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WASHINGTON,DC (June 11, 2012) — A new report issued today by theAmerican College of Cardiology (ACC) and developed in collaboration with 10other leading professional societies provides detailed criteria to helpclinicians maximize the appropriate use of certain noninvasive vascular testswhen caring for patients with suspected or known non-coronary arterial disorders.
“Thisis the first systematic and comprehensive evaluation looking at appropriateindications for vascular testing, such as ultrasound or functional testing,”said Emile R. Mohler III, M.D., director of vascular medicine for theUniversity of Pennsylvania Health System and chair of the writing committee.“We hope this document will help clinicians determine whether or not and whento refer individual patients for testing.”
Such decisions affect a growing numberof patients as the population ages. Dr. Mohler estimates more than 20 millionadults in the U.S. have some form of vascular disease, and would likely be acandidate for these types of tests.
Ultrasoundand other noninvasive laboratory tests can be essential tools to helpclinicians evaluate vascular blockages and disease, for example, in thearteries of the neck, kidneys, abdomen, and lower extremities, as well as theaorta itself. Such testing also plays a central role in surveillance of thevascular system in some patients to help inform treatment decisions and preventserious problems, and is part of follow-up after peripheral vascularprocedures, such as arterial bypass, surgical removal of plaque(endarterectomy), or stenting.
Thepanel identified common clinical scenarios when noninvasive vascular testingmight be considered in patients with suspected or known non-coronary arterialdisorders (e.g., narrowing or blockages in the arteries of the neck, kidneys,abdomen or legs, abdominal aortic aneurysms, arterial dissection). Applying arigorous rating scale, the 19-member panel then assessed the appropriateness ofeach indication and often at different time intervals (3-5, 6-8 and 9-12months).
The group found arterial vascular testing to be “appropriate” in about half of theclinical situations evaluated. Overall, vascular studies were deemedappropriate when clinical signs and symptoms were the main reason for testing.For example, Dr. Mohler explains it is reasonable to order a lower extremityvascular study for a patient who reports calf pain upon walking that resolveswith rest. Tests that were conducted in patients with existing atheroscleroticdisease or to establish a “baseline” after a revascularization procedure werealso considered appropriate based on ratings.
One-third of the indications were ratedas “uncertain.” According to Dr. Mohler, these indications represent variationsin practice and reveal important gaps in the evidence, prompting the panel tocall for clinical and cost-effectiveness studies on non-invasive vasculartesting.
Notably,the panel determined one in five uses of vascular testing to be “inappropriate”meaning that, although doing the test does not cause harm, the informationgleaned would not further inform clinical judgment. A few examples include:
· Orderingan ultrasound of the carotids or neck arteries in someone at low risk for heartattack or stroke.
· Screeningfor kidney artery disease in someone with peripheral artery disease with wellcontrolled high blood pressure (hypertension) on one medication
· Choosingto perform an abdominal ultrasound in a patient with non-specific lowerextremity discomfort
· Orderinga mesenteric artery ultrasound (arteries thatsupply the small and large intestines) as an initial test to evaluate thepatient with chronic constipation or diarrhea
· Performinga follow-up study for a patient with a normal baseline study who has no newsymptoms
“As imaging technology and clinicalapplications continue to advance, the health care community needs to understandhow to best incorporate these technologies into daily clinical care,” said Dr.Mohler. “These appropriate use criteria should guide clinicians as to what isan appropriate and inappropriate test so that we can rationally decide whentesting is the best next step, especially in this time of cost-effectiveness inmedicine.”
In addition to looking at the reasonsfor ordering these tests, the work group also sought to determine howfrequently repeat testing is needed in clinical practice in light of the needfor ongoing surveillance in some patients.
Dr.Mohler stresses these criteria should not supersede sound clinical judgment forindividual patients. The document also outlines key research areas movingforward. A related report presenting appropriate use criteria for vascularlaboratory testing to evaluate venous circulation is expected to be released inlate fall of this year.
Theappropriate use criteria were developed in collaboration with the AmericanCollege of Radiology, American Instituteof Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology,Intersocietal Commission for the Accreditation of Vascular Laboratories, Society forCardiovascular Angiography and Interventions, Society of CardiovascularComputed Tomography, Society of Interventional Radiology, Society for VascularMedicine and Society for Vascular Surgery. The document is further endorsed bythe American Academy of Neurology, American Podiatric Medical Association,Society for Clinical Vascular Surgery, Society for Cardiovascular MagneticResonance, and Society for Vascular Ultrasound.
About the American College of Cardiology
The mission of the American College ofCardiology is to transform cardiovascular care and improve heart health. TheCollege is a 40,000-member nonprofit medical society comprised of physicians,surgeons, nurses, physician assistants, pharmacists and practice managers, andbestows credentials upon cardiovascular specialists who meet its stringentqualifications. The College is a leader in the formulation of health policy, standardsand guidelines, and is a staunch supporter of cardiovascular research. The ACCprovides professional education and operates national registries for themeasurement and improvement of quality care. More information about theassociation is available online at http://www.cardiosource.org/ACC .