Appropriate Use Criteria for Imaging in Nonvalvular HD

Megan Brooks

January 09, 2019

The American College of Cardiology (ACC), the American Heart Association (AHA), and eight other organizations have released appropriate use criteria (AUC) for a wide array of imaging modalities available for the evaluation and management of structural (nonvalvular) heart disease.

Using standardized methodology, 102 commonly encountered clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday clinical practice.

A separate independent rating panel scored all 102 scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario.

The AUC for nonvalvular heart disease were published online January 7 in the Journal of the American College of Cardiology.

A Framework for Assessment

The main objective of the AUC is to "provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making," the authors say.

The clinical scenarios cover the spectrum of patients with nonvalvular heart disease — from patients with no symptoms who are suspected of having nonvalvular heart disease to patients with signs and symptoms ranging from mild to severe.

"As might be expected," say the authors, transthoracic echocardiography is recognized as appropriate in virtually all of the scenarios. Among the other imaging modalities and indications:

  • Coronary angiography is deemed appropriate in the evaluation of the patient with sustained ventricular tachycardia or ventricular fibrillation but not as an initial testing modality across other scenarios.

  • The presence of atrial fibrillation in which ischemia may be a trigger led to a "may be appropriate" rating for single-photon emission computed tomography (SPECT) and stress echocardiography.

  • For scenarios such as a newly diagnosed right bundle branch block, supraventricular tachycardia, and palpitations without other symptoms or signs of heart disease, transthoracic echo was given a "may be appropriate" rating; all other modalities were given a "rarely appropriate" rating.

  • For mechanical complications of myocardial infarction, both transthoracic and transesophageal echo were given an "appropriate" rating; cardiac MRI, cardiac CT, and coronary angiography with ventriculography received a "may be appropriate" rating.

  • F-18 fluorodeoxyglucose–positron emission tomography and technetium 99m pyrophosphate injection garnered a "may be appropriate" rating for the evaluation of cardiac sarcoid and amyloid, respectively.

If more than one modality falls into the same appropriate use category, physician judgment and available local expertise should be used to determine choice of test, the authors say.

"This document is going to be useful for clinicians, but with over 100 case scenarios, it's not the kind of document that somebody is going to sit down and read cover to cover and commit it to memory. It's going to be used more as a reference," John U. Doherty, MD, chair of the writing group, told theheart.org | Medscape Cardiology.

"For example, if you have a patient who has a thoracic aortic aneurysm and you want to know what the proper imaging study is, and if one has been done already, what the appropriate interval follow-up is," he explained.

The plan, said Doherty, is to integrate the AUC for multimodality imaging in nonvalvular heart disease into electronic medical records for point-of-care use. In this way, it will tell the ordering physician whether or not the imaging study they order is going to be approved.

If not approved, it will deliver educational content to let the ordering physician know why it was not approved. There will also likely be a mobile application for the document.

In addition to the ACC and the AHA, authors on the report are from the American Association for Thoracic Surgery, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons.

A companion appropriate use document that focuses on evaluation and use of multmodality imaging in the diagnosis and management of valvular heart disease was released in 2017. Both documents signal a shift from evaluating a single imaging modality in various disease states to evaluating multiple imaging modalities within a given disease category.

The transition in the appropriate use documents from single to multiple imaging modalities "replicates more of the way clinicians think," Doherty said. "When you see a patient, you don't ask yourself, can I do an echo? You ask, what is the best way to make this diagnosis? These documents put all the imaging tools at the disposal of the ordering physician."

The AUC process is now integrated with the Centers for Medicare & Medicaid Services, he added. "Going forward, the approval or lack of approval of these imaging studies will depend upon appropriate use criteria, and typically the other insurers usually follow suit," he said.

The work received no commercial funding. Disclosures of the authors' relevant financial relationships are included in the original article.

J Am Coll Cardiol. Published online January 7, 2019. Full text

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