


r. RoryHachamovitch

● Bristol-MyersSquibb MedicalImaging

● GE Healthcare None ● Astellas● Bracco Diagnostics● GE Healthcare● Siemens

None None

r. Warren R.Janowitz


r. ChristopherM. Kramer

● Siemens None None ● Astellas● GlaxoSmithKline● Merck● Siemens

None None

r. Michael H.Picard

● Acusphere None None ● Edwards Lifesciences None None

r. MichaelPoon


r. Miguel A.Quinones

None None None None None ● Diet pills and valvedisease

r. Raymond F.Stainback




D

D

D

D

D

D

Tadmi

S

AJTJRKLCEP

R




Principal Research



r. Mark I.Travin

None None None None None ● Adding exercise topharmacologicstress

● ECG stress testingand orderingnuclear studies

r. SamuelWann


r. R. ParkerWard

None None None ● Pfizer None None

r. Neil J.Weissman

● Takeda● Wyeth

None None ● Acusphere● Arena Pharmaceutical● ATS● Biotronik● Boston Scientific● Edwards Lifesciences● Lipid Science● Point Biomedical● Sorin Carbomedics● Spectranetics● St. Jude● Zilver

None ● Anorexic agents

r. Jack A. Ziffer ● Tyco Healthcare None ● CVTherapeutics


● Bristol-Myers Squibb● CV Therapeutics

None None

r. William A.Zoghbi


his table represents the relevant relationships of committee members with industry and other entities that were reported orally at the initial writing committee meeting and updated in conjunction withll meetings and conference calls of the writing committee during the document development process. It does not necessarily reflect relationships with industry at the time of publication. A person iseemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10 000 or more of the fair
arket value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest
st unles

1

f it is less than significant under the preceding definition. Relationships in this table are mode

taff

merican College of Cardiology Foundationohn C. Lewin, MD, Chief Executive Officerhomas E. Arend, Jr., Esq., Chief Operating Officer

oseph M. Allen, MA, Director, TRIP (Translatingesearch Into Practice)ennedy Elliott, Specialist, Appropriate Use Criteriaindsey Law, MHS, Senior Specialist, Appropriate Useriteriarin A. Barrett, Senior Specialist, Science and Clinicalolicy

EFERENCES

1. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropri-ateness criteria for single-photon emission computed tomographymyocardial perfusion imaging (SPECT MPI): a report of the Amer-ican College of Cardiology Foundation Strategic Direction Commit-tee Appropriateness Criteria Working Group and the AmericanSociety of Nuclear Cardiology. J Am Coll Cardiol. 2005;46:1587–605.

2. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/
AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria forstress echocardiography. J Am Coll Cardiol. 2008;51:1127–47.

s otherwise noted.

3. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria forcardiac computed tomography and cardiac magnetic resonance imag-ing. J Am Coll Cardiol. 2006;48:1475–97.

4. Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method forevaluating the appropriateness of cardiovascular imaging. J Am CollCardiol. 2005;46:1606–13.

5. Fitch K, Bernstein, SJ, Aguilar, MD, et al. The RAND/UCLAAppropriateness Method User’s Manual. Arlington, Va: RAND;2001.

6. Ficaro E. Imaging guidelines for nuclear cardiology procedures. J NuclCardiol. 2006;13:888.

7. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guidelineupdate for exercise testing: summary article: a report of the AmericanCollege of Cardiology/American Heart Association Task Force onPractice Guidelines (Committee to Update the 1997 Exercise TestingGuidelines). J Am Coll Cardiol. 2002;40:1531–40.

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

9. Grundy SM, Pasternak R, Greenland P, et al. AHA/ACC scientificstatement: assessment of cardiovascular risk by use of multiple-riskfactor assessment equations: a statement for healthcare professionalsfrom the American Heart Association and the American College ofCardiology. J Am Coll Cardiol. 1999;34:1348–59.

0. Morise AP, Haddad WJ, Beckner D. Development and validation of
a clinical score to estimate the probability of coronary artery disease in


1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

Kii


men and women presenting with suspected coronary disease. Am JMed. 1997;102:350–6.

1. Pryor DB, Shaw L, McCants CB, et al. Value of the history andphysical in identifying patients at increased risk for coronary arterydisease. Ann Intern Med. 1993;118:81–90.

2. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guidelineupdate for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(Writing Committee on the Management of Patients With ChronicStable Angina). J Am Coll Cardiol. 2003;41:159–68.

3. Diamond GA, Forrester JS. Analysis of probability as an aid in theclinical diagnosis of coronary-artery disease. N Engl J Med. 1979;300:1350–8.

4. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guidelineupdate for exercise testing: summary article: a report of the AmericanCollege of Cardiology/American Heart Association Task Force onPractice Guidelines (Committee to Update the 1997 Exercise TestingGuidelines). J Am Coll Cardiol. 2002;40:1531–40.

5. Mehta R, Agarwal S, Chandra S, Ward RP, Williams KA. Evaluationof the American College of Cardiology Foundation/American Societyof Nuclear Cardiology Appropriateness Criteria for SPECT Myocar-dial Perfusion Imaging, J Nucl Cardiol. 2008;15:337–44.

6. Gibbons RJ, Miller TD, Hodge D, et al. Application of appropriate-ness criteria to stress single-photon emission computed tomographysestamibi studies and stress echocardiograms in an academic medicalcenter. J Am Coll Cardiol. 2008;51:1283–9.

7. Ward RP, Al-Mallah MH, Grossman GB, et al. American Society ofNuclear Cardiology review of the ACCF/ASNC AppropriatenessCriteria for Single-Photon Emission Computed Tomography Myo-cardial Perfusion Imaging (SPECT MPI). J Nucl Cardiol. 2007;14:e26–38.

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

9. Douglas, P, Iskandrian, AE, Krumholz, HM, et al. Achieving qualityin cardiovascular imaging: proceedings from the American College ofCardiology-Duke University Medical Center Think Tank on Qualityin Cardiovascular Imaging. J Am Coll Cardiol. 2006;48:2141–51.

0. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score forunstable angina/non-ST elevation MI: a method for prognosticationand therapeutic decision making. JAMA. 2000;284:835–42.

1. Askew JW, Miller TD, Hodge DO, Gibbons RJ. The value ofmyocardial perfusion single-photon emission computed tomographyin screening asymptomatic patients with atrial fibrillation for coronaryartery disease. J Am Coll Cardiol. 2007;50:1080–5.

2. Bierig SM, Ehler D, Knoll ML, Waggoner AD. American Society ofEchocardiography minimum standards for the cardiac sonographer: aposition paper. J Am Soc Echocardiogr. 2006;19:471–4.

3. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelinesfor the management of patients with ST-elevation myocardial infarc-tion—executive summary: a report of the American College ofCardiology/American Heart Association Task Force on PracticeGuidelines (Writing Committee to Revise the 1999 Guidelines for theManagement of Patients With Acute Myocardial Infarction). J AmColl Cardiol. 2004;44:671–719.

4. Campeau L. Letter: grading of angina pectoris. Circulation. 1976;54:522–3.

5. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American Collegeof Cardiology/American Heart Association Task Force on PracticeGuidelines (Writing Committee to Revise the 2002 Guidelines for theManagement of Patients With Unstable Angina/Non–ST-ElevationMyocardial Infarction). J Am Coll Cardiol. 2007;50:e1–157.

ey Words: ACCF Appropriate Use Criteria y cardiac radionuclidemaging y SPECT MPI y PET y coronary artery disease y cardiacmaging y diagnostic testing.

APPENDIX

upplementary materials cited in this article are available online.



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 PhysiciansCardiovascular 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 AmericanCriteria 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 February 25, 2010

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