Appropriate Use Criteria for Cardiac Computed Tomography

Questions Answered

Jill M Steiner; Allen J Taylor

Expert Rev Cardiovasc Ther. 2013;11(4):411-416.

Expert Commentary & Five-year View

Further study into the effectiveness of AUC is ongoing. The effects of AUC use on cost, resource utilization, patient management and the occurrence of cardiovascular events remain to be fully defined. Quality initiatives continue to be developed, such as those comparing outcomes in AUC-guided versus control groups. As AUC become increasingly incorporated into decision-making trees and electronic health-record software, their effects need to be examined. In addition, comparative evaluations of the appropriate use of multiple imaging modalities to assess each modality's relative strengths should be developed. AUC must remain current to provide a useful tool in patient selection. Thus, these documents require periodic review and revision as technology and clinical experience evolves. Doing so will ensure that CCT is, to the fullest extent possible, the right test, in the right patient, at the right time!

1 2 3 4 5 6 7

Next Section

Abstract and Introduction
What are AUC?
How are They Developed?
How are the 2010 Criteria Different From 2006?
What are the Key Points of the 2010 CCT AUC?
How May AUC Improve Performance?
Expert Commentary & Five-year View
References
Sidebar

Table 1. Summary of the 2010 appropriate use criteria for cardiac computed tomography, broken down by indication.
Summary of 2010 AUC: indications for CCT
For the purpose of:	Appropriateness rating
Preoperative risk assessment evaluation for noncardiac surgery	Low risk surgery: –Inappropriate Intermediate risk and vascular surgery: –Inappropriate if functional capacity is less than or equal to four METs or without clinical risk predictors, or if the patient is asymptomatic for less than 1 year following a normal coronary study or revascularization –Uncertain if functional capacity is less than four METs with one or more clinical risk predictor
Detection of CAD in symptomatic patients without known heart disease but with symptomatic acute presentation suggestive of acute coronary syndrome	Definite MI: –Inappropriate Persistent ECG ST-segment elevation following MI exclusion or 'triple rule out': –Uncertain Normal ECG and biomarkers, uninterpretable or nondiagnostic ECG, or equivocal biomarkers: –Appropriate if low or intermediate pretest probability of CAD –Uncertain if high pretest probability of CAD
Risk assessment postrevascularization	Symptomatic patient or ischemic equivalent: –Appropriate for evaluation of graft patency after CABG –Inappropriate if prior coronary stent diameter is less than 3 mm or unknown –Uncertain if prior coronary stent diameter is greater than or equal to 3 mm Asymptomatic patient: –Appropriate if prior left main coronary stent with diameter greater than or equal to 3 mm –Inappropriate if time from CABG is less than 5 years, if time from prior PCI is less than 2 years or if time from prior PCI is greater than or equal to 2 years but stent diameter is less than 3 mm –Uncertain if time from CABG is greater than or equal to 5 years or if time from prior PCI is greater than or equal to 2 years but stent diameter is greater than or equal to 3 mm
Use in the setting of prior test results	Sequential testing after recent stress imaging: –Appropriate if equivocal or if ECG is discordant –Inappropriate if recent imaging revealed moderate or severe ischemia –Uncertain if recent imaging revealed mild ischemia –Inappropriate for periodic repeat imaging in asymptomatic individuals or in those with stable symptoms In the setting of new or worsening symptoms: –Appropriate if prior study was normal –Uncertain if past study was abnormal ECG exercise testing: –Appropriate if results showed intermediate risk findings or with continued symptoms despite normal exercise testing –Inappropriate if results showed low or high risk findings Diagnostic impact of prior coronary calcium score: –Appropriate if score less than or equal to 400 –Uncertain if score is 401–1000
Detection of CAD in symptomatic patients without known heart disease but with symptomatic nonacute presentation	If ECG is interpretable and patient is able to exercise: –Appropriate for intermediate pretest probability of CAD –Inappropriate for high pretest probability of CAD –Uncertain for low pretest probability of CAD If ECG is not interpretable or patient is not able to exercise: –Appropriate for those with low and intermediate pretest probability of CAD –Uncertain for high pretest probability of CAD
Evaluation of asymptomatic patients	Noncontrast CT for coronary calcium: –Appropriate if this is the first CT scan in a person with an intermediate global CHD risk estimate or with a low global CHD risk estimate but with family history –Inappropriate if this is a repeat scan with a positive calcium score older than or equal to 2 years ago or if this is the first CT scan in a person with a low global CHD risk estimate –Uncertain if this is a repeat scan with a zero calcium score older than 5 years ago or if this is the first CT scan in a person with a high global CHD risk estimate Coronary CTA: –Inappropriate for evaluation in a person with low or intermediate global CHD risk without a heart transplant –Uncertain for evaluation in a person with high global CHD risk without a heart transplant or as a routine evaluation of coronary arteries following a heart transplant
Detection of CAD in other clinical scenarios	New-onset or newly diagnosed clinical heart failure without prior CAD: –Appropriate if pretest probability of CAD is low or intermediate in a person with reduced left ventricular ejection fraction –Uncertain if pretest probability of CAD is high in a person with reduced left ventricular ejection fraction or with a normal ejection fraction Preoperative coronary assessment prior to noncoronary cardiac surgery: –Appropriate if intermediate pretest probability of CAD –Inappropriate if high pretest probability of CAD –Uncertain if low pretest probability of CAD Arrhythmia of unclear etiology after initial evaluation: –Inappropriate for new-onset atrial fibrillation –Uncertain for syncope or nonsustained ventricular tachycardia Elevated troponin of uncertain clinical significance: uncertain
Evaluation of cardiac structure and function	Congenital heart disease: –Appropriate Evaluation of ventricular morphology and systolic function: –Appropriate to evaluate left ventricular ejection fraction following MI or in heart failure patients with inadequate other noninvasive imaging, to quantitatively assess right ventricular function or for assessment of right ventricular morphology in suspected arrhythmogenic right ventricular dysplasia –Inappropriate for initial evaluation of left ventricular function following acute MI or in heart failure patients –Uncertain for assessment of myocardial viability prior to revascularization for ischemic left ventricular systolic dysfunction when other imaging modalities are inadequate or contraindicated Evaluation of intra- and extra-cardiac structures: –Appropriate for evaluation of pericardial anatomy, pulmonary vein anatomy prior to radiofrequency ablation for atrial fibrillation, for evaluation of cardiac mass if other imaging is inadequate, to characterize valves when significant dysfunction is suspected and other imaging is inadequate, for noninvasive coronary vein mapping prior to biventricular pacemaker placement and for localization of retrosternal anatomy prior to reoperative chest or cardiac surgery –Inappropriate for initial evaluation of cardiac mass

AUC: Appropriate use criteria; CABG: Coronary artery bypass grafting; CAD: Coronary artery disease; CCT: Cardiac CT; CHD: Coronary heart disease; CT: Computed tomography; CTA: CT angiography; MET: Metabolic equivalent; MI: Myocardial infarction; PCI: Percutaneous coronary intervention.

Table 2. The relative distribution of appropriateness ratings for the most common indications for cardiac computed tomography.
Indication	Ratings
Evaluation of chest pain	✓✓✓✓✓✓✓✓✓✓???????øø
Asymptomatic patients	✓✓???øøø
Congestive heart failure	✓✓????
Prior stress test results	✓✓✓✓✓✓????øøøøøøøø
Preoperative testing	??øøøøøøø
Prior revascularization	✓???øøøøø
Structure and function	✓✓✓✓✓✓✓✓✓✓✓✓?øø