A task force from the American College of Cardiology (ACC), in collaboration with American Association for Thoracic Surgery (AATS) and other national organizations, has released an Appropriate Use Criteria (AUC) statement for 2019 regarding multimodality imaging of cardiac structure and function evaluation in nonvalvular heart disease. The report was published in the Journal of the American College of Cardiology.
Experts in structural heart disease formed a writing committee to identify and categorized treatment indications. For evaluating appropriate use, the committee members considered cost as an additional factor. In addition, panel members rated AUC of each assessment as either Appropriate (median score of 7-9), May Be Appropriate (median score of 4-6), or Rarely Appropriate (median score of 1-3).
Initial Assessment of Cardiac Structure and Function
In the initial evaluation for transthoracic echocardiography (TTE), the AUC panel attributed an Appropriate rating for the screening of first-degree relatives of a patient with an inherited cardiomyopathy as well as an initial assessment of a patient prior to medications/radiation exposure that carry risks of heart failure or cardiotoxicity.
Additionally, for TTE, assessment of a suspected pulmonary arterial hypertension (eg, assessment of estimated pulmonary artery pressure and right ventricular function in patients at risk of pulmonary arterial hypertension) as well as screening of relatives of patients with dissection or aortic aneurysm were deemed appropriate.
These scenarios were attributed Rarely Appropriate scores for transesophageal echocardiography. Other tests described in this section included stress echo, strain/strain rate imaging by speckle or tissue Doppler, radionuclide ventriculography (RVG), myocardial perfusion imaging (MPI) (single-photon emission computed tomography [SPECT]/PET), CMR, and CT.
The test with the most Rarely Appropriate scores was MPI (SPECT/PET), which was attributed to all indications in the initial assessment of structure and function.
Assessment of Cardiac Structure and Function in Patients with Previous Testing
For patients with newly diagnosed left bundle branch block, frequent ventricular premature contractions without other evidence of heart disease, non-sustained ventricular tachycardia (VT), and sustained VT or ventricular fibrillation (VF), the expert committee suggests that TTE is Appropriate, whereas TEE is rarely appropriate for these indications.
May Be Appropriate scores were primarily attributed to stress echo, MPI (SPECT/PET), and CMR when it corresponded with non-sustained VT and sustained VT or VF as well as syncope without other symptoms or signs of cardiovascular disease.
Conversely, Rarely Appropriate scores were categorized for the majority of tests, including F-18 FDG PET and Tc-99m PYP as well as TEE, for several indications. Indications with Rarely Appropriate scores for TEE, for instance, included the majority across arrhythmias or conduction disorders, palpitations/presyncope/syncope, hypertensive heart disease, and pulmonary hypertension. Also, TTE was found to be mostly Appropriate across all indications comprising device therapy, cardiac transplantation, and other indications (eg, suspected pericardial diseases and suspected acute aortic pathology).
Assessment of Cardiac Structure and Function in Patients Receiving Transcatheter Treatment for Structural Heart Disease
In follow-up testing to validate an initial diagnostic test, all tests were deemed Rarely Appropriate for further examination of a suspected or known “small cardiovascular implantable electronic device-related thrombus identified by TTE in an asymptomatic patient.” The only Appropriate tests included MPI (SPECT/PET), CMR, and CT for left ventricular systolic dysfunction without severe valvular disease and excluding coronary artery disease (CAD) in heart failure (HF) and left ventricular systolic dysfunction patients without angina.
Additionally, all tests were Rarely Appropriate for the <1-year re-evaluation of known aortic dilatation and the size and morphology of the aortic sinuses and ascending aorta in patients with a bicuspid aortic valve.
Tests considered Appropriate for the evaluation of transient ischemic stroke (TIA) or ischemic stroke for all indications included TTE and TEE. In addition, TTE, TEE, 3D-TEE, CMR, and CTA were considered Appropriate for the preprocedural evaluation atrial septum anatomy, atrial septum aneurysm, and suitability for percutaneous device closure. The TEE test was also deemed Appropriate for most indications in the pre-procedural evaluation for LAA occlusion and intraprocedural guidance for LAA occlusion categories.
The AUC as published in this new report were designed “to inform clinicians, patients, and health policy makers about the reasonable use of technologies to help improve patient symptoms and health outcomes”.
“We believe the multimodality approach more closely replicates clinical decision making and will be useful,” the expert committee wrote. “Future documents will not provide single-source guidance for appropriateness of a single imaging modality in all disease states. Echocardiography indications, for example, will be spread across complimentary documents such as the multimodality stable ischemic heart disease AUC, the valvular heart disease multimodality document, the current document, and the multimodality imaging in pre-operative evaluation document, which is under development.”
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 [published online January 7, 2019]. JACC. doi: 10.1016/j.jacc.2018.10.038