New Appropriate-Use Criteria Issued for Diagnostic Tests in Stable CAD

Shelley Wood

December 16, 2013

WASHINGTON, DC — Cardiology groups have released new appropriate-use criteria (AUC) covering the use of seven tests used in the detection and risk assessment of stable ischemic heart disease[1]. Unlike past guidance, which has covered single modalities, this new document is the first to consider seven tests side by side, for the same clinical indication, writing group chair Dr Michael J Wolk (Weill Cornell Medical School, New York, NY) told heartwire .

"Going forward, this could mean that some tests could be winners and others losers, in any given scenario," Wolk observed, adding the aim was not to "rank" tests in any particular order; rather, it was to help guide patients and physicians "toward more reasonable decision making going forward."

The new AUC document reviews the use of exercise ECG, stress radionuclide imaging, stress echo, stress cardiac magnetic resonance imaging (CMR), calcium scoring, coronary computed tomography angiography (CCTA), and invasive coronary angiography, side by side, across different clinical indications. These include patients with signs and/or symptoms and/or various levels of risk for coronary disease; patients undergoing follow-up for prior test results or coronary revascularization; patients scheduled for noncardiac surgery, and patients with an exercise prescription or referral to cardiac rehabilitation.

Each test, in each indication, is ranked as "appropriate," "may be appropriate," or "rarely appropriate."

Wolk explained that the "multimodality" AUC are consistent with prior, single-modality AUC documents, although some rankings "have really changed because of new knowledge that has come out on advanced imaging," as well as newer guidelines released by the American Heart Association (AHA) and American College of Cardiology (ACC).

The new multimodality AUC were developed by the ACC Foundation Appropriate Use Criteria Task Force, AHA, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons.

Which Test, Which Scenario?

Wolk gave several examples of clinical scenarios in which certain commonly replied upon tests should or should not be used.

For example, in asymptomatic patients with low global risk of CHD, all of the seven tests were deemed "rarely appropriate." The same was true for low-risk patients who were asymptomatic postrevascularization (less than two years post-PCI or less than five years post-CABG): all of the tests reviewed are not appropriate and, as Wolk put it, are "really wasting resources."

Appropriateness of certain tests, he stressed, is tied to risk level. As such, in asymptomatic patients at either intermediate or high risk, calcium scoring and exercise or stress testing may be appropriate, with CCTA also getting a "may be appropriate" in high-risk patients only. Of note, however, invasive coronary angiography remained "rarely" appropriate across all levels of risk in asymptomatic subjects.

The choice of "rarely appropriate" reflects a shift on the part of the writing committee away from the term "inappropriate," which Wolk says he believes was really misunderstood by the press and the public. The choice of "rarely appropriate" reflects situations where evidence and clinical consensus do not support the use of a given modality but where it may nevertheless be used in very specific circumstances—namely, "when the patient thinks he would feel better and sleep better and have better quality of life [if he knew the results]. So after discussion with their doctor, an informed conversation, those tests can be done."

The multimodality AUC are also in line with the "Choosing Wisely" do-not-do procedures released by the ACC in 2012, Wolk noted; four of the five on this list relate to imaging procedures. Wolk says the plan is to try to keep updating the multimodality AUC document on an annual basis, as new information comes in. One of the biggest studies that may provide new information in this arena is the >8000-patient ISCHEMIA study, evaluating management of patients with stable ischemic heart disease.

Those study results and others will be considered in due course, he said.

Wolk had no conflicts of interest. Disclosures for other members of the writing group and technical panel are listed in the document.

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