2019 Appropriate Use Criteria for Multimodality Imaging in Nonvalvular Heart Disease

Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P.
ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2019;Jan 7:[Epub ahead of print].

The following are key points to remember from the multisociety document on 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease:

  1. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of structural (nonvalvular) heart disease.
  2. The goal of this document is the determination of the range of modalities that may or may not be reasonable for specific indications rather than determination of a single best test for each indication or a rank order.
  3. In the scenario, if more than one modality falls into the same Appropriate Use category, physician judgment and available local expertise should be used to determine choice of test.
  4. Transthoracic echocardiography (TTE) is considered “appropriate” for the initial cardiac evaluation of a known systemic, congenital, or acquired disease that could be associated with structural heart disease.
  5. TTE, cardiac magnetic resonance imaging (MRI), or radionuclide ventriculography is considered appropriate evaluation after appropriate time interval following revascularization and/or optimal medical therapy to determine candidacy for implantable cardioverter-defibrillator/cardiac resynchronization therapy and/or to determine optimal choice of device.
  6. TTE, transesophageal echocardiography (TEE), cardiac MRI, or cardiac computed tomography (CT) is considered “appropriate” for initial evaluation of cardiac mass, suspected tumor or thrombus, or potential cardiac source of emboli.
  7. TEE, cardiac MRI, or cardiac CT is considered “appropriate” for comprehensive further evaluation of dilated aortic sinuses or ascending aorta identified by TTE.
  8. TEE or intracardiac echocardiography (ICE) and fluoroscopy are considered “appropriate” for intraprocedural guidance for closure of patent foramen ovale or atrial septal defect.
  9. TEE and fluoroscopy are considered “appropriate” for intraprocedural guidance for left atrial appendage occlusion. ICE “may be appropriate” in this situation.
  10. The writing committee states that the modalities are not to be considered in a rank order and may be used relative to individual patient circumstances and the balance of risk versus benefit. Accordingly, a study rated “may be appropriate” should not be denied reimbursement in lieu of one rated “appropriate.” In some circumstances, a study ranked “rarely appropriate” may be clinically useful if rationale is properly documented.

Keywords: Acute Coronary Syndrome, Angiography, Arrhythmias, Cardiac, Cardiac Imaging Techniques, Cardiac Imaging Techniques, Cardiomyopathies, Cardiac Resynchronization Therapy, Defibrillators, Implantable, Echocardiography, Echocardiography, Transesophageal, Magnetic Resonance Imaging, Fluoroscopy, Multidetector Computed Tomography, Heart Failure, Heart Septal Defects, Atrial, Heart Transplantation, Heart Valve Diseases, Hypertension, Hypotension, Diagnostic Imaging, Cardiac Imaging Techniques, Pacemaker, Artificial, Myocardial Perfusion Imaging, Septal Occluder Device, Foramen Ovale, Patent, Positron-Emission Tomography, Hypertension, Pulmonary, Radionuclide Imaging, Risk Factors, Exercise Test, Stroke, Syncope, Ischemic Attack, Transient, Ultrasonography, Secondary Prevention

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