First Appropriate-Use Criteria for Imaging in Congenital HD

Megan Brooks

January 09, 2020

For the first time, appropriate-use criteria (AUC) have been issued to provide guidance on which cardiac imaging modalities to use — and which to avoid — in the follow-up care of children and adults with established congenital heart disease (CHD).

This document identifies "reasonable" imaging modality options available for evaluation and surveillance of such patients and serves as an "educational and quality improvement tool" to reduce the number of rarely appropriate tests, the writing group says.

"AUC should not replace clinician judgment and practice experience, but should function as a tool to improve patient care and health outcomes in a cost-effective manner," Ty  . Gluckman, MD, chair of the American College of Cardiology (ACC) Solution Set Oversight Committee, writes in a preface to the document.

The 47-page document was published online January 6 in the Journal of the American College of Cardiology.

This was a joint effort by the ACC Solution Set Oversight Committee and the AUC Task Force, American Heart Association (AHA), American Society of Echocardiography (ASE), Heart Rhythm Society (HRS), International Society for Adult Congenital Heart Disease (ISACHD), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), Society for Cardiovascular Magnetic Resonance (SCMR), and Society of Pediatric Echocardiography (SOPE).

Significant advances in the diagnosis and treatment of patients with CHD have led to improved survival and outcomes, the authors write. However, many patients require lifelong follow-up to monitor sequelae after cardiac surgery or catheter-based intervention or to address the development of complications, such as valvular and ventricular dysfunction, the writing group notes.

Noninvasive cardiac imaging plays an important role in diagnosis and follow-up of these patients. Transthoracic echocardiography (TTE) remains the "cornerstone" of cardiac imaging in patients with CHD, but other imaging modalities, such as transesophageal echocardiography (TEE), cardiovascular magnetic resonance (CMR), cardiovascular computed tomography (CCT), and stress imaging, also play an important role, they point out.

"Although these tests can all be used for patients with CHD, there is a paucity of lesion-specific guidance for clinicians to utilize as decision support tools," they say.

To develop AUC for cardiac imaging in the CHD population, the writing group used guidelines, clinical trial data, and expert opinion to develop 324 patient scenarios (or "clinical indications") with up to seven imaging modalities offered per indication, resulting in a total of 1035 unique scenarios.

The indications are separated into 19 tables, according to type of cardiac lesion, and relate primarily to evaluation before and after cardiac surgery or catheter-based intervention. They address routine surveillance as well as evaluation of new-onset signs or symptoms.

A separate, independent panel rated each of the scenarios and scored each on a scale of 1 to 9, with 1 to 3 being "rarely appropriate," 4 to 6 being "may be appropriate," and 7 to 9 being "appropriate." For all scenarios, 44% were rated as appropriate, 39% as may be appropriate, and 17% as rarely appropriate.

"These ratings are based on currently available technology, resources, and evidence-based medicine, which may change over time and dictate future revisions of this document," the writing group says.

"Implementation studies using this document may help improve appropriate use and reduce practice variation for noninvasive cardiac imaging modalities utilized during the follow-up care of patients with CHD," they add.

J Am Coll Cardiol. Published online January 6, 2020. Full text

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