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A new report issued today by the American College of Cardiology (ACC), developed in partnership with the Society of Cardiovascular Computed Tomography (SCCT), provides new and expanded criteria to help clinicians optimally select patients who could benefit from cardiac computed tomography (CCT) and inform payers about appropriate clinical scenarios for its use.
Like other tests, optimal use of CCT—an imaging test that uses x-rays to either diagnose artery blockages in patients with chest pain, breathing difficulties, and other heart-related symptoms, or in those who do not have symptoms of heart disease to determine if they have the beginnings of artery disease – requires selecting patients with appropriate clinical circumstances, and avoidance of inappropriate testing which can lead to unnecessary costs to the health care system and lack of benefit or even harm.
“As the field of cardiac CT continues to advance along with other biomedical imaging tests, the health care community needs to understand how to best incorporate this technology into daily clinical care,” said Allen J. Taylor, M.D., chair of the writing committee and professor of medicine, Georgetown University, Washington, DC. “This update adds to our understanding of selecting the best candidates for cardiac CT imaging so that doctors can help perform the right test in the right patient at the right time.”
The original appropriate use criteria for CCT were issued in 2006 when this technology was still relatively new. Since that time, advances in this technology have made it easier to use and safer for patients, and there has also been an explosion in new clinical data related to its use, according to Dr. Taylor.
“This document reflects this progress in knowledge and our desire to make the criteria more comprehensive to more closely match a patient situation to the test and help in clinical decision making,” he added, emphasizing that selecting the proper patients for testing is an essential first step in the provision of quality cardiac care.
The criteria were developed using a multi-step process first described by the Rand Corporation in which clinical scenarios are developed and then rated by an external panel of technical advisors. For the CCT update, the panel assessed the appropriateness of CCT imaging for 93 different clinical scenarios – an increase from 39 in the 2006 report – scoring each to determine if the use of CCT imaging was appropriate, inappropriate or uncertain for a given situation. The clinical scenarios include two tests: 1) CCT angiography that uses contrast, or x-ray, dye, and 2) non-contrast CT scanning for calcium scoring, which is used to detect calcium deposits in the arteries.
In general, CCT angiography is considered appropriate for diagnosis and risk assessment in patients with symptoms of possible heart disease who have a low to intermediate risk of a heart problem, or uncertainty regarding their diagnosis after other tests are performed; however, testing in high-risk patients, routine repeat testing and general screening in patients with no symptoms or other clinical scenarios are generally not considered appropriate.
“If we know a patient has existing heart problems or is at high risk for heart disease, doing the test isn’t generally going to add any valuable clinical information,” explained Dr. Taylor. “Ordering a test when a patient doesn’t need it—or won’t benefit—is not quality cardiac care.”
The updated criteria broadened the number of patients and applications of non-contrast CT for calcium scanning. According to the appropriateness ratings, calcium scanning is considered appropriate among patients without heart symptoms who have an intermediate risk of heart disease or selected patients with low risk (particularly women or younger men) who have a family history of heart problems.
Examples of clinical scenarios – drawn mostly from common applications or anticipated uses – include acute and chronic chest pain, testing in symptomatic and asymptomatic patients, heart failure, preoperative risk assessment before both cardiac and noncardiac surgery, and evaluation of cardiac structure and function, among others. Of the clinical scenarios evaluated, cardiac CT was deemed appropriate in 37 percent, and the others were considered either inappropriate uses or uncertain.
“We hope that by providing broadened and more defined clinical scenarios, these criteria will impact clinical decision making, performance and reimbursement policy,” said Dr. Taylor. “But these criteria are only as good as the level to which they are implemented. If used broadly, they can help us deliver higher quality and more efficient cardiac care.”
These appropriate use criteria were endorsed by the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, the American College of Radiology, and the Society for Cardiovascular Magnetic Resonance.
Full text of this report will be published in the November 23, 2010, issue of the Journal of the American College of Cardiology and available on the ACC (www.cardiosource.org) web site. It will also be co-published in Circulation and the Journal of Cardiovascular Computed Tomography.
Dr. Taylor reports no conflicts of interest.
About the American College of Cardiology:
The American College of Cardiology is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 39,000-member nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at http://www.cardiosource.org/ACC.