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doi:10.1016/j.jacc.2010.07.005 published online Oct 25, 2010; J. Am. Coll. Cardiol.
and Geoffrey D. Rubin Manuel Cerqueira, John McB. Hodgson, Daniel Mark, James Min, Patrick O'Gara,
Interventions, Society for Cardiovascular Magnetic Resonance, Allen J. Taylor, Society of Nuclear Cardiology, Society for Cardiovascular Angiography and
American Heart Association, American Society of Echocardiography, American Radiology,Society of Cardiovascular Computed Tomography, American College of
American College of Cardiology Foundation Appropriate Use Criteria Task Force, Criteria for Cardiac Computed Tomography
ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 Appropriate Use
This information is current as of October 27, 2010
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.07.005v1located on the World Wide Web at:
The online version of this article, along with updated information and services, is
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Journal of the American College of Cardiology Vol. 56, No. xx, 2010© 2010 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00P
APPROPRIATE USE CRITERIA
ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR2010 Appropriate Use Criteriafor Cardiac Computed TomographyA Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force,the Society of Cardiovascular Computed Tomography, the American College of Radiology, the AmericanHeart Association, the American Society of Echocardiography, the American Society of NuclearCardiology, the Society for Cardiovascular Angiography and Interventions, and the Society forCardiovascular Magnetic Resonance
ublished by Elsevier Inc. doi:10.1016/j.jacc.2010.07.005
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CardiacComputedTomographyWriting Group
ardiovascular Computed Tomerican Heart Association
llen J. Taylor, MD, FACC, FAHA, Chair*
anuel Cerqueira, MD, FACC, FASNC†ohn McB. Hodgson, MD, FACC, FSCAI‡aniel Mark, MD, MPH, FACC, FAHA*
ames Min, MD, FACC§atrick O’Gara, MD, FACC, FAHA�
mography, the American College of Radiology, the, the American Society of Echocardiography, the
of Cardiologhealthpermissi
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Official American College of Cardiology Foundation Representative;Official American Society of Nuclear Cardiology Representative;Official Society for Cardiovascular Angiography and Interventionsepresentative; §Official Society of Cardiovascular Computed Tomog-
aphy Representative; �Official American Heart Association Represen-ative; ¶Official American College of Radiology Representative;Official North American Society for Cardiovascular Imagingepresentative
Geoffrey D. Rubin, MD, FSCBTMR¶#
TechnicalPanel
Christopher M. Kramer, MD, FACC,FAHA, Moderator
Allen J. Taylor, MD, FACC, FAHA,Writing Group Liaison
Daniel Berman, MD, FACC§Alan Brown, MD, FACC, FAHA, FNLA*Farooq A. Chaudhry, MD, FACC, FAHA,
FASE**Ricardo C. Cury, MD§††Milind Y. Desai, MD, FACC††Andrew J. Einstein, MD, PHD, FACC,
FAHA, FASNC†Antoinette S. Gomes, MD, FAHA, FSIR¶Robert Harrington, MD, FACC, FAHA,
FSCAI*
Udo Hoffmann, MD, MPH#Rahul Khare, MD‡‡John Lesser, MD, FACC§Christopher McGann, MD, FACC§§Alan Rosenberg, MD, FACC� �Robert Schwartz, MD, FACC‡Marc Shelton, MD, FACC*Gerald W. Smetana, MD¶¶Sidney C. Smith, JR, MD, FACC, FAHA�
**Official American Society of Echocardiography Representative;††Official Society for Cardiovascular Magnetic Resonance Representa-tive; ‡‡Official American College of Emergency Physicians Represen-tative; §§Official Heart Rhythm Society Representative; � �OfficialHealth Plan Representative; ¶¶Official American College of Physi-cians Representative
his document was approved by the American College of Cardiology Foundation, inune 2010, the American College of Radiology, the American Society of Echocardi-graphy, the American Society of Nuclear Cardiology, the Society for Cardiovascularngiography and Interventions, the Society for Cardiovascular Magnetic Resonance,
nd Society of Cardiovascular Computed Tomography, and by the American Heartssociation in September 2010.The American College of Cardiology Foundation requests that this document be
ited as follows: Taylor AJ, Cequeira M, Hodgson JM, Mark D, Min J, O’Gara P,ubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropri-
te use criteria for cardiac computed tomography: a report of the American Collegef Cardiology Foundation Appropriate Use Criteria Task Force, the Society of
American Society of Nuclear Cardiology, the Society for Cardiovascular Angiographyand Interventions, and the Society for Cardiovascular Magnetic Resonance. J AmColl Cardiol 2010;56:xxx–xx.
This article is copublished in Circulation and the Journal of Cardiovascular ComputedTomography.
Copies: This document is available on the World Wide Web site of the AmericanCollege of Cardiology (www.cardiosource.org). For copies of this document, pleasecontact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com.
Permissions: Modification, alteration, enhancement, and/or distribution of thisdocument are not permitted without the express permission of the American College
y Foundation. Please contact Elsevier’s permission departmentons@elsevier.com
October 27, 2010
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ACCFAppropriateUse CriteriaTask Force
Michael J. Wolk, MD, MACC, Chair
Joseph M. Allen, MASteven Bailey, MD, FACC, FSCAIPamela S. Douglas, MD, MACC, FAHA,
Robert C. Hendel, MD, FACC, FAHA, FASNCChristopher M. Kramer, MD, FACC, FAHAJames Min, MD, FACC, FSCCTManesh R. Patel, MD, FACCLeslee Shaw, PHD, FACC, FASNC
FASE Raymond F. Stainback, MD, FACC, FASE
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TABLE OF CONTENTS
bstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
reface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. General Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Results of Ratings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Cardiac Computed Tomography AppropriateUse Criteria (By Indication) . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 1. Detection of CAD in SymptomaticPatients Without Known Heart Disease . . . . . . . . . .XXXX
Table 2. Detection of CAD/Risk Assessmentin Asymptomatic Individuals WithoutKnown CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 3. Detection of CAD in Other ClinicalScenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 4. Use of CT Angiography in the Settingof Prior Test Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 5. Risk Assessment Preoperative Evaluationof Noncardiac Surgery Without ActiveCardiac Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 6. Risk Assessment Postrevascularization(PCI or CABG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 7. Evaluation of Cardiac Structure andFunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
. Cardiac Computed Tomography AppropriateUse Criteria (By Appropriate Use Criteria) . . . . . . .XXXX
Table 8. Appropriate Indications(Median Score 7–9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 9. Uncertain Indications(Median Score 4–6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
Table 10. Inappropriate Indications
(Median Score 1–3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX pcontent.onlinejacDownloaded from
. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
9.1. Clinical Scenarios and Their Ratings . . . . . . . . . . .XXXX
9.2. Application of Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
ppendix A: Additional Cardiac Computedomography Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
ppendix B: Additional Methods . . . . . . . . . . . . . . . . . . . . . . .XXXX
Relationships With Industry and Other Entities . . . .XXXX
Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
ppendix C: ACCF/SCCT/ACR/AHA/ASE/ASNC/CAI/SCMR 2010 Appropriate Use Criteriaor Cardiac Computed Tomography Participants . . . .XXXX
ppendix D: ACCF/SCCT/ACR/AHA/ASE/ASNC/CAI/SCMR 2010 Cardiac Computed Tomographyppropriate Use Criteria Writing Group,echnical Panel, Task Force, and Indicationeviewers—Relationships With Industry andther Entities (In Alphabetical Order) . . . . . . . . . . . . . . . .XXXX
eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX
bstract
he American College of Cardiology Foundation (ACCF),long with key specialty and subspecialty societies, con-ucted an appropriate use review of common clinical sce-arios where cardiac computed tomography (CCT) is fre-uently considered. The present document is an update tohe original CCT/cardiac magnetic resonance (CMR) ap-ropriateness criteria published in 2006, written to reflecthanges in test utilization, to incorporate new clinical data,nd to clarify CCT use where omissions or lack of clarityxisted in the original criteria (1).
The indications for this review were drawn from commonpplications or anticipated uses, as well as from currentlinical practice guidelines. Ninety-three clinical scenariosere developed by a writing group and scored by a separate
echnical panel on a scale of 1 to 9 to designate appropriatese, inappropriate use, or uncertain use.In general, use of CCT angiography for diagnosis and
isk assessment in patients with low or intermediate risk or
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iewed favorably, whereas testing in high-risk patients,outine repeat testing, and general screening in certain clinicalcenarios were viewed less favorably. Use of noncontrastomputed tomography (CT) for calcium scoring was rated asppropriate within intermediate- and selected low-risk pa-ients. Appropriate applications of CCT are also within theategory of cardiac structural and functional evaluation. It isnticipated that these results will have an impact on physicianecision making, performance, and reimbursement policy, andhat they will help guide future research.
reface
n an effort to respond to the need for the rational use ofmaging services in the delivery of high-quality care, theCCF has undertaken a process to determine the appro-riate use of cardiovascular imaging for selected patientndications.
Appropriate use criteria publications reflect an ongoingffort by the ACCF to critically and systematically create,eview, and categorize clinical situations where diagnosticests and procedures are utilized by physicians caring foratients with cardiovascular diseases. The process is basedn current understanding of the technical capabilities of themaging modalities examined. Although not intended to bentirely comprehensive, the indications are meant to iden-ify common scenarios encompassing the majority of con-emporary practice. Given the breadth of information theyonvey, the indications do not directly correspond to theinth revision of the International Classification of DiseasesICD-9) system as these codes do not include clinicalnformation, such as symptom status.
The ACCF believes that careful blending of a broadange of clinical experiences and available evidence-basednformation will help guide a more efficient and equitablellocation of healthcare resources in cardiovascular imaging.he ultimate objective of appropriate use criteria is to
mprove patient care and health outcomes in a cost-effectiveanner but is not intended to ignore ambiguity and nuance
ntrinsic to clinical decision making. Local parameters, suchs the availability or quality of equipment or personnel, maynfluence the selection of appropriate imaging procedures.ppropriate use criteria thus should not be considered substi-
utes for sound clinical judgment and practice experience.The ACCF appropriate use criteria process itself is also
volving. In the current iteration, technical panel membersere asked to rate indications for CCT in a manner
ndependent and irrespective of the prior published ACCFatings for CCT and CMR (1) as well as the prior ACCFatings for similar diagnostic stress imaging modalities suchs cardiac radionuclide imaging (2) or stress echocardiogra-hy (3) (see Appendix A for the definitions of terms usedhroughout the indication set). Given the iterative nature ofhe process, readers are counseled not to compare too closely
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ifferent times over the past 2 years. A comparative evalu-tion of the appropriate use of multiple imaging techniquess currently being undertaken to assess the relative strengthsf each modality for various clinical scenarios.We are grateful to the technical panel, a professional
roup with a wide range of skills and insights, for theirhoughtful and thorough deliberation of the merits of CCTor various indications. In addition to our thanks to theechnical panel for their dedicated work and review, weould like to offer special thanks to the many individualsho provided a careful review of the draft indications; toeggy Christiansen, the ACCF librarian for her compre-ensive literature searches; to Lindsey Law, Starr Webb,nd Joseph M. Allen, who continually drove the processorward; and to Allen J. Taylor, MD, the chair of the writingommittee for his dedication, insight, and leadership.
Christopher M. Kramer, MD, FACC, FAHAModerator, Cardiac Computed Tomography Technical Panel
Michael J. Wolk, MD, MACCChair, Appropriate Use Criteria Task Force
. Introduction
his report addresses the appropriate use of CCT. Improve-ents in cardiovascular imaging technology and their ap-
lication, coupled with increasing therapeutic options forardiovascular disease, have led to an increase in cardiovas-ular imaging. At the same time, the armamentarium ofoninvasive diagnostic tools has expanded with innovations
n new contrast agents, molecular radionuclide imaging,erfusion echocardiography, computed tomography for cor-nary angiography and calcium scoring, and magnetic res-nance imaging for myocardial structure and viability. Ashe field of CCT continues to advance along with othermaging modalities, the healthcare community needs tonderstand how to best incorporate this technology intoaily clinical care.All prior appropriate use criteria publications from the
CCF and collaborating organizations have reflected anngoing effort to critically and systematically create, review,nd categorize the appropriate use of certain cardiovasculariagnostic tests. The ACCF recognizes the importance ofevising these criteria in a timely manner in order to providehe cardiovascular community with the most accurate indi-ations. The present document is the second update to anxisting appropriate use criteria document, the “ACCF/CR/SCCT/SCMR/ASNC/SCAI/SIR Appropriatenessriteria for Cardiac Computed Tomography and Cardiacagnetic Resonance Imaging,” published in 2006 (1).linicians, payers, and patients are interested in the specificenefits of CCT. Of importance, inappropriate use of CCTay be potentially harmful to patients and generate unwar-
anted costs to the health care system, whereas appropriate
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his is a critical shift because the intent is for the potentialenefits and risks of the treatment to be explicitly consid-red, rather than the potential usefulness of a diagnostic tests a prelude to further treatment. This document presentshe results of this effort, but it is critical to understand theackground and scope of this document before interpretinghe rating tables.
. Methods
he indications included in this review are purposefullyroad, and they comprise a wide array of cardiovascularigns and symptoms as well as clinical judgment as to theikelihood of cardiovascular findings.
Further description of the methods used for ranking ofhe selected clinical indications is outlined in Appendix Bnd is also found more generally in a previous publication,ACCF Proposed Method for Evaluating the Appropriate-ess of Cardiovascular Imaging” (4). Briefly, this processombines evidence-based medicine and practice experiencey engaging a technical panel in a modified Delphi exercise.ecause the original CCT/CMR criteria document andethods paper was published, several important processes
ave been put in place to further enhance this process. Theynclude convening a formal writing committee with diversexpertise in imaging, circulating the indications for externaleview prior to rating by the technical panel, ensuringppropriate balance of the technical panel, a standardizedating package, and creating formal roles for facilitatinganel interaction at the face-to-face meeting.The panel first rated indications independently. In rating
hese criteria, the Cardiac Computed Tomography Appro-riate Use Criteria Technical Panel was asked to assesshether the use of the test for each indication is appropri-
te, uncertain, or inappropriate as defined in the followingext.
An appropriate imaging study is one in which the expectedncremental information, combined with clinical judgment,xceeds the expected negative consequences* by a sufficientlyide margin for a specific indication that the procedure is
enerally considered acceptable care and a reasonable ap-roach for the indication.The technical panel scores each indication as follows:
Score 7 to 9Appropriate test for specific indication (test is generally
acceptable and is a reasonable approach for theindication).
Score 4 to 6Uncertain for specific indication (test may be generally
acceptable and may be a reasonable approach for theindication). (Uncertainty also implies that more re-
Negative consequences include the risks of the procedure (radiation or contrast
exposure) and the downstream impact of poor test performance such as delay iniagnosis (false negatives) or inappropriate diagnosis (false positives).
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search and/or patient information is needed to classifythe indication definitively.)
Score 1 to 3Inappropriate test for specific indication (test is not
generally acceptable and is not a reasonable approachfor the indication).
Then the panel was convened for a face-to-face meetingor discussion of each indication. At this meeting, panelembers were provided with their scores and a blinded
ummary of their peers’ scores. After the consensus meeting,anel members were then asked to independently provideheir final scores for each indication. Following the secondound ratings, a supplemental rating process was conductedor a revised set of criteria for preoperative testing (31 to 38)nd the clinical scenario of prior revascularization (40 to 41).lthough these categories had been considered within theriginal 2 rounds of rating, the clinical scenarios wereewritten to more closely mirror prior documents, and thealloting was repeated.The contributors acknowledge that the division of these
cores into 3 categories of appropriate use is somewhatrbitrary and that the numeric designations should beiewed as a continuum. The contributors also recognizeiversity in clinical opinion for particular clinical scenarios.cores in the intermediate level of appropriate use shouldherefore be labeled uncertain, as critical patient or researchata may be lacking or discordant. This designation shoulde a prompt to the field to carry out definitive research,henever possible. It is anticipated that the appropriate use
riteria reports will require updates as further data areenerated and information from the implementation of theriteria is accumulated.
To avoid bias in the scoring process, the technical paneleliberately was not comprised solely of specialists in thearticular procedure under evaluation. Specialists, whileffering important clinical and technical insights, mightave a natural tendency to rate the indications within theirpecialty as more appropriate than nonspecialists. In addi-ion, care was taken in providing objective, nonbiasednformation, including guidelines and key references, to theechnical panel. Panel members were not provided explicitost information to help determine their appropriate useatings, but they were asked to implicitly consider cost as andditional factor in their evaluation of appropriate use.
The level of agreement among panel members, as definedy RAND (5), was analyzed for each indication based onhe BIOMED rule for a panel of 14 to 16 (a simplifiedAND method for determining disagreement). Per theIOMED definition, agreement was defined as an indica-
ion where 4 or fewer panel members ratings fell outside the-point region containing the median score. Disagreementas defined as a situation where at least 5 panel members
atings fell in both the appropriate and the inappropriateategories. Because the panel had 17 representatives, which
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greement analysis as described by RAND was performedhat examines the interpercentile range (IPR) comparedith the interpercentile range adjusted for symmetry
IPRAS). This information was used by the moderator touide the panel’s discussion by highlighting areas of differ-nces among the panel members. There was also a thirdategory for indications that were not classified in either thegreement or disagreement categories. Any indication hav-ng disagreement was categorized as uncertain regardless ofhe final median score. Indications that met neither defini-ion for agreement or disagreement are in a third, unlabeled,ategory.
. General Assumptions
ll indications were considered with the following impor-ant assumptions for CCT:
. CCT is performed in accordance with best practicestandards as delineated in the imaging guidelines of theSociety of Cardiovascular Computed Tomography (6,7),by competent (8) and appropriately credentialed physi-cians. This includes the optimization of the scan protocolto limit radiation exposure.
. CCT imaging equipment is available that has the min-imal technical capabilities required for the indication.Typical technical parameters for studies performed onmulti-detector row scanners include CT equipment en-abling 64 or more slices, submillimeter spatial resolution,and gantry rotation time no greater than 420 millisec-onds. Appropriate computer software must be availablefor image analysis.
. Patients are optimally suited for CCT under the follow-ing conditions:a. Regular heart rate and rhythm including a heart rate
at a level commensurate with the temporal resolutionof the available scanner.
b. Body mass index below 40 kg/m2.c. Normal renal function.
. For CT angiography, patient requirements may includethe ability to:a. Hold still and follow breathing instructions.b. Tolerate beta blockers.c. Tolerate sublingual nitroglycerin.d. Lift both arms above the shoulders.
. All indications for CCT were considered with thefollowing important assumptions:a. All indications should first be evaluated based on the
available medical literature.b. In many cases, studies published in the medical
literature are reflections of the capabilities and limi-tations of the test but provide minimal informationabout the role of the test in clinical decision making.
c. Appropriate use criteria development requires deter-
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decision making based on a risk/benefit trade-off asdetermined by individual patient indications.
. For all stress imaging referenced in the indications, themode of stress testing was assumed to be exercise forpatients able to exercise. For patients unable to exercise,pharmacological stress testing was assumed to be used.Further background on the rationale for the assumptionof exercise testing is available in the ACC/AHA 2002Guideline Update for Exercise Testing (9).
. Definitions
complete set of definitions of terms used throughout thendication set is listed in Appendix A. These definitionsere provided and discussed with the technical panel prior
o ratings of indications.schemic Equivalent Chest Pain Syndrome, Anginalquivalent, or Ischemic Electrocardiographic Abnor-alities: Any constellation of clinical findings that is
linically judged to be consistent with obstructive CAD.xamples of such findings include, but are not limited to,
hest pain, chest tightness, burning, shoulder pain, jaw pain,nd new electrocardiographic abnormalities suggestive ofschemic heart disease. Nonchest pain symptoms, such asyspnea or worsening effort tolerance that are felt to beonsistent with CAD may also be considered to be annginal equivalent.
etermining Pretest Risk Assessment forisk Stratification
oronary Heart Disease (CHD) Risk in Asymptomaticatients: Estimation of CHD risk applied to asymptom-tic patients without known CHD. It is assumed thatlinicians will use CCT studies in addition to standardethods of risk assessment as presented in the Nationaleart, Lung, and Blood Institute report (10) on “Detec-
ion, Evaluation, and Treatment of High Blood Choles-erol in Adults (Adult Treatment Panel III [ATP III]).”
Absolute risk is defined as the probability of developingHD, including myocardial infarction or CHD death overgiven time period. The ATP III report specifies absolute
isk for CHD over the next 10 years. CHD risk refers to0-year risk for any hard cardiac event. However, incknowledgment that global absolute risk scores may beiscalibrated to certain populations (e.g., women, youngeren), clinical judgment must be applied in selecting cate-
orical risk thresholds.
• CHD Risk—LowDefined by the age-specific risk level that is belowaverage. In general, low risk will correlate with a10-year absolute CHD risk �10%.
• CHD Risk—IntermediateDefined by the age-specific risk level that is average or
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with a 10-year absolute CHD risk between 10% to20%. Among women and younger men, an expandedintermediate risk range of 6% to 20% may be appro-priate.
• CHD Risk—HighDefined as the presence of diabetes mellitus in apatient �40 years of age, peripheral arterial disease orother coronary risk equivalents, or the 10-year absoluteCHD risk of �20%.
retest Probability of Obstructive/Significant CAD forymptomatic (Ischemic Equivalent) Patients: Once thehysician determines the presence of symptoms that mayepresent obstructive CAD (ischemic equivalent present),he pretest probability of CAD should be assessed. Therere a number of risk algorithms (11,12) available that can besed to calculate this probability. Clinicians should becomeamiliar with those that pertain to the populations theyncounter most often. In scoring the indications, the fol-owing probabilities as calculated from any of the variousvailable algorithms should be applied:
• Low pretest probability: �10% pretest probability ofCAD.
• Intermediate pretest probability: Between 10% and90% pretest probability of CAD.
• High pretest probability: �90% pretest probability ofCAD.
The method recommended by the ACC/AHA Guide-ines for Chronic Stable Angina (13) is provided in theollowing text as 1 example of a method used to calculateretest probability and is a modification of a previouslyublished literature review (14). Please refer to definitions ofngina and Table A. Please note that the table only predictsretest probability in patients based upon presenting symp-oms, age, and sex. Additional history and electrocardio-raphic evidence of prior infarction dramatically affectretest probability. Although they are not incorporated intohe algorithm, cardiovascular risk factors, discussed in riskssessment indications, may also affect pretest likelihood ofAD. Detailed normograms are available that incorporate
able A. Pretest Probability of CAD by Age, Sex, and Symptom
Age SexTypical/DefiniteAngina Pectoris
�39 Men Intermediate
Women Intermediate
40–49 Men High
Women Intermediate
50–59 Men High
Women Intermediate
�60 Men High
Women High
igh: �90% pretest probability; intermediate: between 10% and 90% pretest probability; low: bModified from Gibbons et al. (9) to reflect all age ranges.
he effects of a history of prior infarction, electrocardio- r
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raphic Q waves, electrocardiographic ST- and T-wavehanges, diabetes, smoking, and hypercholesterolemia (9).
. Abbreviations
CS � acute coronary syndromeABG � coronary artery bypass grafting surgeryAD � coronary artery diseaseCS � coronary calcium scoreHD � coronary heart diseaseT � computed tomographyTA � computed tomographic angiographyCG � electrocardiogramF � heart failureET � estimated metabolic equivalent of exerciseI � myocardial infarction
CI � percutaneous coronary intervention
. Results of Ratings
he final ratings for CCT (Tables 1 to 7) are listed byndication sequentially as obtained from second roundating sheets submitted by each panel member. The finalcore reflects the median score of the 17 panel members andas been labeled according to the 3 appropriate use catego-ies of appropriate, uncertain, and inappropriate. Tables 8 to0 present the indications by these categories. Algorithmigures 1 to 10 describe the application of criteria asresented in these tables.A majority of ratings were in agreement as defined in the
receding text, including 66% of appropriate and 55% ofnappropriate indications. In contrast, only 7% of indica-ions rated as uncertain showed agreement, indicatingreater diversity of opinion on these indications. Only 2 ofhe 93 indications (Indications 1 [low] and 15 [low], both ofhich were rated as uncertain), were statistically classified aseing in disagreement. Because these indications werelready placed in the uncertain category, no changes were
ypical/Probablengina Pectoris
NonanginalChest Pain Asymptomatic
Intermediate Low Very low
Very low Very low Very low
Intermediate Intermediate Low
Low Very low Very low
Intermediate Intermediate Low
Intermediate Low Very low
Intermediate Intermediate Low
Intermediate Intermediate Low
5% and 10% pretest probability; and very low: �5% pretest probability.
s
AtA
equired to reflect disagreement.
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. Cardiac Computed Tomography Appropriate Use Criteria (By Indication)
able 1. Detection of CAD in Symptomatic Patients Without Known Heart Disease*
Indication Appropriate Use Score (1–9)
Nonacute Symptoms Possibly Representing an Ischemic Equivalent
Pretest Probability of CAD Low Intermediate High
1. ● ECG interpretable AND● Able to exercise
U (5) A (7) I (3)
2. ● ECG uninterpretable OR● Unable to exercise
A (7) A (8) U (4)
Acute Symptoms With Suspicion of ACS (Urgent Presentation)
3. ● Definite MI I (1)
4. ● Persistent ECG ST-segment elevation following exclusion of MI U (6)
5. ● Acute chest pain of uncertain cause (differential diagnosis includes pulmonaryembolism, aortic dissection, and ACS [“triple rule out”])
U (6)
Pretest Probability of CAD Low Intermediate High
6. ● Normal ECG and cardiac biomarkers A (7) A (7) U (4)
7. ● ECG uninterpretable A (7) A (7) U (4)
8. ● Nondiagnostic ECG OR● Equivocal cardiac biomarkers
A (7) A (7) U (4)
Note: All indications are for CTA unless otherwise noted.A indicates appropriate; I, inappropriate; and U, uncertain.
able 2. Detection of CAD/Risk Assessment in Asymptomatic Patients Without Known CAD
Indication Appropriate Use Score (1–9)
Noncontrast CT for CCS
Global CHD Risk Estimate Low Intermediate High
9. ● Family history of premature CHD A (7)
10. ● Asymptomatic● No known CAD
I (2) A (7) U (4)
Coronary CTA
Global CHD Risk Estimate Low Intermediate High
11. ● Asymptomatic● No known CAD
I (2) I (2) U (4)
Coronary CTA Following Heart Transplantation
12. ● Routine evaluation of coronary arteries U (6)
indicates appropriate; I, inappropriate; and U, uncertain.
able 3. Detection of CAD in Other Clinical Scenarios
Indication Appropriate Use Score (1–9)
New-Onset or Newly Diagnosed Clinical HF and No Prior CAD
Pretest Probability of CAD Low Intermediate High
13. ● Reduced left ventricular ejection fraction A (7) A (7) U (4)
14. ● Normal left ventricular ejection fraction U (5) U (5) U (4)
Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery
Pretest Probability of CAD Low Intermediate High
15. ● Coronary evaluation before noncoronary cardiac surgery U (6) A (7) I (3)
Arrhythmias—Etiology Unclear After Initial Evaluation
16. ● New-onset atrial fibrillation (atrial fibrillation is underlying rhythm during imaging) I (2)
17. ● Nonsustained ventricular tachycardia U (6)
18. ● Syncope U (4)
Elevated Troponin of Uncertain Clinical Significance
19. ● Elevated troponin without additional evidence of ACS or symptoms suggestive of CAD U (6)
indicates appropriate; I, inappropriate; and U, uncertain.
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able 4. Use of CTA in the Setting of Prior Test Results
Indication Appropriate Use Score (1–9)
Prior ECG Exercise Testing20. ● Prior normal ECG exercise test
● Continued symptomsA (7)
Duke Treadmill Score—Risk Findings Low Intermediate High
21. ● Prior ECG exercise testing I (2) A (7) I (3)
Sequential Testing After Stress Imaging Procedures
22. ● Discordant ECG exercise and imaging results A (8)
Test Result/Ischemia Equivocal MildModerateor Severe
23. ● Prior stress imaging procedure A (8) U (6) I (2)
Prior CCS
24. ● Zero CCS �5 y ago U (4)
25. ● Positive CCS �2 y ago I (2)
CCS <100 100–400 401–1000 >1000
26. Diagnostic impact of coronary calcium on the decisionto perform contrast CTA in symptomatic patients
A (8) A (8) U (6) U (4)
Asymptomatic OR Stable SymptomsPeriodic Repeat Testing in the Setting of Prior Stress Imaging or Prior Coronary Angiography
Last Study Done <2 y Ago >2 y Ago
27. ● No known CAD I (2) I (3)
28. ● Known CAD I (2) I (3)
Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study
Previous Stress Imaging Study Normal Abnormal
29. ● Evaluation of new or worsening symptoms A (8) U (6)
indicates appropriate; I, inappropriate; and U, uncertain.
able 5. Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions
IndicationAppropriate Use
Score (1–9)
Low-Risk Surgery
30. ● Preoperative evaluation for noncardiac surgery risk assessment, irrespective of functional capacity I (1)
Intermediate-Risk Surgery
31. ● No clinical risk predictors I (2)
32. ● Functional capacity �4 METs I (2)
33. ● Functional capacity �4 METs with 1 or more clinical risk predictors U (5)
34. ● Asymptomatic �1 y following a normal coronary angiogram, stress test, or a coronary revascularizationprocedure
I (1)
Vascular Surgery
35. ● No clinical risk predictors I (2)
36. ● Functional capacity �4 METs I (2)
37. ● Functional capacity �4 METs with 1 or more clinical risk predictors U (6)
38. ● Asymptomatic �1 y following a normal coronary angiogram, stress test, or a coronary revascularizationprocedure
I (2)
indicates appropriate; I, inappropriate; and U, uncertain.
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able 6. Risk Assessment Postrevascularization (PCI or CABG)
IndicationAppropriate Use Score
(1–9)
Symptomatic (Ischemic Equivalent)
39. ● Evaluation of graft patency after CABG A (8)
40. ● Prior coronary stent with stent diameter �3 mm or not known I (3)
41. ● Prior coronary stent with stent diameter �3 mm U (6)
Asymptomatic—CABG
Time Since CABG <5 y Ago >5 y Ago
42. ● Prior CABG I (2) U (5)
Asymptomatic—Prior Coronary Stenting
43. ● Prior left main coronary stent● Stent diameter �3 mm
A (7)
Time Since PCI <2 y >2 y
44. ● Stent diameter �3 mm or not known I (2) I (2)
45. ● Stent diameter �3 mm I (3) U (4)
indicates appropriate; I, inappropriate; and U, uncertain.
able 7. Evaluation of Cardiac Structure and Function
IndicationAppropriate Use
Score (1–9)
Adult Congenital Heart Disease46. ● Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels A (9)
47. ● Assessment of complex adult congenital heart disease A (8)
Evaluation of Ventricular Morphology and Systolic Function
48. ● Initial evaluation of left ventricular function● Following acute MI or in HF patients
I (2)
49. ● Evaluation of left ventricular function● Following acute MI or in HF patients● Inadequate images from other noninvasive methods
A (7)
50. ● Quantitative evaluation of right ventricular function A (7)
51. ● Assessment of right ventricular morphology● Suspected arrhythmogenic right ventricular dysplasia
A (7)
52. ● Assessment of myocardial viability● Prior to myocardial revascularization for ischemic left ventricular systolic dysfunction● Other imaging modalities are inadequate or contraindicated
U (5)
Evaluation of Intra- and Extracardiac Structures
53. ● Characterization of native cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods
A (8)
54. ● Characterization of prosthetic cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods
A (8)
55. ● Initial evaluation of cardiac mass (suspected tumor or thrombus) I (3)
56. ● Evaluation of cardiac mass (suspected tumor or thrombus)● Inadequate images from other noninvasive methods
A (8)
57. ● Evaluation of pericardial anatomy A (8)
58. ● Evaluation of pulmonary vein anatomy● Prior to radiofrequency ablation for atrial fibrillation
A (8)
59. ● Noninvasive coronary vein mapping● Prior to placement of biventricular pacemaker
A (8)
60. ● Localization of coronary bypass grafts and other retrosternal anatomy● Prior to reoperative chest or cardiac surgery
A (8)
indicates appropriate; I, inappropriate; and U, uncertain.
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. Cardiac Computed Tomography Appropriate Use Criteria (By Appropriate Use Criteria)
able 8. Appropriate Indications (Median Score 7–9)
IndicationAppropriate Use
Score (1–9)
Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent
1. ● ECG interpretable AND● Able to exercise● Intermediate pretest probability of CAD
A (7)
2. ● ECG uninterpretable or unable to exercise● Low pretest probability of CAD
A (7)
2. ● ECG uninterpretable or unable to exercise● Intermediate pretest probability of CAD
A (8)
Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation)
6. ● Normal ECG and cardiac biomarkers● Low pretest probability of CAD
A (7)
6. ● Normal ECG and cardiac biomarkers● Intermediate pretest probability of CAD
A (7)
7. ● ECG uninterpretable● Low pretest probability of CAD
A (7)
7. ● ECG uninterpretable● Intermediate pretest probability of CAD
A (7)
8. ● Nondiagnostic ECG or equivocal cardiac biomarkers● Low pretest probability of CAD
A (7)
8. ● Nondiagnostic ECG or equivocal cardiac biomarkers● Intermediate pretest probability of CAD
A (7)
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS
9. ● Family history of premature CHD● Low global CHD risk estimate
A (7)
10. ● Asymptomatic● No known CAD● Intermediate global CHD risk estimate
A (7)
Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD
13. ● Reduced left ventricular ejection fraction● Low pretest probability of CAD
A (7)
13. ● Reduced left ventricular ejection fraction● Intermediate pretest probability of CAD
A (7)
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery
15. ● Coronary evaluation before noncoronary cardiac surgery● Intermediate pretest probability of CAD
A (7)
Use of CTA in the Setting of Prior Test Results—Prior ECG Exercise Testing
20. ● Normal ECG exercise test● Continued symptoms
A (7)
21. ● Prior ECG exercise testing● Duke Treadmill Score—intermediate risk findings
A (7)
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures
22. ● Discordant ECG exercise and imaging results A (8)
23. ● Stress imaging results: equivocal A (8)
Use of CTA in the Setting of Prior Test Results—Prior CCS
26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS �100
A (8)
26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS 100–400
A (8)
Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study
29. ● Previous stress imaging study normal A (8)
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent)
39. ● Evaluation of graft patency after CABG A (8)
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able 8. Continued
Indication
Risk Assessment Postrevascularization (PCI o
43. ● Prior left main coronary stent with stent diameter �3
Evaluation of Cardiac Structure and F
46. ● Assessment of anomalies of coronary arterial and oth
47. ● Assessment of complex adult congenital heart diseas
Evaluation of Cardiac Structure and Function—Eva
49. ● Evaluation of left ventricular function● Following acute MI or in HF patients● Inadequate images from other noninvasive methods
50. ● Quantitative evaluation of right ventricular function
51. ● Assessment of right ventricular morphology● Suspected arrhythmogenic right ventricular dysplasia
Evaluation of Cardiac Structure and Function
53. ● Characterization of native cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods
54. ● Characterization of prosthetic cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods
56. ● Evaluation of cardiac mass (suspected tumor or throm● Inadequate images from other noninvasive methods
57. ● Evaluation of pericardial anatomy
58 ● Evaluation of pulmonary vein anatomy● Prior to radiofrequency ablation for atrial fibrillation
59. ● Noninvasive coronary vein mapping● Prior to placement of biventricular pacemaker
60. ● Localization of coronary bypass grafts and other retro● Prior to reoperative chest or cardiac surgery
indicates appropriate; I, inappropriate; and U, uncertain.
able 9. Uncertain Indications (Median Score 4–6)
Indication
Detection of CAD in SymptomaticSymptomatic—Nonacute Symptoms Po
1. ● ECG interpretable and able to exercise● Low pretest probability of CAD
2. ● ECG uninterpretable or unable to exercise● High pretest probability of CAD
Detection of CAD in SymptomaticSymptomatic—Acute Symptoms Wit
4. ● Persistent ECG ST-segment elevation following exclus
5. ● Acute chest pain of uncertain cause (differential diagnand ACS [“triple rule out”])
6. ● Normal ECG and cardiac biomarkers● High pretest probability of CAD
7. ● ECG uninterpretable● High pretest probability of CAD
8. ● Nondiagnostic ECG or equivocal cardiac biomarkers● High pretest probability of CAD
Detection of CAD/Risk Assessment in Asymptomatic
10. ● Asymptomatic● No known CAD● High global CHD risk estimate
Appropriate UseScore (1–9)
r CABG)—Asymptomatic—Prior Coronary Stenting
mm A (7)
unction—Adult Congenital Heart Disease
er thoracic arteriovenous vessels A (9)
e A (8)
luation of Ventricular Morphology and Systolic Function
A (7)
A (7)
A (7)
—Evaluation of Intra- and Extracardiac Structures
A (8)
A (8)
bus) A (8)
A (8)
A (8)
A (8)
sternal anatomy A (8)
Appropriate UseScore (1–9)
Patients Without Known Heart Diseasessibly Representing an Ischemic Equivalent
U (5)
U (4)
Patients Without Known Heart Diseaseh Suspicion of ACS (Urgent Presentation)
ion of MI U (6)
osis includes pulmonary embolism, aortic dissection, U (6)
U (4)
U (4)
U (4)
Individuals Without Known CAD—Noncontrast CT for CCS
U (4)
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able 9. Continued
IndicationAppropriate Use
Score (1–9)
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA
11. ● Asymptomatic● No known CAD● High global CHD risk estimate
U (4)
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA Following Heart Transplantation
12. ● Routine evaluation of coronary arteries U (6)
Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD
13. ● Reduced left ventricular ejection fraction● High pretest probability of CAD
U (4)
14. ● Normal left ventricular ejection fraction● Low pretest probability of CAD
U (5)
14. ● Normal left ventricular ejection fraction● Intermediate pretest probability of CAD
U (5)
14. ● Normal left ventricular ejection fraction● High pretest probability of CAD
U (4)
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery
15. ● Coronary evaluation before noncoronary cardiac surgery● Low pretest probability of CAD
U (6)
Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation
17. ● Nonsustained ventricular tachycardia U (6)
18. ● Syncope U (4)
Detection of CAD in Other Clinical Scenarios—Elevated Troponin of Uncertain Clinical Significance
19. ● Elevated troponin without additional evidence of ACS or symptoms suggestive of CAD U (6)
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures
23. ● Stress imaging results: mild ischemia U (6)
Use of CTA in the Setting of Prior Test Results—Prior CCS
24. ● Zero CCS �5 y ago U (4)
26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS 401–1000
U (6)
26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS �1000
U (4)
Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study
29. ● Previous stress imaging study abnormal U (6)
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery
33. ● Functional capacity �4 METs with 1 or more clinical risk predictors U (5)
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery
37. ● Functional capacity �4 METs with 1 or more clinical risk predictors U (6)
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent)
41. ● Prior coronary stent with stent diameter �3 mm U (6)
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG
42. ● Prior coronary bypass surgery �5 y ago U (5)
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting
44. ● Stent diameter �3 mm● Greater than or equal to 2 y after PCI
U (4)
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function
52. ● Assessment of myocardial viability prior to myocardial revascularization● Ischemic left ventricular systolic dysfunction● Other imaging modalities are inadequate or contraindicated
U (5)
indicates appropriate; I, inappropriate; and U, uncertain.
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able 10. Inappropriate Indications (Median Score 1–3)
IndicationAppropriate Use
Score (1–9)
Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent
1. ● ECG interpretable and able to exercise● High pretest probability of CAD
I (3)
Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation)
3. ● Definite MI I (1)
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS
10. ● Low global CHD risk estimate I (2)
Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA
11. ● Low global CHD risk estimate I (2)
11. ● Intermediate global CHD risk estimate I (2)
Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery
15. ● Coronary evaluation before noncoronary cardiac surgery● High global CHD risk estimate
I (3)
Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation
16. ● New-onset atrial fibrillation (atrial fibrillation is underlying rhythm during imaging) I (2)
Use of CTA in the Setting of Prior Test Results—ECG Exercise Testing
21. ● Exercise ECG testing● Duke Treadmill Score—low-risk findings
I (2)
21. ● Exercise ECG testing● Duke Treadmill Score—high-risk findings
I (3)
Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures
23. ● Stress imaging results: moderate or severe ischemia I (2)
Use of CTA in the Setting of Prior Test Results—Prior CCS
25. ● Positive calcium score �2 y ago I (2)
Periodic Repeat Testing in Asymptomatic OR Stable Symptoms With Prior Stress Imaging or Coronary Angiography
27. ● No known CAD● Last study done �2 y ago
I (2)
27. ● No known CAD● Last study done �2 y ago
I (3)
28. ● Known CAD● Last study done �2 y ago
I (2)
28. ● Known CAD● Last study done �2 y ago
I (3)
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Low-Risk Surgery
30. ● Preoperative evaluation for noncardiac surgery risk assessment, irrespective of functional capacity I (1)
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery
31. ● No clinical risk predictors I (2)
32. ● Functional capacity �4 METs I (2)
34. ● Asymptomatic �1 y following a normal coronary angiogram, stress test, or a coronary revascularizationprocedure
I (1)
Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery
35. ● No clinical risk predictors I (2)
36. ● Functional capacity �4 METs I (2)
38. ● Asymptomatic �1 y following a normal coronary angiogram, stress test, or a coronary revascularizationprocedure
I (2)
Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent)
40. ● Prior coronary stent with stent diameter �3 mm or not known I (3)
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG
42. ● Prior coronary bypass surgery �5 y ago I (2)
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14 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000
igure 1. Hierarchy of Potential Test Ordering Based on Clinical Presentation
able 10. Continued
IndicationAppropriate Use
Score (1–9)
Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting
44. ● Prior coronary stent with stent diameter �3 mm or not known● Less than 2 y after PCI
I (2)
44. ● Prior coronary stent with stent diameter �3 mm or not known● Greater than or equal to 2 y after PCI
I (2)
45. ● Prior coronary stent with stent diameter �3 mm● Less than 2 y after PCI
I (3)
Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function
48. ● Initial evaluation of left ventricular function● Following acute MI or in HF patients
I (2)
Evaluation of Cardiac Structure and Function—Evaluation of Intra- and Extracardiac Structures
55. ● Initial evaluation of cardiac mass (suspected tumor or thrombus) I (3)
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igure 2. Risk Assessment Preoperative Evaluation of Noncardiac Surgery
igure 3. Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic Acute Presentation
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igure 4. Risk Assessment Postrevascularization (PCI or CABG)
igure 5. Use of CT Angiography in the Setting of Prior Test Results
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igure 6. Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Presentation
igure 7. Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known Coronary Artery Disease
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igure 8. Detection of CAD in Other Clinical Scenarios
igure 9. Evaluation of Cardiac Structure and Function
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. Discussion
ppropriate use criteria define common patient subgroupshere expert opinion and the available medical evidence are
ombined to assess the net benefit of a test or procedure, inhis instance CCT. The intent of these criteria is to guidehe rational use of the procedure, namely avoidance of eithernder- or overutilization, and thereby lead to more optimalealthcare delivery and justifiable healthcare expenditures.This document is an update to the original appropriate-
ess criteria for CCT published in 2006 (1), written toeflect changes in test utilization in the context of rapidlyeveloping technical and clinical applications and within theonceptual framework of dynamic appropriate use criteriaevelopment. Several aspects of the present document areoteworthy, including careful alignment to and, whereossible, definition of language in the radionuclide imagingppropriate use criteria (2) to enhance integration intoomparable decision support tools and performance metrics.he underlying assumptions for the document are intended
o broadly reflect the present community standards ofechnology and performance of the technique with anmphasis on adherence to imaging guidelines, patientafety, and laboratory quality and accreditation.
The clinical scenarios included in this report were de-igned to reflect the most common and important potentialpplications for CCT imaging. After the initial writing byhe writing group, extensive review from external editors,nd then ranking by the technical panel itself, the result is aet of scenarios that define patient-specific applications. Theppropriate use criteria in this report provide a consensus
igure 10. Evaluation of Cardiac Structure and Function: Evalu
udgment of whether it is reasonable to use CCT imaging scontent.onlinejacDownloaded from
or the particular clinical scenario described, such as those3 indications listed in this document. These criteria arexpected to be useful for clinicians, healthcare facilities, andhird-party payers engaged in the delivery of cardiovascularmaging services. Although numerous, the indications areommonly divided among subclasses of patient CHD risk orretest probability of CAD, as such characteristics aremportant considerations within the test performance char-cteristics. In total, 35 of 93 indications were judged to beppropriate, and 58 were judged to be either inappropri-te or uncertain. It is important to note however, that annderstanding of pretest patient characteristics is anmportant determinant of the appropriate use ratings.ew categories are uniform in the ratings for all patientharacteristics.
Appropriate use criteria represent the first component ofhe chain of quality recommendations for cardiovascularmaging (15). In addition to appropriate use, patient safetylso should be considered when ordering coronary com-uted tomographic angiography (CTA), as it should behen ordering any cardiac imaging test. A consideration of
he appropriate balance of using radiation dose reductionechniques to minimize radiation exposure while preservingmage quality and the related benefits of imaging for apecific patient should be undertaken. This issue is discussedn more depth in a 2010 expert consensus document onoronary CTA (16). The present document greatly expandshe number of potential clinical scenarios in comparison tohe original 2006 document. The clinical scenarios includecute and chronic chest pain, testing in symptomatic andsymptomatic patients, heart failure, preoperative risk as-
of Intra- and Extracardiac Structures
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20 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000
n the setting of prior test results (exercise testing, stressmaging procedures, coronary calcium scores, and repeatesting), prior revascularization, and the evaluation of car-iac structure and function. Although these criteria are
ntended to provide guidance for patients and clinicians,hey are not intended to serve as substitutes for soundlinical judgment and practice experience. The writingroup recognizes that many patients encountered in clinicalractice may not be represented in these appropriate useriteria or may have extenuating features when comparedith the clinical scenarios presented. Although the appro-riate use ratings reflect critical medical literature as well asxpert consensus, physicians and other stakeholders shouldnderstand the role of clinical judgment in determininghether to order a test for an individual patient. Addition-
lly, uncertain indications often require individual physicianudgment and understanding of the patient to better deter-
ine the usefulness of a test for a particular scenario. Asuch, the ranking of an indication as uncertain (4 to 6)hould not be viewed as limiting the use of CCT imagingor such patients. It should be emphasized that the technicalanel was instructed that the uncertain designation was stillesigned to be considered as a “reimbursable” category.These ratings are intended to evaluate the appropriate use
f specific patient scenarios to determine overall patterns ofare regarding CCT. In situations where there is substantialariation between the appropriate use rating and what thelinician believes is the best recommendation for the pa-ient, further considerations or actions, such as a secondpinion, may be appropriate. Moreover, it is not anticipatedhat all physicians or facilities will have 100% of their CCTrocedures deemed appropriate. However, related to theverall patterns of care, if the national average of appropriatend uncertain ratings is 80%, for example, and a physician oracility has a 40% rate of inappropriate procedures, furtherxamination of the patterns of care may be warranted andelpful. Implementation of these criteria is highly encour-ged through provider education, as it is anticipated thatncreasing emphasis by laboratory accreditation bodies andther organizations focused on provider quality will apply.
.1. Clinical Scenarios and Their Ratings
irect comparison to the 2006 document is difficult becausef the many changes in the number and wording of clinicalcenarios. In summary:
• A total of 31 indications were carried forward from the2006 document, including prior ratings where 10 wereappropriate, 10 were uncertain, and 11 were inappro-priate. Among these, 8 shifted up 1 category fromeither uncertain to appropriate (Indications 1 [inter-mediate], 6 [low], 10 [intermediate], 39, 49, 54) orfrom inappropriate to uncertain (Indications 2 [high],42 [�5 y]). The other 23 indications had unchanged
appropriate use ratings.content.onlinejacDownloaded from
• One area of expansion compared with the 2006 criteriainvolves symptomatic patients without known heartdisease. CCT was felt to be appropriate primarily forsituations involving a low or intermediate pretestprobability of obstructive CAD. Scenarios involvinghigh-probability CAD patients were rated as uncertainwith the exceptions of a patient with an interpretableECG who was able to exercise, and for definitemyocardial infarction.
• Noncontrast CT calcium scoring was judged as appro-priate for intermediate CHD risk patients, and for thespecific subset of low-risk patients in whom a familyhistory of premature CHD was present. Intermediaterisk was defined as a 10-year risk of between 10% and20%, although individual patient exceptions to abroadened intermediate risk range of 6% to 20% wererecognized for certain patient subsets with generallylow absolute risk but high relative risk (younger menand women). Screening asymptomatic patients usingcoronary CT angiography was considered inappropri-ate, as was repeat coronary calcium testing. Repeat CTangiography in asymptomatic patients or patients withstable symptoms with prior test results was broadlyconsidered inappropriate.
• Within heart failure, CT angiography was appropriateor uncertain as a test across both normal (new to thisdocument) and abnormal left ventricular ejection frac-tion, although the only appropriate scenarios werewith reduced left ventricular ejection fraction with lowor intermediate pretest CAD probability.
• As part of the preoperative evaluation, CT angiogra-phy was viewed as a potential option among patientsundergoing heart surgery for noncoronary indications(e.g., valve replacement surgery or atrial septal defectclosure) when the pretest CAD risk was either inter-mediate (appropriate) or low (uncertain). In compari-son, there were no appropriate indications for coronaryCT angiography as part of the preoperative evaluationfor noncardiac surgery.
• The evaluation of coronary stents was considered as afunction of patient symptom status, time from revas-cularization, and stent size. Only with larger stents(�3 mm in diameter) after long time periods (�2years) was stent imaging considered uncertain, andonly with left main stents was imaging of stentsconsidered appropriate.
• A strength of cardiac CT imaging is the evaluation ofcardiac structure and function. Appropriate indicationsinclude coronary anomalies, congenital heart disease,evaluation of right ventricular function, evaluation ofleft ventricular ejection fraction when images fromother techniques are inadequate, or evaluation ofprosthetic heart valves. New to this document is theuse of CCT for evaluation of myocardial viability when
other modalities are inadequate or contraindicated by on October 27, 2010 c.org9
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21JACC Vol. 56, No. xx, 2010 Taylor et al.Month 2010:000–000 Appropriate Use Criteria for Cardiac Computed Tomography
(uncertain), and in suspected arrhythmogenic rightventricular dysplasia (appropriate).
• The use of CCT was appropriate prior to electrophys-iological procedures for anatomic mapping, or prior torepeat sternotomy in reoperative cardiac surgery.
• There was disagreement on the panel in 2 of theclinical scenarios: 1) detection of CAD in the settingof a low pretest probability for CAD when the ECGis interpretable and the patient is able to exercise(Indication 1); and 2) preoperative coronary assess-ment prior to noncoronary cardiac surgery in thesetting of a low pretest probability for CAD (Indica-tion 30). Both of these indications were ranked in theuncertain category.
.2. Application of Criteria
here are many potential applications for appropriate useriteria. Clinicians could use the ratings for decision supportr an educational tool when considering the need for CCTmaging. Moreover, these criteria could be used to facilitateiscussion with patients and/or referring physicians about
igure A1. Stepwise Approach to Perioperative Cardiac Assess
ardiac evaluation and care algorithm for noncardiac surgery based on active clinica
ears of age. HR indicates heart rate; LOE, level of evidence; and MET, metabolic equivalecontent.onlinejacDownloaded from
he need for CCT imaging. Facilities and payers may chooseo use these criteria either prospectively in the design ofrotocols and preauthorization procedures, or retrospec-ively for quality reports. It is hoped that payers would usehese criteria as the basis for the development of rationalayment management strategies.These criteria were developed with the intent that they be
onsidered in both the delivery and in the policy positionsor these services, including reimbursement. In contrast,ervices performed for inappropriate indications shouldikely require additional documentation to justify reimburse-
ent because of the unique circumstances or the clinicalrofile that must exist in such a patient. It is critical tomphasize that the writing group, technical panel, Appro-riate Use Criteria Task Force, and clinical community doot believe an uncertain rating is grounds to deny reim-ursement for CCT imaging. Rather, uncertain ratings arehose where expert opinion or the available data vary or areapidly evolving. The opinions of the technical panel oftenaried for these indications reflecting that additional re-earch is needed. By the same right, appropriate indications
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22 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000
ay still benefit from further clinical trials and evidenceevelopment.In conclusion, this document represents the current
nderstanding of the net clinical benefit of CCT imagingith respect to the balance between benefit and risk to
he patient as assessed under the ACCF’s appropriate useriteria methodology. It is intended to provide a practicaluide and perspective to clinicians and patients whenonsidering CCT imaging and promote more appropriateest utilization including avoidance of either under- orverutilization. As with other appropriate use criteria,ome of these ratings will require research and furthervaluation to provide the greatest information and benefito clinical decision making. Finally, it will be necessary toeriodically assess and update the indications and criterias technology evolves and new data and field experienceecome available.
ppendix A: Additional Cardiacomputed Tomography Definitions
ngina: As defined by the ACC/AHA Guidelines onxercise Testing (9)
• Typical Angina (Definite):1. Substernal chest pain, or an ischemic equivalent
discomfort that isa. provoked by exertion or emotional stress andb. relieved by rest and/or nitroglycerin (17).
• Atypical Angina (Probable): Chest pain or discomfortwith two characteristics of definite or typical angina (17).
• Nonanginal Chest Pain: Chest pain or discomfort thatmeets one or none of the typical angina characteristics (17).
cute Coronary Syndrome: As defined by the ACC/AHAuidelines for the Management of Patients With ST-levation Myocardial Infarction, patients with an acute
oronary syndrome include those whose clinical presenta-ions cover the following range of diagnoses: unstablengina, MI without ST-elevation (NSTEMI), and myocar-ial infarction with ST-elevation (STEMI) (18).
valuating Perioperative Risk for Noncardiac Surgery
ETHOD FOR DETERMINING PERIOPERATIVE RISK
eview Figure A1, “Stepwise Approach to Perioperativeardiac Assessment,” from the ACC/AHA 2009 Periop-
rative Guidelines (19). Based on the algorithm, once it isetermined that the patient does not require urgent surgery,he clinician should determine the patient’s active cardiaconditions and/or perioperative risk predictors—see defini-ions in the following text. If any active cardiac conditionsTable A1) and/or major risk predictors (Table A2) areresent, Figure A1 suggests consideration of coronary an-iography and postponing or canceling noncardiac surgery.nce perioperative risk predictors are assessed based on the
lgorithm, then the surgical risk and patient’s functional*n
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tatus should be used to establish the need for noninvasiveesting.
CG—Uninterpretable: Refers to electrocardiograms withesting ST-segment depression (�0.10 mV), complete leftundle-branch block, pre-excitation (Wolff-Parkinson-
hite syndrome), or paced rhythm.
ble to Exercise: Able to complete a diagnostic exercisereadmill examination.
ppendix B: Additional Methods
ee the Methods section for a description of panel selection,ndication development, scope of indications, and ratingrocess.
elationships With Industry and Other Entities
list of all individuals participating in the development andeview of this document and their institutional and/or
able A1. Active Cardiac Conditions for Which the Patienthould Undergo Evaluation and Treatment Before Noncardiacurgery (Class I, Level of Evidence: B)
Condition Examples
nstable coronary syndromes Unstable or severe angina*(CCS class III or IV)†
Recent MI‡
ecompensated HF (NYHAfunctional class IV;worsening or new-onset HF)
ignificant arrhythmias High-grade atrioventricular block
Mobitz II atrioventricular block
Third-degree atrioventricular heart block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (includingatrial fibrillation) with uncontrolledventricular rate (HR �100 bpm atrest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
evere valvular disease Severe aortic stenosis (mean pressuregradient �40 mm Hg, aortic valvearea �1.0 cm2, or symptomatic)
Symptomatic mitral stenosis(progressive dyspnea on exertion,exertional presyncope, or HF)
According to Campeau (20); †May include “stable” angina in patients who are unusuallyedentary; ‡The American College of Cardiology National Database Library defines recent MI as7 days but �1 month (within 30 days). Reprinted from Fleisher (19).CCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI,yocardial infarction; and NYHA, New York Heart Association.
able A2. Perioperative Clinical Risk Factors*
History of ischemic heart diseaseHistory of compensated or prior heart failureHistory of cerebrovascular diseaseDiabetes mellitus (requiring insulin)Renal insufficiency (creatinine �2.0)
As defined by the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care foroncardiac surgery (1). Note that these are not standard coronary artery disease risk factors.
by on October 27, 2010 c.org
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23JACC Vol. 56, No. xx, 2010 Taylor et al.Month 2010:000–000 Appropriate Use Criteria for Cardiac Computed Tomography
rganizational affiliations is presented in Appendix C. TheCCF and its partnering organizations rigorously avoid any
ctual, perceived, or potential conflicts of interest that mightrise as a result of an outside relationship or personal interestf a member of the technical panel. Specifically, all panelembers are asked to provide disclosure statements of all
elationships that might be perceived as real or potentialonflicts of interest. These statements were reviewed by theppropriate Use Criteria Task Force, discussed with allembers of the technical panel at the face-to-face meeting,
nd updated and reviewed as necessary. A table of disclo-ures by the technical panel and oversight task force mem-ers can be found in Appendix D.
iterature Review
he technical panel members were asked to refer to theelevant literature provided for each indication table whenompleting their ratings (Online Appendix at http://ontent.onlinejacc.org/cgi/content/full/j.jacc.2010.07.005/C1).
ppendix C: ACCF/SCCT/ACR/AHA/ASE/SNC/SCAI/SCMR 2010 Appropriate Useriteria for Cardiac Computed Tomographyarticipants
ardiac Computed Tomography Writing Group
llen J. Taylor, MD, FACC, FAHA—Chair, Appropriatese Criteria for Cardiac Computed Tomography Writingroup, Co-Director Noninvasive Imaging, Washingtonospital Center, Washington, DCManuel Cerqueira, MD, FACC, FASNC—Chairman ofolecular and Functional Imaging, Cleveland Clinic Foun-
ation, Cleveland, OHJohn McB. Hodgson, MD, FACC, FSCAI—Chairman,epartment of Cardiology Geisinger Health System, Dan-
ille, PADaniel Mark, MD, MPH, FACC, FAHA—Professor ofedicine, Duke Clinical Research Institute, Duke Univer-
ity, Durham, NCJames Min, MD, FACC—Assistant Professor of Medi-
ine, Weil Cornell Medical College, New York, NYPatrick O’Gara, MD, FACC, FAHA—Associate Pro-
essor of Medicine, Harvard University School of Medicine,irector of Clinical Cardiology, Brigham & Women’sospital, Boston, MAGeoffrey D. Rubin, MD, FSCBTMR—Professor of
adiology, Associate Dean for Clinical Affairs, Chief ofardiovascular Imaging, Stanford University School ofedicine, Palo Alto, CA
ardiac Computed Tomography Technical Panel
hristopher M. Kramer, MD, FACC, FAHA—Moderator
f the Technical Panel, Professor of Radiology and Medi- Bcontent.onlinejacDownloaded from
ine, and Director, Cardiovascular Imaging Center, Univer-ity of Virginia Health System, Charlottesville, VA
Allen J. Taylor, MD, FACC, FAHA—Writing Groupiaison, Appropriate Use Criteria for Cardiac Computedomography Technical Panel, Co-Director of Noninvasive
maging, Washington Hospital Center, Washington, DCDaniel Berman, MD, FACC—Director of Cardiac Im-
ging, Cedars-Sinai Medical Center Department of Imag-ng, Los Angeles, CA
Alan Brown, MD, FACC, FAHA, FNLA—Clinicalssociate Professor of Medicine, Loyola Stritch School ofedicine, Maywood, IL; Medical Director of Midwesteart Disease Prevention Center, Midwest Heart Special-
sts, Edward Heart Hospital, Naperville, ILFarooq A. Chaudhry, MD, FACC, FAHA, FASE—
ssociate Professor of Medicine, Columbia University Col-ege of Physicians and Surgeons, Associate Chief of Cardi-logy, Director of Echocardiography, New York, NYRicardo C. Cury, MD—Director of Cardiac Imaging,
aptist Hospital of Miami and Baptist Cardiac and Vascu-ar Institute, Miami, FL
Milind Y. Desai, MD, FACC—Cardiologist, Section ofardiovascular Imaging, Cleveland Clinic, Cleveland, OHAndrew J. Einstein, MD, PhD, FACC, FAHA,
ASNC—Assistant Professor of Clinical Medicine, Direc-or, Cardiac CT Research, Co-Director, Cardiac CT and
RI, Columbia University, New York, NYAntoinette S. Gomes, MD, FAHA, FSIR—Professor of
adiology and Medicine, David Geffen School of Medicinet UCLA, Los Angeles, CA
Robert Harrington, MD, FACC, FAHA, FSCAI—rofessor of Medicine, Duke University, Director of Dukelinical Research Institute, Durham, NCUdo Hoffmann, MD, MPH—Director of Cardiac MR,
ET, and CT program, Massachusetts General Hospital,oston, MARahul Khare, MD—Instructor, Department of Emer-
ency Medicine, Northwestern University, Feinberg Schoolf Medicine, Chicago, ILJohn Lesser, MD, FACC—Director of Cardiovascular
T and MRI, Minneapolis Heart Institute, Minneapolis, MNChristopher McGann, MD, FACC—Associate Profes-
or of Medicine, Division of Cardiology, University of Utahedical Center, Salt Lake City, UTAlan Rosenberg, MD, FACC—Vice President of Med-
cal Policy and Credentialing Programs, WellPoint, Inc.,hicago, ILRobert Schwartz, MD, FACC—Cardiolgist, Minneap-
lis Heart Institute, Minneapolis, MNMarc Shelton, MD, FACC—President, Prairie Cardio-
ascular Consultants, Ltd., Springfield, ILGerald W. Smetana, MD—Associate Professor of Medi-
ine, Harvard University School of Medicine, Internal Medi-ine Physician, Division of General Medicine & Primary Care,
eth Israel Deaconess Medical Center, Boston, MAby on October 27, 2010 c.org
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24 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000
Sidney C. Smith, Jr., MD, FACC, FAHA—Professor ofedicine, Director of Center for Cardiovascular Science andedicine, University of North Carolina, Chapel Hill, NC
xternal Reviewers of the Appropriate Use Criteriandications
ichael Atalay, MD, PhD, FACC—Director CardiacRI and CT, Assistant Professor of Diagnostic Imaging
nd Cardiology Warren Alpert School of Medicine atrown University, Rhode Island Hospital, Providence, RIMatthew Budoff, MD, FACC—Program Director, Di-
ision of Cardiology, Los Angeles Biomedical Researchnstitute, Torrance, CA
Tracy Callister, MD, FACC—Director, Tennesseeeart and Vascular Institute, Hendersonville, TNJeffrey Carr, MD, FACC—Cardiologist, Cardiovascular
ssociates of East Texas, PA, Tyler, TXSu Min Chang, MD, FACC—Assistant Professor ofedicine, Weill Cornell Medical College, Associate Direc-
or of the Cardiac Computed Tomography Laboratory—he Methodist DeBakey Heart & Vascular Center, Hous-
on, TXBenjamin Cheong, MD, FACC—Attending Physician,
linical Director, Cardiovascular MR and CT, St. Luke’spiscopal Health System/The Texas Heart Institute, Hous-
on, TXKavitha Chinnaiyan, MD, FACC—Director, Cardiovas-
ular Imaging Education, William Beumont Hospital,oyal Oak, MIPhilip Costello, MD—Chair of Radiology, Medical Uni-
ersity of South Carolina, Charleston, SCE. Gordon DePuey, MD, FACC—Director of Nuclearedicine, St. Luke’s-Roosevelt Hospital Professor of Ra-
iology, Columbia University, New York, NYAndrew J. Einstein, MD, PhD, FACC, FAHA,
ASNC—Assistant Professor of Clinical Medicine, Direc-or, Cardiac CT Research, Co-Director, Cardiac CT and
RI, Columbia University, New York, NYLee Fleisher, MD, FACC—Professor of Anesthesiology,
niversity of Pennsylvania Department of Anesthesiology,hiladelphia, PAMario Garcia, MD, FACC—Director of Cardiovascular
maging, Mount Sinai Hospital Cardiovascular Institute,ew York, NYThomas Gerber, MD, FACC—Professor of Radiology
nd Medicine, Jacksonville, FLRaymond Gibbons, MD, FACC—Professor of Medi-
ine, Co-Director of Nuclear Cardiology Lab, Mayo Clinic,ochester, MNHarvey Hecht, MD, FACC, FSCCT—Director of Car-
iovascular CT, Lenox Hill Heart and Vascular Institute ofew York, New York, NYMilena Henzlova, MD, FACC—Director of Nuclear
ardiology, Mount Sinai Medical Center, New York, NY C
content.onlinejacDownloaded from
Jill Jacobs, MD—Associate Professor of Radiology, Chieff Cardiac Imaging, NYU Langone Medical Center, Nework, NYScott Jerome, DO, FACC—Assistant Professor of Med-
cine, Cardiology Division, University of Maryland Medicalenter, Finksburg, MDNorman Kato, MD, FACC—Cardiothoracic Surgeon,
ardiac Care Medical Group, Encino, CARichard Kovacs, MD, FACC—Professor of Clinical Med-
cine, Krannert Institute of Cardiology, Indianapolis, INMichael Lauer, MD, FACC—Director, Division of
ardiovascular Sciences, National Heart, Lung, and Bloodnstitute, Bethesda, MD
John Mahmarian, MD, FACC—Professor of Medicine,he Methodist Hospital Organization, Houston, TXDavid Malenka, MD—Professor of Medicine, Dart-outh Hitchcock Medical Center Section of Cardiology,ebanon, NHFrederick A. Masoudi, MD, MSPH, FACC, FAHA—
ssociate Professor of Medicine, Denver Health Center,enver, COJulie Miller, MD, FACC—Assistant Professor of Med-
cine, Johns Hopkins University, Baltimore, MDDebabrata Mukherjee, MD, FACC—Chief, Cardiovas-
ular Medicine, Professor of Medicine, Texas Tech Univer-ity, El Paso, TX
Meagan Murphy, MD—Internist, Massachusetts Gen-ral Hospital, Boston, MA
Jagat Narula, MD, FACC—Professor of Medicine,hief of Division of Cardiology, University of California,
rvine, Orange, CAJohn Nixon, MD, FACC, FAHA—Professor of Medi-
ine, Medical College of Virginia, Richmond, VAE. Magnus Ohman, MD, FACC—Professor of Medi-
ine, Duke University Medical Center; Associate Director,uke Heart Center-Ambulatory Care; Director, Program
or Advanced Coronary Disease, Duke Clinical Researchnstitute, Durham, NC
Michael H. Picard, MD, FACC, FAHA, FASE—irector of Echocardiography, Massachusetts Generalospital, Boston, MAMichael Poon, MD, FACC—Professor of Medicine and
adiology, Stony Brook School of Medicine, Stony Brook, NYMiguel Quinones, MD, FACC—Professor of Medicine,eill Cornell Medical College; Chairman, Department of
ardiology, The Methodist Hospital Physician Organiza-ion, Houston, TX
Daniel Rader, MD—Cooper-McClure Professor of Med-cine, Director of Preventive Cardiovascular Medicine andipid Clinic, University of Pennsylvania, Philadelphia, PARita Redberg, MD, FACC—Professor of Medicine,
niversity of California San Francisco, San Francisco, CAU. Joseph Schoepf, MD, FAHA, FSCBT-MR,
SCCT—Professor of Radiology and Medicine, Directorf Cardiovascular Imaging, Medical University of South
arolina, Charleston, SCby on October 27, 2010 c.org
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25JACC Vol. 56, No. xx, 2010 Taylor et al.Month 2010:000–000 Appropriate Use Criteria for Cardiac Computed Tomography
Samuel Wann, MD—Cardiologist, Wheaton Franciscanedical Group, Wauwatosa, WIWilliam Guy Weigold, MD, FACC—Director of CT,ashington Hospital Center, Washington, DCJonathan Weinsaft, MD, FACC—Director of CardiacRI Program, New York Presbyterian Hospital, Cornelledical Center, New York, NYWilliam Weintraub, MD, FACC—Chief of Cardiology,
hristiana Care Health System, Newark, DEKim Allan Williams, MD, FACC, FAHA, FASNC—
hair, Division of Cardiology, Wayne State Universitychool of Medicine, Detroit, MI
CCF Appropriate Use Criteria Task Force
ichael J. Wolk, MD, MACC—Chair, Task Force, Pastresident, American College of Cardiology Foundation andlinical Professor of Medicine, Weill-Cornell Medicalchool, New York, NYSteven Bailey, MD, FACC, FSCAI—Chair, Division of
ardiology, Professor of Medicine and Radiology, Janeyriscoe Distinguished Chair, University of Texas Healthciences Center, San Antonio, TXPamela S. Douglas, MD, MACC, FAHA, FASE—Past
resident, American College of Cardiology Foundation;ast President, American Society of Echocardiography; andrsula Geller Professor of Research in Cardiovasculariseases and Chief, Cardiovascular Disease, Duke Univer-
ity Medical Center, Durham, NC F
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Robert C. Hendel, MD, FACC, FAHA, FASNC—hair, Appropriate Use Criteria for Radionuclide Imagingriting Group—Director of Cardiac Imaging and Outpa-
ient Services, Division of Cardiology, Miami Universitychool of Medicine, Miami, FLChristopher M. Kramer, MD, FACC, FAHA—
rofessor of Medicine and Radiology and Director, Cardio-ascular Imaging Center, University of Virginia Healthystem, Charlottesville, VAJames Min, MD, FACC—Assistant Professor of Medi-
ine, Weil Cornell Medical College, New York, NYManesh R. Patel, MD, FACC—Assistant Professor ofedicine, Division of Cardiology, Duke University Medi-
al Center, Durham, NCLeslee Shaw, PhD, FACC, FASNC—Professor of Med-
cine, Emory University School of Medicine, Atlanta, GARaymond F. Stainback, MD, FACC, FASE—Medicalirector of Noninvasive Cardiac Imaging, Texas Heart
nstitute at St. Luke’s Episcopal Hospital, Houston,X; Clinical Associate Professor of Medicine, Baylorollege of Medicine; President-Elect, Intersocietalommission for the Accreditation of Echocardiographyaboratories (ICAEL); Hall-Garcia Cardiology Associ-tes, Houston, TX
Joseph M. Allen, MA—Director, TRIP (Translatingesearch into Practice), American College of Cardiology
oundation, Washington, DCby on October 27, 2010 c.org
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26 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000
PPENDIX D. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 CARDIAC COMPUTED TOMOGRAPHYPPROPRIATE USE CRITERIA WRITING GROUP, TECHNICAL PANEL, TASK FORCE, AND INDICATION REVIEWERS—ELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (IN ALPHABETICAL ORDER)
CommitteeMember
ResearchGrant Speaker
StockOwnership Salary
Board ofDirectors
Consulting Fees/Honoraria
ExpertWitness
Cardiac Computed Tomography Use Criteria Writing Group
anuelCerqueira
● PerceptiveInformatics, Inc.
● GE Healthcare● Astellas
None None None ● Astellas● GE Healthcare● MDS Nordion● Siemens
None
ohn McB.Hodgson
● BostonScientific
● RADI● Volcano Corp
None ● GuardianVPM
None None ● Volcano Corp ● Myocardialinfarct
● Review ofcaredelivered topatient withprostheticvalveendocarditis
aniel Mark None None None None None None None
ames Min None ● GE Healthcare None None None None None
atrick O’Gara ● Lantheus None None None None None None
eoffery D.Rubin
None None ● Terarecon None None ● Fovia● Medtronic● Trivascular 2
None
llen J. Taylor ● Abbott● Resverlogix
None None None None ● Abbott None
Cardiac Computed Tomography Appropriate Use Criteria Technical Panel
aniel Berman ● Siemens● GE/Amersham● Astellas● Lantheus
None None None None ● Bracco● Cedars Sinai
Medical Center-software royalties
● Floura Pharma● Lantheus● Spectrum
Dynamics
None
lan Brown ● Astellas● GlaxoSmithKline● Siemens
None None None None ● AstraZeneca● Merck● Merck/Schering-
Plough● Pfizer● Reliant
None
arooq A.Chaudhry
● Lantheus ● Lantheus None None None None None
icardo C. Cury ● AstellasPharma
● Pfizer Inc.
None None None ● Society ofCardiovascularComputedTomography
● Astellas Pharma None
ilind Y. Desai None ● Philips None None None None None
ndrew J.Einstein
● SpectrumDynamics
None None None None None None
ntoinette S.Gomes
None None None None None None None
by on October 27, 2010 content.onlinejacc.orgDownloaded from
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27JACC Vol. 56, No. xx, 2010 Taylor et al.Month 2010:000–000 Appropriate Use Criteria for Cardiac Computed Tomography
CommitteeMember
ResearchGrant Speaker
StockOwnership Salary
Board ofDirectors
Consulting Fees/Honoraria
ExpertWitness
obertHarrington
● AstraZeneca● Bristol-Myers
Squibb● GlaxoSmithKline● Merck● Millenium● Portola● Schering-Plough● The Medicines
Company
None None None None ● AstraZeneca● Baxter● CSL Behring● Eli Lilly● Heart.org● Luitpold● Merck● Novartis● Otsuka Maryland
Research Institute● Regado● Schering-Plough● WebMD
None
do Hoffmann None None None None None None None
ahul Khare None None None None None None None
hristopher M.Kramer
● Astellas● GlaxoSmithKline● Siemens
None None None None None None
ohn Lesser None ● SiemensMedicalSystems
None None None ● Vital Images None
hristopherMcGann
None None None None None None None
lan Rosenberg None None None ● WellPointInc.
None None None
obert Schwartz None None None None None None None
arc Shelton None None None None None None None
erald W.Smetana
None None ● AnvitaHealth
None None None None
idney C. Smith,Jr.
None None None None None None None
llen J. Taylor ● Abbott● Resverlogix
None None None None ● Abbott None
Cardiac Computed Tomography Appropriate Use Criteria Task Force
oseph M. Allen None None None None None None None
teven Bailey ● BostonScientificCorporation
● Data SafetyMonitoringBoard
None None None None ● Volcano None
amela S.Douglas
● Abiomed● Amgen● Atritech● Edwards
Lifesciences● MAP
Pharmaceuticals● Medtronic● Osiris● Viacor
None ● CardioDX
● Elsevier
None ● TranslationalResearch inOncology
● 23andME● BG Medicine● CancerGuideDX● Heart.org● Institute of
Medicine● National Institutes
of Health● Novartis● Pappas Ventures● Veterans
Administration● WebMD● Xceed Molecular
None
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CommitteeMember
ResearchGrant Speaker
StockOwnership Salary
Board ofDirectors
Consulting Fees/Honoraria
ExpertWitness
obert C.Hendel
● GE Healthcare ● Astellas None None None ● PHx Health● United Healthcare
None
hristopher M.Kramer
● Astellas● GlaxoSmithKline● Siemens
None None None None None None
ames Min None ● GE Healthcare None None None None None
anesh R. Patel ● Genzyme None None None None None None
eslee Shaw ● Astellas● Bracco
Diagnostics
None None None None None None
aymond F.Stainback
None None None None None None None
ichael J. Wolk None None None None None None None
Cardiac Computed Tomography Appropriate Use Criteria Indication Reviewers
ichael Atalay None None None None None None None
atthew Budoff None ● General Electric None None None None ● CT scanning
racy Callister None ● GE Healthcare None None None None None
efferey Carr None None None None None None None
u Min Chang ● LantheusImaging
None None None None None None
enjaminCheong
● Bracco Inc.● St. Jude
Medical
None None None None None None
avithaChinnaiyan
● BayerHealthcare
None None None None None None
hilip Costello None None None None None None None
. GordonDePuey
None None None None None None None
ndrew J.Einstein
● SpectrumDynamics
None None None None None None
ee Fleisher None None None None None ● AstraZeneca ● Preoperativestroke
ario Garcia ● SpectrumDynamics
None ● Pfizer None ● IntersocietalAccreditationCouncil
● BG Medicine● MD Imaging● TheHeart.org
None
homas Gerber None None None None None None None
aymondGibbons
● Velomedix None None None None ● CardiovascularClinical Studies
● Lantheus MedicalImaging
● Medscape(Heart.org)
● Molecular InsightPharmaceuticals
● TherOx (WomenStudy)
None
arvey Hecht ● Philips MedicalSystems
● Philips MedicalSystems
None None None None None
ilena Henzlova None None ● Astellas None None None None
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29JACC Vol. 56, No. xx, 2010 Taylor et al.Month 2010:000–000 Appropriate Use Criteria for Cardiac Computed Tomography
CommitteeMember
ResearchGrant Speaker
StockOwnership Salary
Board ofDirectors
Consulting Fees/Honoraria
ExpertWitness
ill Jacobs ● SiemensMedical
● GE Healthcare None None None None None
cott Jerome ● Astellas ● Astellas None None None None None
orman Kato None None None None None None None
ichard Kovacs None None None None None ● Abbott● BG Medicine● Biomedical
Systems● Cook Inc-Med
Institute● ECG Scanning
Services● Eli Lilly● Endocyte● Essentials● XenoPort
None
ichael Lauer None None None None None None None
ohn Mahmarian None None None None None None None
avid Malenka ● Abbott Vascular● St. Jude
MedicalFoundation
None None None None None None
rederick A.Masoudi
None None None ● AmericanCollege ofCardiology
● OklahomaFoundationforMedicalQuality
None ● United Healthcare(previous)
None
ulie Miller ● Toshiba MedicalSystems
None None None None None None
ebabrataMukherjee
None None None None None None None
eagan Murphy None None None None None None None
agat Narula None None None None None None None
ohn Nixon None None None None None None None
. MagnusOhman
● Bristol-MyersSquibb
● CV Therapeutics● Daiichi Sankyo● Datascope● Eli Lilly● Sanofi-Aventis● Schering-Plough● The Medicines
Company
● Gilead Sciences None None None ● Abiomed● AstraZeneca● CV Therapeutics● Datascope● Gilead Sciences● Liposcience● Northpoint
Domain● Pozen, Inc.● Response
Biomedical● The Medicines
Company● WebMD
None
ichael H.Picard
None None None None None None None
ichael Poon None None None None None None None
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30 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000
CommitteeMember
ResearchGrant Speaker
StockOwnership Salary
Board ofDirectors
Consulting Fees/Honoraria
ExpertWitness
iguel Quinones None None None None None None None
aniel Rader ● Abbott● AstraZeneca● Bristol-Myers
Squibb● Merck● Otsuka
● AstraZeneca● Merck/
Schering-Plough
● Merck None None ● IsisPharmaceuticals
None
ita Redberg None None None None None None None
. JosephSchoepf
● Bayer-Schering● Bracco● GE● Medrad● Siemens
● Bayer● Bracco● GE● Medrad● Merck● Siemens
None None None ● Bayer-Schering● Bracco● GE● Medrad● Siemens
None
amuel Wann None None None None None None None
illiam GuyWeigold
● Philips MedicalSystems
None None None None None None
onathanWeinsaft
None None None None None None None
illiamWeintraub
● Abbott● AstraZeneca● Bristol-Myers
Squibb● Otsuka● Sanofi-Aventis
None None None None ● AstraZeneca● Bayer● Bristol-Myers
Squibb● Cardionet● Eli Lilly● Pfizer● Sanofi-Aventis● Shionogi
● Celebrexlitigation
● Quetiapinelitigation
im AllanWilliams
● Bristol-MyersSquibb
● PGx Inc.
● Astellas None None None ● Astellas None
his table represents the relationships of the writing group, technical panel, task force, and indication reviewers with industry and other entities. These relationships were reviewed and updated inonjunction with all meetings and/or conference calls of the writing committee and technical panel during the document development process. The table does not necessarily reflect relationships athe time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership
f $10 000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationshipships in
s considered to be modest if it is less than significant under the preceding definition. Relationtaff
merican College of Cardiology Foundationohn C. Lewin, MD, Chief Executive Officeroseph M. Allen, MA, Director, TRIP (Translating Re-earch Into Practice)indsey Law, MHS, Senior Specialist, Appropriate Useriteriatarr Webb, MPH, Senior Specialist, Appropriate Useriteriarin A. Barrett, MPS, Senior Specialist, Science andlinical Policy
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Quality Strategic Directions Committee Appropriateness CriteriaWorking Group, American College of Radiology, Society of Cardio-content.onlinejacDownloaded from
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4. Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method forevaluating the appropriateness of cardiovascular imaging. J Am CollCardiol. 2005;46:1606–13.
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8. Budoff MJ, Cohen MC, Garcia MJ, et al. ACCF/AHA clinicalcompetence statement on cardiac imaging with computed tomographyand magnetic resonance: a report of the American College of Cardi-ology Foundation/American Heart Association/American College ofPhysicians Task Force on Clinical Competence and Training. J AmColl Cardiol. 2005;46:383–402.
9. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guidelineupdate for exercise testing: summary article. A report of the AmericanCollege of Cardiology/American Heart Association Task Force onPractice Guidelines (Committee to Update the 1997 Exercise TestingGuidelines). J Am Coll Cardiol. 2002;40:1531–40.
0. National Institutes of Health: National Heart LaBI. Third Report pfthe National Cholesterol Education Program (NCEP) Expert Panelon Detection, Evaluation, and Treatment of High Blood Cholesterolin Adults (Adult Treatment Panel III). NIH Publication No. 02-5215.September 2002.
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3. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guidelineupdate for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/
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6. Mark DB, Berman DS, Budoff MJ, et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document oncoronary computed tomographic angiography: a report of the Amer-ican College of Cardiology Foundation Task Force on Expert Con-sensus Documents. J Am Coll Cardiol. 2010;55:2663–99.
7. Diamond GA. A clinically relevant classification of chest discomfort.J Am Coll Cardiol. 1983;1:574–5.
8. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelinesfor the management of patients with ST-elevation myocardial infarc-tion: a report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines (Committee to Revisethe 1999 Guidelines for the Management of Patients with AcuteMyocardial Infarction). J Am Coll Cardiol. 2004;44:e1–211.
9. Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHAfocused update on perioperative beta blockade incorporated into theACC/AHA 2007 guidelines on perioperative cardiovascular evaluationand care for noncardiac surgery: a report of the American College ofCardiology Foundation/American Heart Association Task Force onPractice Guidelines. J Am Coll Cardiol. 2009;54:e13–118.
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ey Words: ACCF Appropriate Use Criteria y coronary artery bypassraft surgery y coronary artery disease y coronary heart disease yoronary calcium score y computed tomography y computedomographic angiography y electrocardiogram y heart failure ystimated metabolic equivalents of exercise y myocardial infarction y
ercutaneous coronary intervention y perioperative evaluation.by on October 27, 2010 c.org
doi:10.1016/j.jacc.2010.07.005 published online Oct 25, 2010; J. Am. Coll. Cardiol.
and Geoffrey D. Rubin Manuel Cerqueira, John McB. Hodgson, Daniel Mark, James Min, Patrick O'Gara,
Interventions, Society for Cardiovascular Magnetic Resonance, Allen J. Taylor, Society of Nuclear Cardiology, Society for Cardiovascular Angiography and
American Heart Association, American Society of Echocardiography, American Radiology,Society of Cardiovascular Computed Tomography, American College of
American College of Cardiology Foundation Appropriate Use Criteria Task Force, Criteria for Cardiac Computed Tomography
ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 Appropriate Use
This information is current as of October 27, 2010
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