New "Multimodality Imaging Appropriate Use Criteria (AUC) for the Detection and Risk Assessment of Stable Ischemic Heart Disease (SIHD)" for the first time integrates the ratings of a variety of imaging tests ranging from exercise ECG to the diagnostic coronary angiogram.

The new AUC, released by the ACC and nine other key cardiovascular specialty societies, update previous criteria for radionuclide imaging (RNI), stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR) and invasive coronary angiography. The criteria address 80 different clinical scenarios for the diagnosis and management of SIHD patients using various imaging modalities and rates these scenarios as appropriate, may be appropriate and rarely appropriate.

"A major innovation in this document is the rating of tests side by side for the same indication," the AUC authors note. "The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test."

In general, the AUC rate the use of many imaging tests in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope as appropriate or may be appropriate. The technical panel, however, noted an exception for cases where low pre-test probability or low risk limited the benefit of most testing except for exercise ECG.

The AUC also found testing for the evaluation of new or worsening symptoms following a prior test or procedure to be appropriate. In addition, testing for patients within 90 days of an abnormal or uncertain prior result was found to be appropriate or may be appropriate. Pre-operative testing, however, was rated appropriate or may be appropriate only for patients with poor functional capacity and who were undergoing vascular or intermediate-risk surgery with one or more clinical risk factors or an organ transplant.

Testing in asymptomatic patients was generally found to be rarely appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals – all of which were rated as may be appropriate. In addition, all modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within two years and within five years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated rarely appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within one year, or prior to low-risk surgery, as well as imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation, also received rarely appropriate ratings.

"We believe that this evidence synthesis, representing decades of published reports, will foster a greater knowledge base on the part of the referring physician to promote optimized decision making within the diagnostic evaluation of SIHD," the AUC authors said. Moving forward, they note that future AUC will like model this combined document rather than focus on single, specific procedures.

Keywords: Myocardial Ischemia, Follow-Up Studies, Echocardiography, Stress, Syncope, Electrocardiography, Calcium, Percutaneous Coronary Intervention, Coronary Angiography, Tomography, Heart Failure, Risk Assessment, Coronary Artery Bypass, Magnetic Resonance Spectroscopy, Exercise Test