Appropriate Use of Cardiac Imaging in Emergency Department Patients With Chest Pain

Rybicki FJ, Udelson JE, Peacock WF, et al.
SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016;Jan 22:[Epub ahead of print].

The following are key points to remember about this statement on the Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain:

  1. This publication, with representation from the American College of Cardiology (ACC)/American Heart Association (AHA) and Emergency Department Societies as well as all relevant imaging societies, provides guidelines for appropriate utilization of cardiovascular imaging in patients presenting to the emergency department with chest pain.
  2. Clinical presentations were grouped into four categories, and for each category, multiple clinical scenarios were considered. The four clinical presentation groups included: 1) Suspected non–ST-segment elevation acute coronary syndrome (NSTE ACS) (10 scenarios); 2) Suspected pulmonary embolism (five scenarios); 3) Suspected acute syndrome of the aorta (three scenarios); 4) Patients for whom a leading diagnosis is problematic or not possible (two scenarios).
  3. Imaging and other diagnostic tests considered included cardiac catheterization, coronary computed tomography angiography (CCTA), cardiac magnetic resonance imaging (CMR), echocardiography (echo), electrocardiogram (ECG), and single-photon emission computed tomography (SPECT). Separate appropriateness criteria were developed for resting and stress imaging.
  4. Appropriateness was scored by a separate panel convened for this publication and was not simply extracted from previously published appropriate use criteria documents. Studies were graded as appropriate (score 7, 8, or 9), may be appropriate (score 4, 5, or 6), and rarely appropriate (score 1, 2, or 3). A test was assigned an appropriateness rating when there was ≥60% consensus among the panel. When consensus could not be achieved, a test was rated (M*), indicating that a rating of “may be appropriate” was given on the basis of lack of consensus.
  5. Select clinical scenarios are highlighted as follows:
    • Scenario 1: ECG diagnostic for ST-segment elevation myocardial infarction (STEMI): cardiac catheterization is considered appropriate, with all other imaging modalities considered rarely appropriate.
    • Scenario 3: Initial ECG and/or biomarker unequivocally positive for ischemia: cardiac catheterization is considered appropriate, with all other imaging modalities rated as rarely appropriate.
    • Scenario 4: Equivocal initial troponin or single troponin elevation without additional evidence of ACS: CCTA and rest SPECT were considered appropriate, catheterization rarely appropriate, and resting echo and CMR were graded as M*.
    • Scenario 8: Patients in the “observational pathway” after initial assessment (typically 9-24 hours out from presentation) with unequivocal evidence for NSTEMI/ACS: cardiac catheterization was considered appropriate and all other imaging modalities including rest and stress modalities graded as M*.
    • Scenario 9: Serial ECG and troponins negative for NSTEMI/ACS in the observational time frame: CCTA and stress rest echo, CMR, and SPECT were considered appropriate. The committee suggested that low-risk patients in this category may be evaluated as outpatients.
    • Scenario 10: Serial ECG or troponins borderline for NSTEMI/ACS: CCTA and stress/rest modalities were all considered appropriate and catheterization graded as M*.
    • Scenarios 12 and 13: Suspected pulmonary embolism with either positive D-dimer or high clinical likelihood: CT pulmonary angiography and ventilation-perfusion (VQ) scan were considered appropriate.
    • Scenario 16: Suspected acute aortic syndrome: CT aortography was considered appropriate and all other imaging modalities including MR aortography were graded as M* in the hemodynamically unstable patient.
    • Scenario 17: Suspected acute aortic syndrome in hemodynamically stable patient: CT aortography, MR aortography, and transesophageal echo were considered appropriate.
    • Scenario 20: Imaging when a definitive diagnosis is problematic or not possible and where the overall likelihood of ACS, pulmonary embolism, or acute aortic syndrome is not low, a “triple-rule-out” CTA to evaluate coronary anatomy, aortic anatomy, and screen for pulmonary embolism was considered appropriate.
  6. The reader should note that by design, these recommendations are for the early evaluation of patients presenting in the emergency department and emphasize the first diagnostic test to be obtained. The issue of the appropriateness of second imaging tests, and imaging tests for assessing prognosis after a diagnosis is established, was not addressed in this manuscript.

Keywords: Acute Coronary Syndrome, Angina Pectoris, Aortography, Biomarkers, Cardiac Catheterization, Chest Pain, Diagnostic Imaging, Echocardiography, Electrocardiography, Emergency Service, Hospital, Magnetic Resonance Imaging, Myocardial Infarction, Pulmonary Embolism, Tomography, X-Ray Computed, Troponin

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