New ACCF/ACR Document Provides Guidance on Appropriate Use of Imaging in HF Patients

A new Appropriate Utilization of Imaging (AUI) document released by the ACC and the American College of Radiology (ACR) aims to provide guidance on the appropriate use of cardiovascular imaging modalities for specific clinical scenarios in heart failure (HF) patients.

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The document — the first collaboration between the two groups — provides a framework for decisions regarding judicious use of imaging in the management of patients with suspected, incompletely characterized or known HF. "The ACR, ACC and the collaborators in this document believe that careful balancing of a broad range of clinical experiences and available evidence-based information will help guide a more effective, efficient and equitable allocation of health care resources," the authors note.

The AUI focuses on five key scenarios: 1) Newly suspected or potential HF; 2) HF associated with myocardial infarction (MI); 3) HF assessment for consideration of revascularization; 4) Consideration of and follow-up for device therapy; 5) Repeat evaluation of HF.

Under the first scenario, the rating panel found no role in general for routine use of stress cardiovascular imaging, cardiac CT, or invasive angiography in patients undergoing initial evaluation for potential or suspected HF. However, the panel noted that both echocardiography and CMR could provide clinically meaningful information, and that radionuclide ventriculography (RNV) may be useful in situations where only EF information is needed. In addition, both echocardiography and CMR were considered by the panel to be useful for routine evaluation for comprehensive cardiac structure and function, including in patients with familial cardiomyopathy, congenital heart disease, or post-MI. The panel also noted that ventricular function evaluation might also be performed at time of coronary arteriography in acute MI or suspected ischemia.

Upon diagnosis of HF, the rating panel identified stress testing with any of the available modalities, or angiography with CT, or invasive cardiac catheterization as most appropriate. In patients with HF and angina, invasive cardiac catheterization and angiography was felt to be appropriate, if the patient was otherwise a candidate for revascularization. In terms of viability, the rating panel suggested many of the modalities were sufficient for determining viability across a spectrum of patients, with resting CMR and PET felt to be appropriate and useful in the patients with severe ventricular dysfunction, along with stress echo or SPECT which may also be considered reasonable.

In terms of device therapy, the rating panel felt that echocardiography and CMR testing were useful in patient selection, while CMR and cardiac CT were rated appropriate for device planning. CMR was also felt to be useful for identification of myocardial fibrosis and possible thrombus, however, the rating panel suggested that patients did not need a stress evaluation or invasive cardiac catheterization. Finally, the rating panel felt it was appropriate to re-evaluate LV function for patients who had a change in clinical status, but thought the indication for routine follow-up EF testing was rarely appropriate, with the possible exception of echocardiography, which was rated as may be appropriate. According to the AUI authors, it is hoped that document will "provide guidance at the time of test consideration, especially in patients with HF who are seen in multiple locations within the health care system."

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