ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease

The American College of Cardiology Foundation along withkey specialty and subspecialty societies, conducted an appropriateuse review of common clinical presentations for stableischemic heart disease (SIHD) to consider use of stress testingand anatomic diagnostic procedures. This document reflectsan updating of the prior Appropriate Use Criteria (AUC)published for radionuclide imaging (RNI), stress echocardiography(Echo), calcium scoring, coronary computedtomography angiography (CCTA), stress cardiac magneticresonance (CMR), and invasive coronary angiography forSIHD. This is in keeping with the commitment to revise andrefine theAUCon a frequent basis.Amajor innovation in thisdocument is the rating of tests side by side for the same indication.The side-by-side rating removes any concerns aboutdifferences in indication or interpretation stemming from prioruse of separate documents for each test. However, the ratingswere explicitly not competitive rankings due to the limitedavailability of comparative evidence, patient variability, andrange of capabilities available in any given local setting.The indications for this review are limited to thedetection and risk assessment of SIHD and were drawnfrom common applications or anticipated uses, as well asfrom current clinical practice guidelines. Eighty clinicalscenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1 to 9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes.Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to lowrisk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.