ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 Appropriate Use for CCT.pdf · American College of Cardiology Foundation Appropriate Use Criteria Task Force, Criteria for Cardiac Computed

doi:10.1016/j.jacc.2010.07.005 published online Oct 25, 2010; J. Am. Coll. Cardiol.

and Geoffrey D. Rubin Manuel Cerqueira, John McB. Hodgson, Daniel Mark, James Min, Patrick O'Gara,

Interventions, Society for Cardiovascular Magnetic Resonance, Allen J. Taylor, Society of Nuclear Cardiology, Society for Cardiovascular Angiography and

American Heart Association, American Society of Echocardiography, American Radiology,Society of Cardiovascular Computed Tomography, American College of

American College of Cardiology Foundation Appropriate Use Criteria Task Force, Criteria for Cardiac Computed Tomography

ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 Appropriate Use

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Journal of the American College of Cardiology Vol. 56, No. xx, 2010© 2010 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00P

APPROPRIATE USE CRITERIA

ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR2010 Appropriate Use Criteriafor Cardiac Computed TomographyA Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force,the Society of Cardiovascular Computed Tomography, the American College of Radiology, the AmericanHeart Association, the American Society of Echocardiography, the American Society of NuclearCardiology, the Society for Cardiovascular Angiography and Interventions, and the Society forCardiovascular Magnetic Resonance

ublished by Elsevier Inc. doi:10.1016/j.jacc.2010.07.005

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CardiacComputedTomographyWriting Group

ardiovascular Computed Tomerican Heart Association

llen J. Taylor, MD, FACC, FAHA, Chair*

anuel Cerqueira, MD, FACC, FASNC†ohn McB. Hodgson, MD, FACC, FSCAI‡aniel Mark, MD, MPH, FACC, FAHA*

ames Min, MD, FACC§atrick O’Gara, MD, FACC, FAHA�

mography, the American College of Radiology, the, the American Society of Echocardiography, the

of Cardiologhealthpermissi

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Official American College of Cardiology Foundation Representative;Official American Society of Nuclear Cardiology Representative;Official Society for Cardiovascular Angiography and Interventionsepresentative; §Official Society of Cardiovascular Computed Tomog-

aphy Representative; �Official American Heart Association Represen-ative; ¶Official American College of Radiology Representative;Official North American Society for Cardiovascular Imagingepresentative

Geoffrey D. Rubin, MD, FSCBTMR¶#

TechnicalPanel

Christopher M. Kramer, MD, FACC,FAHA, Moderator

Allen J. Taylor, MD, FACC, FAHA,Writing Group Liaison

Daniel Berman, MD, FACC§Alan Brown, MD, FACC, FAHA, FNLA*Farooq A. Chaudhry, MD, FACC, FAHA,

FASE**Ricardo C. Cury, MD§††Milind Y. Desai, MD, FACC††Andrew J. Einstein, MD, PHD, FACC,

FAHA, FASNC†Antoinette S. Gomes, MD, FAHA, FSIR¶Robert Harrington, MD, FACC, FAHA,

FSCAI*

Udo Hoffmann, MD, MPH#Rahul Khare, MD‡‡John Lesser, MD, FACC§Christopher McGann, MD, FACC§§Alan Rosenberg, MD, FACC� �Robert Schwartz, MD, FACC‡Marc Shelton, MD, FACC*Gerald W. Smetana, MD¶¶Sidney C. Smith, JR, MD, FACC, FAHA�

**Official American Society of Echocardiography Representative;††Official Society for Cardiovascular Magnetic Resonance Representa-tive; ‡‡Official American College of Emergency Physicians Represen-tative; §§Official Heart Rhythm Society Representative; � �OfficialHealth Plan Representative; ¶¶Official American College of Physi-cians Representative

his document was approved by the American College of Cardiology Foundation, inune 2010, the American College of Radiology, the American Society of Echocardi-graphy, the American Society of Nuclear Cardiology, the Society for Cardiovascularngiography and Interventions, the Society for Cardiovascular Magnetic Resonance,

nd Society of Cardiovascular Computed Tomography, and by the American Heartssociation in September 2010.The American College of Cardiology Foundation requests that this document be

ited as follows: Taylor AJ, Cequeira M, Hodgson JM, Mark D, Min J, O’Gara P,ubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropri-

te use criteria for cardiac computed tomography: a report of the American Collegef Cardiology Foundation Appropriate Use Criteria Task Force, the Society of

American Society of Nuclear Cardiology, the Society for Cardiovascular Angiographyand Interventions, and the Society for Cardiovascular Magnetic Resonance. J AmColl Cardiol 2010;56:xxx–xx.

This article is copublished in Circulation and the Journal of Cardiovascular ComputedTomography.

Copies: This document is available on the World Wide Web site of the AmericanCollege of Cardiology (www.cardiosource.org). For copies of this document, pleasecontact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected].

Permissions: Modification, alteration, enhancement, and/or distribution of thisdocument are not permitted without the express permission of the American College

y Foundation. Please contact Elsevier’s permission [email protected]

October 26, 2010

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2 Taylor et al. JACC Vol. 56, No. xx, 2010Appropriate Use Criteria for Cardiac Computed Tomography Month 2010:000–000

ACCFAppropriateUse CriteriaTask Force

Michael J. Wolk, MD, MACC, Chair

Joseph M. Allen, MASteven Bailey, MD, FACC, FSCAIPamela S. Douglas, MD, MACC, FAHA,

Robert C. Hendel, MD, FACC, FAHA, FASNCChristopher M. Kramer, MD, FACC, FAHAJames Min, MD, FACC, FSCCTManesh R. Patel, MD, FACCLeslee Shaw, PHD, FACC, FASNC

FASE Raymond F. Stainback, MD, FACC, FASE

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TABLE OF CONTENTS

bstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

reface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. General Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Results of Ratings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Cardiac Computed Tomography AppropriateUse Criteria (By Indication) . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 1. Detection of CAD in SymptomaticPatients Without Known Heart Disease . . . . . . . . . .XXXX

Table 2. Detection of CAD/Risk Assessmentin Asymptomatic Individuals WithoutKnown CAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 3. Detection of CAD in Other ClinicalScenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 4. Use of CT Angiography in the Settingof Prior Test Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 5. Risk Assessment Preoperative Evaluationof Noncardiac Surgery Without ActiveCardiac Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 6. Risk Assessment Postrevascularization(PCI or CABG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 7. Evaluation of Cardiac Structure andFunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

. Cardiac Computed Tomography AppropriateUse Criteria (By Appropriate Use Criteria) . . . . . . .XXXX

Table 8. Appropriate Indications(Median Score 7–9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 9. Uncertain Indications(Median Score 4–6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 10. Inappropriate Indications
(Median Score 1–3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX p
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. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

9.1. Clinical Scenarios and Their Ratings . . . . . . . . . . .XXXX

9.2. Application of Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ppendix A: Additional Cardiac Computedomography Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ppendix B: Additional Methods . . . . . . . . . . . . . . . . . . . . . . .XXXX

Relationships With Industry and Other Entities . . . .XXXX

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ppendix C: ACCF/SCCT/ACR/AHA/ASE/ASNC/CAI/SCMR 2010 Appropriate Use Criteriaor Cardiac Computed Tomography Participants . . . .XXXX

ppendix D: ACCF/SCCT/ACR/AHA/ASE/ASNC/CAI/SCMR 2010 Cardiac Computed Tomographyppropriate Use Criteria Writing Group,echnical Panel, Task Force, and Indicationeviewers—Relationships With Industry andther Entities (In Alphabetical Order) . . . . . . . . . . . . . . . .XXXX

eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

bstract

he American College of Cardiology Foundation (ACCF),long with key specialty and subspecialty societies, con-ucted an appropriate use review of common clinical sce-arios where cardiac computed tomography (CCT) is fre-uently considered. The present document is an update tohe original CCT/cardiac magnetic resonance (CMR) ap-ropriateness criteria published in 2006, written to reflecthanges in test utilization, to incorporate new clinical data,nd to clarify CCT use where omissions or lack of clarityxisted in the original criteria (1).

The indications for this review were drawn from commonpplications or anticipated uses, as well as from currentlinical practice guidelines. Ninety-three clinical scenariosere developed by a writing group and scored by a separate

echnical panel on a scale of 1 to 9 to designate appropriatese, inappropriate use, or uncertain use.In general, use of CCT angiography for diagnosis and

isk assessment in patients with low or intermediate risk or
retest probability for coronary artery disease (CAD) was
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3JACC Vol. 56, No. xx, 2010 Taylor et al.Month 2010:000–000 Appropriate Use Criteria for Cardiac Computed Tomography

iewed favorably, whereas testing in high-risk patients,outine repeat testing, and general screening in certain clinicalcenarios were viewed less favorably. Use of noncontrastomputed tomography (CT) for calcium scoring was rated asppropriate within intermediate- and selected low-risk pa-ients. Appropriate applications of CCT are also within theategory of cardiac structural and functional evaluation. It isnticipated that these results will have an impact on physicianecision making, performance, and reimbursement policy, andhat they will help guide future research.

reface

n an effort to respond to the need for the rational use ofmaging services in the delivery of high-quality care, theCCF has undertaken a process to determine the appro-riate use of cardiovascular imaging for selected patientndications.

Appropriate use criteria publications reflect an ongoingffort by the ACCF to critically and systematically create,eview, and categorize clinical situations where diagnosticests and procedures are utilized by physicians caring foratients with cardiovascular diseases. The process is basedn current understanding of the technical capabilities of themaging modalities examined. Although not intended to bentirely comprehensive, the indications are meant to iden-ify common scenarios encompassing the majority of con-emporary practice. Given the breadth of information theyonvey, the indications do not directly correspond to theinth revision of the International Classification of DiseasesICD-9) system as these codes do not include clinicalnformation, such as symptom status.

The ACCF believes that careful blending of a broadange of clinical experiences and available evidence-basednformation will help guide a more efficient and equitablellocation of healthcare resources in cardiovascular imaging.he ultimate objective of appropriate use criteria is to

mprove patient care and health outcomes in a cost-effectiveanner but is not intended to ignore ambiguity and nuance

ntrinsic to clinical decision making. Local parameters, suchs the availability or quality of equipment or personnel, maynfluence the selection of appropriate imaging procedures.ppropriate use criteria thus should not be considered substi-

utes for sound clinical judgment and practice experience.The ACCF appropriate use criteria process itself is also

volving. In the current iteration, technical panel membersere asked to rate indications for CCT in a manner

ndependent and irrespective of the prior published ACCFatings for CCT and CMR (1) as well as the prior ACCFatings for similar diagnostic stress imaging modalities suchs cardiac radionuclide imaging (2) or stress echocardiogra-hy (3) (see Appendix A for the definitions of terms usedhroughout the indication set). Given the iterative nature ofhe process, readers are counseled not to compare too closely
ndividual appropriate use ratings among modalities rated at p

ifferent times over the past 2 years. A comparative evalu-tion of the appropriate use of multiple imaging techniquess currently being undertaken to assess the relative strengthsf each modality for various clinical scenarios.We are grateful to the technical panel, a professional

roup with a wide range of skills and insights, for theirhoughtful and thorough deliberation of the merits of CCTor various indications. In addition to our thanks to theechnical panel for their dedicated work and review, weould like to offer special thanks to the many individualsho provided a careful review of the draft indications; toeggy Christiansen, the ACCF librarian for her compre-ensive literature searches; to Lindsey Law, Starr Webb,nd Joseph M. Allen, who continually drove the processorward; and to Allen J. Taylor, MD, the chair of the writingommittee for his dedication, insight, and leadership.

Christopher M. Kramer, MD, FACC, FAHAModerator, Cardiac Computed Tomography Technical Panel

Michael J. Wolk, MD, MACCChair, Appropriate Use Criteria Task Force

. Introduction

his report addresses the appropriate use of CCT. Improve-ents in cardiovascular imaging technology and their ap-

lication, coupled with increasing therapeutic options forardiovascular disease, have led to an increase in cardiovas-ular imaging. At the same time, the armamentarium ofoninvasive diagnostic tools has expanded with innovations

n new contrast agents, molecular radionuclide imaging,erfusion echocardiography, computed tomography for cor-nary angiography and calcium scoring, and magnetic res-nance imaging for myocardial structure and viability. Ashe field of CCT continues to advance along with othermaging modalities, the healthcare community needs tonderstand how to best incorporate this technology intoaily clinical care.All prior appropriate use criteria publications from the

CCF and collaborating organizations have reflected anngoing effort to critically and systematically create, review,nd categorize the appropriate use of certain cardiovasculariagnostic tests. The ACCF recognizes the importance ofevising these criteria in a timely manner in order to providehe cardiovascular community with the most accurate indi-ations. The present document is the second update to anxisting appropriate use criteria document, the “ACCF/CR/SCCT/SCMR/ASNC/SCAI/SIR Appropriatenessriteria for Cardiac Computed Tomography and Cardiacagnetic Resonance Imaging,” published in 2006 (1).linicians, payers, and patients are interested in the specificenefits of CCT. Of importance, inappropriate use of CCTay be potentially harmful to patients and generate unwar-

anted costs to the health care system, whereas appropriate
rocedures should likely improve patients’ clinical outcomes.


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his is a critical shift because the intent is for the potentialenefits and risks of the treatment to be explicitly consid-red, rather than the potential usefulness of a diagnostic tests a prelude to further treatment. This document presentshe results of this effort, but it is critical to understand theackground and scope of this document before interpretinghe rating tables.

. Methods

he indications included in this review are purposefullyroad, and they comprise a wide array of cardiovascularigns and symptoms as well as clinical judgment as to theikelihood of cardiovascular findings.

Further description of the methods used for ranking ofhe selected clinical indications is outlined in Appendix Bnd is also found more generally in a previous publication,ACCF Proposed Method for Evaluating the Appropriate-ess of Cardiovascular Imaging” (4). Briefly, this processombines evidence-based medicine and practice experiencey engaging a technical panel in a modified Delphi exercise.ecause the original CCT/CMR criteria document andethods paper was published, several important processes

ave been put in place to further enhance this process. Theynclude convening a formal writing committee with diversexpertise in imaging, circulating the indications for externaleview prior to rating by the technical panel, ensuringppropriate balance of the technical panel, a standardizedating package, and creating formal roles for facilitatinganel interaction at the face-to-face meeting.The panel first rated indications independently. In rating

hese criteria, the Cardiac Computed Tomography Appro-riate Use Criteria Technical Panel was asked to assesshether the use of the test for each indication is appropri-

te, uncertain, or inappropriate as defined in the followingext.

An appropriate imaging study is one in which the expectedncremental information, combined with clinical judgment,xceeds the expected negative consequences* by a sufficientlyide margin for a specific indication that the procedure is

enerally considered acceptable care and a reasonable ap-roach for the indication.The technical panel scores each indication as follows:

Score 7 to 9Appropriate test for specific indication (test is generally

acceptable and is a reasonable approach for theindication).

Score 4 to 6Uncertain for specific indication (test may be generally

acceptable and may be a reasonable approach for theindication). (Uncertainty also implies that more re-

Negative consequences include the risks of the procedure (radiation or contrast

exposure) and the downstream impact of poor test performance such as delay iniagnosis (false negatives) or inappropriate diagnosis (false positives).


search and/or patient information is needed to classifythe indication definitively.)

Score 1 to 3Inappropriate test for specific indication (test is not

generally acceptable and is not a reasonable approachfor the indication).

Then the panel was convened for a face-to-face meetingor discussion of each indication. At this meeting, panelembers were provided with their scores and a blinded

ummary of their peers’ scores. After the consensus meeting,anel members were then asked to independently provideheir final scores for each indication. Following the secondound ratings, a supplemental rating process was conductedor a revised set of criteria for preoperative testing (31 to 38)nd the clinical scenario of prior revascularization (40 to 41).lthough these categories had been considered within theriginal 2 rounds of rating, the clinical scenarios wereewritten to more closely mirror prior documents, and thealloting was repeated.The contributors acknowledge that the division of these

cores into 3 categories of appropriate use is somewhatrbitrary and that the numeric designations should beiewed as a continuum. The contributors also recognizeiversity in clinical opinion for particular clinical scenarios.cores in the intermediate level of appropriate use shouldherefore be labeled uncertain, as critical patient or researchata may be lacking or discordant. This designation shoulde a prompt to the field to carry out definitive research,henever possible. It is anticipated that the appropriate use

riteria reports will require updates as further data areenerated and information from the implementation of theriteria is accumulated.

To avoid bias in the scoring process, the technical paneleliberately was not comprised solely of specialists in thearticular procedure under evaluation. Specialists, whileffering important clinical and technical insights, mightave a natural tendency to rate the indications within theirpecialty as more appropriate than nonspecialists. In addi-ion, care was taken in providing objective, nonbiasednformation, including guidelines and key references, to theechnical panel. Panel members were not provided explicitost information to help determine their appropriate useatings, but they were asked to implicitly consider cost as andditional factor in their evaluation of appropriate use.

The level of agreement among panel members, as definedy RAND (5), was analyzed for each indication based onhe BIOMED rule for a panel of 14 to 16 (a simplifiedAND method for determining disagreement). Per theIOMED definition, agreement was defined as an indica-

ion where 4 or fewer panel members ratings fell outside the-point region containing the median score. Disagreementas defined as a situation where at least 5 panel members

atings fell in both the appropriate and the inappropriateategories. Because the panel had 17 representatives, which
xceeded the 16 addressed in this rule, an additional level of


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greement analysis as described by RAND was performedhat examines the interpercentile range (IPR) comparedith the interpercentile range adjusted for symmetry

IPRAS). This information was used by the moderator touide the panel’s discussion by highlighting areas of differ-nces among the panel members. There was also a thirdategory for indications that were not classified in either thegreement or disagreement categories. Any indication hav-ng disagreement was categorized as uncertain regardless ofhe final median score. Indications that met neither defini-ion for agreement or disagreement are in a third, unlabeled,ategory.

. General Assumptions

ll indications were considered with the following impor-ant assumptions for CCT:

. CCT is performed in accordance with best practicestandards as delineated in the imaging guidelines of theSociety of Cardiovascular Computed Tomography (6,7),by competent (8) and appropriately credentialed physi-cians. This includes the optimization of the scan protocolto limit radiation exposure.

. CCT imaging equipment is available that has the min-imal technical capabilities required for the indication.Typical technical parameters for studies performed onmulti-detector row scanners include CT equipment en-abling 64 or more slices, submillimeter spatial resolution,and gantry rotation time no greater than 420 millisec-onds. Appropriate computer software must be availablefor image analysis.

. Patients are optimally suited for CCT under the follow-ing conditions:a. Regular heart rate and rhythm including a heart rate

at a level commensurate with the temporal resolutionof the available scanner.

b. Body mass index below 40 kg/m2.c. Normal renal function.

. For CT angiography, patient requirements may includethe ability to:a. Hold still and follow breathing instructions.b. Tolerate beta blockers.c. Tolerate sublingual nitroglycerin.d. Lift both arms above the shoulders.

. All indications for CCT were considered with thefollowing important assumptions:a. All indications should first be evaluated based on the

available medical literature.b. In many cases, studies published in the medical

literature are reflections of the capabilities and limi-tations of the test but provide minimal informationabout the role of the test in clinical decision making.

c. Appropriate use criteria development requires deter-
mination of a reasonable course of action for clinical

decision making based on a risk/benefit trade-off asdetermined by individual patient indications.

. For all stress imaging referenced in the indications, themode of stress testing was assumed to be exercise forpatients able to exercise. For patients unable to exercise,pharmacological stress testing was assumed to be used.Further background on the rationale for the assumptionof exercise testing is available in the ACC/AHA 2002Guideline Update for Exercise Testing (9).

. Definitions

complete set of definitions of terms used throughout thendication set is listed in Appendix A. These definitionsere provided and discussed with the technical panel prior

o ratings of indications.schemic Equivalent Chest Pain Syndrome, Anginalquivalent, or Ischemic Electrocardiographic Abnor-alities: Any constellation of clinical findings that is

linically judged to be consistent with obstructive CAD.xamples of such findings include, but are not limited to,

hest pain, chest tightness, burning, shoulder pain, jaw pain,nd new electrocardiographic abnormalities suggestive ofschemic heart disease. Nonchest pain symptoms, such asyspnea or worsening effort tolerance that are felt to beonsistent with CAD may also be considered to be annginal equivalent.

etermining Pretest Risk Assessment forisk Stratification

oronary Heart Disease (CHD) Risk in Asymptomaticatients: Estimation of CHD risk applied to asymptom-tic patients without known CHD. It is assumed thatlinicians will use CCT studies in addition to standardethods of risk assessment as presented in the Nationaleart, Lung, and Blood Institute report (10) on “Detec-

ion, Evaluation, and Treatment of High Blood Choles-erol in Adults (Adult Treatment Panel III [ATP III]).”

Absolute risk is defined as the probability of developingHD, including myocardial infarction or CHD death overgiven time period. The ATP III report specifies absolute

isk for CHD over the next 10 years. CHD risk refers to0-year risk for any hard cardiac event. However, incknowledgment that global absolute risk scores may beiscalibrated to certain populations (e.g., women, youngeren), clinical judgment must be applied in selecting cate-

orical risk thresholds.

• CHD Risk—LowDefined by the age-specific risk level that is belowaverage. In general, low risk will correlate with a10-year absolute CHD risk �10%.

• CHD Risk—IntermediateDefined by the age-specific risk level that is average or
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with a 10-year absolute CHD risk between 10% to20%. Among women and younger men, an expandedintermediate risk range of 6% to 20% may be appro-priate.

• CHD Risk—HighDefined as the presence of diabetes mellitus in apatient �40 years of age, peripheral arterial disease orother coronary risk equivalents, or the 10-year absoluteCHD risk of �20%.

retest Probability of Obstructive/Significant CAD forymptomatic (Ischemic Equivalent) Patients: Once thehysician determines the presence of symptoms that mayepresent obstructive CAD (ischemic equivalent present),he pretest probability of CAD should be assessed. Therere a number of risk algorithms (11,12) available that can besed to calculate this probability. Clinicians should becomeamiliar with those that pertain to the populations theyncounter most often. In scoring the indications, the fol-owing probabilities as calculated from any of the variousvailable algorithms should be applied:

• Low pretest probability: �10% pretest probability ofCAD.

• Intermediate pretest probability: Between 10% and90% pretest probability of CAD.

• High pretest probability: �90% pretest probability ofCAD.

The method recommended by the ACC/AHA Guide-ines for Chronic Stable Angina (13) is provided in theollowing text as 1 example of a method used to calculateretest probability and is a modification of a previouslyublished literature review (14). Please refer to definitions ofngina and Table A. Please note that the table only predictsretest probability in patients based upon presenting symp-oms, age, and sex. Additional history and electrocardio-raphic evidence of prior infarction dramatically affectretest probability. Although they are not incorporated intohe algorithm, cardiovascular risk factors, discussed in riskssessment indications, may also affect pretest likelihood ofAD. Detailed normograms are available that incorporate

able A. Pretest Probability of CAD by Age, Sex, and Symptom

Age SexTypical/DefiniteAngina Pectoris

�39 Men Intermediate

Women Intermediate

40–49 Men High

Women Intermediate

50–59 Men High

Women Intermediate

�60 Men High

Women High

igh: �90% pretest probability; intermediate: between 10% and 90% pretest probability; low: bModified from Gibbons et al. (9) to reflect all age ranges.

he effects of a history of prior infarction, electrocardio- r


raphic Q waves, electrocardiographic ST- and T-wavehanges, diabetes, smoking, and hypercholesterolemia (9).

. Abbreviations

CS � acute coronary syndromeABG � coronary artery bypass grafting surgeryAD � coronary artery diseaseCS � coronary calcium scoreHD � coronary heart diseaseT � computed tomographyTA � computed tomographic angiographyCG � electrocardiogramF � heart failureET � estimated metabolic equivalent of exerciseI � myocardial infarction

CI � percutaneous coronary intervention

. Results of Ratings

he final ratings for CCT (Tables 1 to 7) are listed byndication sequentially as obtained from second roundating sheets submitted by each panel member. The finalcore reflects the median score of the 17 panel members andas been labeled according to the 3 appropriate use catego-ies of appropriate, uncertain, and inappropriate. Tables 8 to0 present the indications by these categories. Algorithmigures 1 to 10 describe the application of criteria asresented in these tables.A majority of ratings were in agreement as defined in the

receding text, including 66% of appropriate and 55% ofnappropriate indications. In contrast, only 7% of indica-ions rated as uncertain showed agreement, indicatingreater diversity of opinion on these indications. Only 2 ofhe 93 indications (Indications 1 [low] and 15 [low], both ofhich were rated as uncertain), were statistically classified aseing in disagreement. Because these indications werelready placed in the uncertain category, no changes were

ypical/Probablengina Pectoris

NonanginalChest Pain Asymptomatic

Intermediate Low Very low

Very low Very low Very low

Intermediate Intermediate Low

Low Very low Very low


Intermediate Low Very low



5% and 10% pretest probability; and very low: �5% pretest probability.

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A

T

A


. Cardiac Computed Tomography Appropriate Use Criteria (By Indication)

able 1. Detection of CAD in Symptomatic Patients Without Known Heart Disease*

Indication Appropriate Use Score (1–9)

Nonacute Symptoms Possibly Representing an Ischemic Equivalent

Pretest Probability of CAD Low Intermediate High

1. ● ECG interpretable AND● Able to exercise

U (5) A (7) I (3)

2. ● ECG uninterpretable OR● Unable to exercise

A (7) A (8) U (4)

Acute Symptoms With Suspicion of ACS (Urgent Presentation)

3. ● Definite MI I (1)

4. ● Persistent ECG ST-segment elevation following exclusion of MI U (6)

5. ● Acute chest pain of uncertain cause (differential diagnosis includes pulmonaryembolism, aortic dissection, and ACS [“triple rule out”])

U (6)


6. ● Normal ECG and cardiac biomarkers A (7) A (7) U (4)

7. ● ECG uninterpretable A (7) A (7) U (4)

8. ● Nondiagnostic ECG OR● Equivocal cardiac biomarkers

A (7) A (7) U (4)

Note: All indications are for CTA unless otherwise noted.A indicates appropriate; I, inappropriate; and U, uncertain.

able 2. Detection of CAD/Risk Assessment in Asymptomatic Patients Without Known CAD


Noncontrast CT for CCS

Global CHD Risk Estimate Low Intermediate High

9. ● Family history of premature CHD A (7)

10. ● Asymptomatic● No known CAD

I (2) A (7) U (4)

Coronary CTA

Global CHD Risk Estimate Low Intermediate High

11. ● Asymptomatic● No known CAD

I (2) I (2) U (4)

Coronary CTA Following Heart Transplantation

12. ● Routine evaluation of coronary arteries U (6)

indicates appropriate; I, inappropriate; and U, uncertain.

able 3. Detection of CAD in Other Clinical Scenarios


New-Onset or Newly Diagnosed Clinical HF and No Prior CAD


13. ● Reduced left ventricular ejection fraction A (7) A (7) U (4)

14. ● Normal left ventricular ejection fraction U (5) U (5) U (4)

Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery


15. ● Coronary evaluation before noncoronary cardiac surgery U (6) A (7) I (3)

Arrhythmias—Etiology Unclear After Initial Evaluation

16. ● New-onset atrial fibrillation (atrial fibrillation is underlying rhythm during imaging) I (2)

17. ● Nonsustained ventricular tachycardia U (6)

18. ● Syncope U (4)

Elevated Troponin of Uncertain Clinical Significance

19. ● Elevated troponin without additional evidence of ACS or symptoms suggestive of CAD U (6)




T

A

T

A


able 4. Use of CTA in the Setting of Prior Test Results


Prior ECG Exercise Testing20. ● Prior normal ECG exercise test

● Continued symptomsA (7)

Duke Treadmill Score—Risk Findings Low Intermediate High

21. ● Prior ECG exercise testing I (2) A (7) I (3)

Sequential Testing After Stress Imaging Procedures

22. ● Discordant ECG exercise and imaging results A (8)

Test Result/Ischemia Equivocal MildModerateor Severe

23. ● Prior stress imaging procedure A (8) U (6) I (2)

Prior CCS

24. ● Zero CCS �5 y ago U (4)

25. ● Positive CCS �2 y ago I (2)

CCS <100 100–400 401–1000 >1000

26. Diagnostic impact of coronary calcium on the decisionto perform contrast CTA in symptomatic patients

A (8) A (8) U (6) U (4)

Asymptomatic OR Stable SymptomsPeriodic Repeat Testing in the Setting of Prior Stress Imaging or Prior Coronary Angiography

Last Study Done <2 y Ago >2 y Ago

27. ● No known CAD I (2) I (3)

28. ● Known CAD I (2) I (3)

Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study

Previous Stress Imaging Study Normal Abnormal

29. ● Evaluation of new or worsening symptoms A (8) U (6)


able 5. Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions

IndicationAppropriate Use

Score (1–9)

Low-Risk Surgery

30. ● Preoperative evaluation for noncardiac surgery risk assessment, irrespective of functional capacity I (1)

Intermediate-Risk Surgery

31. ● No clinical risk predictors I (2)

32. ● Functional capacity �4 METs I (2)

33. ● Functional capacity �4 METs with 1 or more clinical risk predictors U (5)

34. ● Asymptomatic �1 y following a normal coronary angiogram, stress test, or a coronary revascularizationprocedure

I (1)

Vascular Surgery





I (2)




T

A

T

A


able 6. Risk Assessment Postrevascularization (PCI or CABG)

IndicationAppropriate Use Score

(1–9)

Symptomatic (Ischemic Equivalent)

39. ● Evaluation of graft patency after CABG A (8)

40. ● Prior coronary stent with stent diameter �3 mm or not known I (3)

41. ● Prior coronary stent with stent diameter �3 mm U (6)

Asymptomatic—CABG

Time Since CABG <5 y Ago >5 y Ago

42. ● Prior CABG I (2) U (5)

Asymptomatic—Prior Coronary Stenting

43. ● Prior left main coronary stent● Stent diameter �3 mm

A (7)

Time Since PCI <2 y >2 y

44. ● Stent diameter �3 mm or not known I (2) I (2)

45. ● Stent diameter �3 mm I (3) U (4)


able 7. Evaluation of Cardiac Structure and Function


Score (1–9)

Adult Congenital Heart Disease46. ● Assessment of anomalies of coronary arterial and other thoracic arteriovenous vessels A (9)

47. ● Assessment of complex adult congenital heart disease A (8)

Evaluation of Ventricular Morphology and Systolic Function

48. ● Initial evaluation of left ventricular function● Following acute MI or in HF patients

I (2)

49. ● Evaluation of left ventricular function● Following acute MI or in HF patients● Inadequate images from other noninvasive methods

A (7)

50. ● Quantitative evaluation of right ventricular function A (7)

51. ● Assessment of right ventricular morphology● Suspected arrhythmogenic right ventricular dysplasia

A (7)

52. ● Assessment of myocardial viability● Prior to myocardial revascularization for ischemic left ventricular systolic dysfunction● Other imaging modalities are inadequate or contraindicated

U (5)

Evaluation of Intra- and Extracardiac Structures

53. ● Characterization of native cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods

A (8)

54. ● Characterization of prosthetic cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods

A (8)

55. ● Initial evaluation of cardiac mass (suspected tumor or thrombus) I (3)

56. ● Evaluation of cardiac mass (suspected tumor or thrombus)● Inadequate images from other noninvasive methods

A (8)

57. ● Evaluation of pericardial anatomy A (8)

58. ● Evaluation of pulmonary vein anatomy● Prior to radiofrequency ablation for atrial fibrillation

A (8)

59. ● Noninvasive coronary vein mapping● Prior to placement of biventricular pacemaker

A (8)

60. ● Localization of coronary bypass grafts and other retrosternal anatomy● Prior to reoperative chest or cardiac surgery

A (8)




8

T


. Cardiac Computed Tomography Appropriate Use Criteria (By Appropriate Use Criteria)

able 8. Appropriate Indications (Median Score 7–9)


Score (1–9)

Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent

1. ● ECG interpretable AND● Able to exercise● Intermediate pretest probability of CAD

A (7)

2. ● ECG uninterpretable or unable to exercise● Low pretest probability of CAD

A (7)

2. ● ECG uninterpretable or unable to exercise● Intermediate pretest probability of CAD

A (8)

Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation)

6. ● Normal ECG and cardiac biomarkers● Low pretest probability of CAD

A (7)

6. ● Normal ECG and cardiac biomarkers● Intermediate pretest probability of CAD

A (7)

7. ● ECG uninterpretable● Low pretest probability of CAD

A (7)

7. ● ECG uninterpretable● Intermediate pretest probability of CAD

A (7)

8. ● Nondiagnostic ECG or equivocal cardiac biomarkers● Low pretest probability of CAD

A (7)

8. ● Nondiagnostic ECG or equivocal cardiac biomarkers● Intermediate pretest probability of CAD

A (7)

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS

9. ● Family history of premature CHD● Low global CHD risk estimate

A (7)

10. ● Asymptomatic● No known CAD● Intermediate global CHD risk estimate

A (7)

Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD

13. ● Reduced left ventricular ejection fraction● Low pretest probability of CAD

A (7)

13. ● Reduced left ventricular ejection fraction● Intermediate pretest probability of CAD

A (7)

Detection of CAD in Other Clinical Scenarios—Preoperative Coronary Assessment Prior to Noncoronary Cardiac Surgery

15. ● Coronary evaluation before noncoronary cardiac surgery● Intermediate pretest probability of CAD

A (7)

Use of CTA in the Setting of Prior Test Results—Prior ECG Exercise Testing

20. ● Normal ECG exercise test● Continued symptoms

A (7)

21. ● Prior ECG exercise testing● Duke Treadmill Score—intermediate risk findings

A (7)

Use of CTA in the Setting of Prior Test Results—Sequential Testing After Stress Imaging Procedures

22. ● Discordant ECG exercise and imaging results A (8)

23. ● Stress imaging results: equivocal A (8)

Use of CTA in the Setting of Prior Test Results—Prior CCS

26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS �100

A (8)

26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS 100–400

A (8)

Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study

29. ● Previous stress imaging study normal A (8)

Risk Assessment Postrevascularization (PCI or CABG)—Symptomatic (Ischemic Equivalent)

39. ● Evaluation of graft patency after CABG A (8)



T

A

T


able 8. Continued

Indication

Risk Assessment Postrevascularization (PCI o

43. ● Prior left main coronary stent with stent diameter �3

Evaluation of Cardiac Structure and F

46. ● Assessment of anomalies of coronary arterial and oth

47. ● Assessment of complex adult congenital heart diseas

Evaluation of Cardiac Structure and Function—Eva

49. ● Evaluation of left ventricular function● Following acute MI or in HF patients● Inadequate images from other noninvasive methods

50. ● Quantitative evaluation of right ventricular function

51. ● Assessment of right ventricular morphology● Suspected arrhythmogenic right ventricular dysplasia

Evaluation of Cardiac Structure and Function

53. ● Characterization of native cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods

54. ● Characterization of prosthetic cardiac valves● Suspected clinically significant valvular dysfunction● Inadequate images from other noninvasive methods

56. ● Evaluation of cardiac mass (suspected tumor or throm● Inadequate images from other noninvasive methods

57. ● Evaluation of pericardial anatomy

58 ● Evaluation of pulmonary vein anatomy● Prior to radiofrequency ablation for atrial fibrillation

59. ● Noninvasive coronary vein mapping● Prior to placement of biventricular pacemaker

60. ● Localization of coronary bypass grafts and other retro● Prior to reoperative chest or cardiac surgery


able 9. Uncertain Indications (Median Score 4–6)

Indication

Detection of CAD in SymptomaticSymptomatic—Nonacute Symptoms Po

1. ● ECG interpretable and able to exercise● Low pretest probability of CAD

2. ● ECG uninterpretable or unable to exercise● High pretest probability of CAD

Detection of CAD in SymptomaticSymptomatic—Acute Symptoms Wit

4. ● Persistent ECG ST-segment elevation following exclus

5. ● Acute chest pain of uncertain cause (differential diagnand ACS [“triple rule out”])

6. ● Normal ECG and cardiac biomarkers● High pretest probability of CAD

7. ● ECG uninterpretable● High pretest probability of CAD

8. ● Nondiagnostic ECG or equivocal cardiac biomarkers● High pretest probability of CAD

Detection of CAD/Risk Assessment in Asymptomatic

10. ● Asymptomatic● No known CAD● High global CHD risk estimate

Appropriate UseScore (1–9)

r CABG)—Asymptomatic—Prior Coronary Stenting

mm A (7)

unction—Adult Congenital Heart Disease

er thoracic arteriovenous vessels A (9)

e A (8)

luation of Ventricular Morphology and Systolic Function

A (7)

A (7)

A (7)

—Evaluation of Intra- and Extracardiac Structures

A (8)

A (8)

bus) A (8)

A (8)

A (8)

A (8)

sternal anatomy A (8)

Appropriate UseScore (1–9)

Patients Without Known Heart Diseasessibly Representing an Ischemic Equivalent

U (5)

U (4)

Patients Without Known Heart Diseaseh Suspicion of ACS (Urgent Presentation)

ion of MI U (6)

osis includes pulmonary embolism, aortic dissection, U (6)

U (4)

U (4)

U (4)

Individuals Without Known CAD—Noncontrast CT for CCS

U (4)



T

A


able 9. Continued


Score (1–9)

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA

11. ● Asymptomatic● No known CAD● High global CHD risk estimate

U (4)

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA Following Heart Transplantation

12. ● Routine evaluation of coronary arteries U (6)

Detection of CAD in Other Clinical Scenarios—New-Onset or Newly Diagnosed Clinical HF and No Prior CAD

13. ● Reduced left ventricular ejection fraction● High pretest probability of CAD

U (4)

14. ● Normal left ventricular ejection fraction● Low pretest probability of CAD

U (5)

14. ● Normal left ventricular ejection fraction● Intermediate pretest probability of CAD

U (5)

14. ● Normal left ventricular ejection fraction● High pretest probability of CAD

U (4)


15. ● Coronary evaluation before noncoronary cardiac surgery● Low pretest probability of CAD

U (6)

Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation

17. ● Nonsustained ventricular tachycardia U (6)

18. ● Syncope U (4)

Detection of CAD in Other Clinical Scenarios—Elevated Troponin of Uncertain Clinical Significance

19. ● Elevated troponin without additional evidence of ACS or symptoms suggestive of CAD U (6)


23. ● Stress imaging results: mild ischemia U (6)


24. ● Zero CCS �5 y ago U (4)

26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS 401–1000

U (6)

26. ● Diagnostic impact of coronary calcium on the decision to perform contrast CTA in symptomatic patients● CCS �1000

U (4)

Use of CTA in the Setting of Prior Test Results—Evaluation of New or Worsening Symptoms in the Setting of Past Stress Imaging Study

29. ● Previous stress imaging study abnormal U (6)

Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery


Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery



41. ● Prior coronary stent with stent diameter �3 mm U (6)

Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG

42. ● Prior coronary bypass surgery �5 y ago U (5)

Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting

44. ● Stent diameter �3 mm● Greater than or equal to 2 y after PCI

U (4)

Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function

52. ● Assessment of myocardial viability prior to myocardial revascularization● Ischemic left ventricular systolic dysfunction● Other imaging modalities are inadequate or contraindicated

U (5)




T


able 10. Inappropriate Indications (Median Score 1–3)


Score (1–9)

Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Nonacute Symptoms Possibly Representing an Ischemic Equivalent

1. ● ECG interpretable and able to exercise● High pretest probability of CAD

I (3)

Detection of CAD in Symptomatic Patients Without Known Heart DiseaseSymptomatic—Acute Symptoms With Suspicion of ACS (Urgent Presentation)

3. ● Definite MI I (1)

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Noncontrast CT for CCS

10. ● Low global CHD risk estimate I (2)

Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known CAD—Coronary CTA

11. ● Low global CHD risk estimate I (2)

11. ● Intermediate global CHD risk estimate I (2)


15. ● Coronary evaluation before noncoronary cardiac surgery● High global CHD risk estimate

I (3)

Detection of CAD in Other Clinical Scenarios—Arrhythmias—Etiology Unclear After Initial Evaluation

16. ● New-onset atrial fibrillation (atrial fibrillation is underlying rhythm during imaging) I (2)

Use of CTA in the Setting of Prior Test Results—ECG Exercise Testing

21. ● Exercise ECG testing● Duke Treadmill Score—low-risk findings

I (2)

21. ● Exercise ECG testing● Duke Treadmill Score—high-risk findings

I (3)


23. ● Stress imaging results: moderate or severe ischemia I (2)


25. ● Positive calcium score �2 y ago I (2)

Periodic Repeat Testing in Asymptomatic OR Stable Symptoms With Prior Stress Imaging or Coronary Angiography

27. ● No known CAD● Last study done �2 y ago

I (2)

27. ● No known CAD● Last study done �2 y ago

I (3)

28. ● Known CAD● Last study done �2 y ago

I (2)

28. ● Known CAD● Last study done �2 y ago

I (3)

Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Low-Risk Surgery

30. ● Preoperative evaluation for noncardiac surgery risk assessment, irrespective of functional capacity I (1)

Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Intermediate-Risk Surgery




I (1)

Risk Assessment Preoperative Evaluation of Noncardiac Surgery Without Active Cardiac Conditions—Vascular Surgery




I (2)


40. ● Prior coronary stent with stent diameter �3 mm or not known I (3)

Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—CABG

42. ● Prior coronary bypass surgery �5 y ago I (2)



F

T

A indicates appropriate; I, inappropriate; and U, uncertain.


igure 1. Hierarchy of Potential Test Ordering Based on Clinical Presentation

able 10. Continued


Score (1–9)

Risk Assessment Postrevascularization (PCI or CABG)—Asymptomatic—Prior Coronary Stenting

44. ● Prior coronary stent with stent diameter �3 mm or not known● Less than 2 y after PCI

I (2)

44. ● Prior coronary stent with stent diameter �3 mm or not known● Greater than or equal to 2 y after PCI

I (2)

45. ● Prior coronary stent with stent diameter �3 mm● Less than 2 y after PCI

I (3)

Evaluation of Cardiac Structure and Function—Evaluation of Ventricular Morphology and Systolic Function

48. ● Initial evaluation of left ventricular function● Following acute MI or in HF patients

I (2)

Evaluation of Cardiac Structure and Function—Evaluation of Intra- and Extracardiac Structures

55. ● Initial evaluation of cardiac mass (suspected tumor or thrombus) I (3)



F

F


igure 2. Risk Assessment Preoperative Evaluation of Noncardiac Surgery

igure 3. Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic Acute Presentation



F

F


igure 4. Risk Assessment Postrevascularization (PCI or CABG)

igure 5. Use of CT Angiography in the Setting of Prior Test Results



F

F


igure 6. Detection of CAD in Symptomatic Patients Without Known Heart Disease Symptomatic—Nonacute Presentation

igure 7. Detection of CAD/Risk Assessment in Asymptomatic Individuals Without Known Coronary Artery Disease



F

F


igure 8. Detection of CAD in Other Clinical Scenarios

igure 9. Evaluation of Cardiac Structure and Function



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. Discussion

ppropriate use criteria define common patient subgroupshere expert opinion and the available medical evidence are

ombined to assess the net benefit of a test or procedure, inhis instance CCT. The intent of these criteria is to guidehe rational use of the procedure, namely avoidance of eithernder- or overutilization, and thereby lead to more optimalealthcare delivery and justifiable healthcare expenditures.This document is an update to the original appropriate-

ess criteria for CCT published in 2006 (1), written toeflect changes in test utilization in the context of rapidlyeveloping technical and clinical applications and within theonceptual framework of dynamic appropriate use criteriaevelopment. Several aspects of the present document areoteworthy, including careful alignment to and, whereossible, definition of language in the radionuclide imagingppropriate use criteria (2) to enhance integration intoomparable decision support tools and performance metrics.he underlying assumptions for the document are intended

o broadly reflect the present community standards ofechnology and performance of the technique with anmphasis on adherence to imaging guidelines, patientafety, and laboratory quality and accreditation.

The clinical scenarios included in this report were de-igned to reflect the most common and important potentialpplications for CCT imaging. After the initial writing byhe writing group, extensive review from external editors,nd then ranking by the technical panel itself, the result is aet of scenarios that define patient-specific applications. Theppropriate use criteria in this report provide a consensus

igure 10. Evaluation of Cardiac Structure and Function: Evalu

udgment of whether it is reasonable to use CCT imaging scontent.onlinejacDownloaded from

or the particular clinical scenario described, such as those3 indications listed in this document. These criteria arexpected to be useful for clinicians, healthcare facilities, andhird-party payers engaged in the delivery of cardiovascularmaging services. Although numerous, the indications areommonly divided among subclasses of patient CHD risk orretest probability of CAD, as such characteristics aremportant considerations within the test performance char-cteristics. In total, 35 of 93 indications were judged to beppropriate, and 58 were judged to be either inappropri-te or uncertain. It is important to note however, that annderstanding of pretest patient characteristics is anmportant determinant of the appropriate use ratings.ew categories are uniform in the ratings for all patientharacteristics.

Appropriate use criteria represent the first component ofhe chain of quality recommendations for cardiovascularmaging (15). In addition to appropriate use, patient safetylso should be considered when ordering coronary com-uted tomographic angiography (CTA), as it should behen ordering any cardiac imaging test. A consideration of

he appropriate balance of using radiation dose reductionechniques to minimize radiation exposure while preservingmage quality and the related benefits of imaging for apecific patient should be undertaken. This issue is discussedn more depth in a 2010 expert consensus document onoronary CTA (16). The present document greatly expandshe number of potential clinical scenarios in comparison tohe original 2006 document. The clinical scenarios includecute and chronic chest pain, testing in symptomatic andsymptomatic patients, heart failure, preoperative risk as-

of Intra- and Extracardiac Structures
ation
essment before both cardiac and noncardiac surgery, testing by on October 26, 2010 c.org


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n the setting of prior test results (exercise testing, stressmaging procedures, coronary calcium scores, and repeatesting), prior revascularization, and the evaluation of car-iac structure and function. Although these criteria are

ntended to provide guidance for patients and clinicians,hey are not intended to serve as substitutes for soundlinical judgment and practice experience. The writingroup recognizes that many patients encountered in clinicalractice may not be represented in these appropriate useriteria or may have extenuating features when comparedith the clinical scenarios presented. Although the appro-riate use ratings reflect critical medical literature as well asxpert consensus, physicians and other stakeholders shouldnderstand the role of clinical judgment in determininghether to order a test for an individual patient. Addition-

lly, uncertain indications often require individual physicianudgment and understanding of the patient to better deter-

ine the usefulness of a test for a particular scenario. Asuch, the ranking of an indication as uncertain (4 to 6)hould not be viewed as limiting the use of CCT imagingor such patients. It should be emphasized that the technicalanel was instructed that the uncertain designation was stillesigned to be considered as a “reimbursable” category.These ratings are intended to evaluate the appropriate use

f specific patient scenarios to determine overall patterns ofare regarding CCT. In situations where there is substantialariation between the appropriate use rating and what thelinician believes is the best recommendation for the pa-ient, further considerations or actions, such as a secondpinion, may be appropriate. Moreover, it is not anticipatedhat all physicians or facilities will have 100% of their CCTrocedures deemed appropriate. However, related to theverall patterns of care, if the national average of appropriatend uncertain ratings is 80%, for example, and a physician oracility has a 40% rate of inappropriate procedures, furtherxamination of the patterns of care may be warranted andelpful. Implementation of these criteria is highly encour-ged through provider education, as it is anticipated thatncreasing emphasis by laboratory accreditation bodies andther organizations focused on provider quality will apply.

.1. Clinical Scenarios and Their Ratings

irect comparison to the 2006 document is difficult becausef the many changes in the number and wording of clinicalcenarios. In summary:

• A total of 31 indications were carried forward from the2006 document, including prior ratings where 10 wereappropriate, 10 were uncertain, and 11 were inappro-priate. Among these, 8 shifted up 1 category fromeither uncertain to appropriate (Indications 1 [inter-mediate], 6 [low], 10 [intermediate], 39, 49, 54) orfrom inappropriate to uncertain (Indications 2 [high],42 [�5 y]). The other 23 indications had unchanged
appropriate use ratings.

• One area of expansion compared with the 2006 criteriainvolves symptomatic patients without known heartdisease. CCT was felt to be appropriate primarily forsituations involving a low or intermediate pretestprobability of obstructive CAD. Scenarios involvinghigh-probability CAD patients were rated as uncertainwith the exceptions of a patient with an interpretableECG who was able to exercise, and for definitemyocardial infarction.

• Noncontrast CT calcium scoring was judged as appro-priate for intermediate CHD risk patients, and for thespecific subset of low-risk patients in whom a familyhistory of premature CHD was present. Intermediaterisk was defined as a 10-year risk of between 10% and20%, although individual patient exceptions to abroadened intermediate risk range of 6% to 20% wererecognized for certain patient subsets with generallylow absolute risk but high relative risk (younger menand women). Screening asymptomatic patients usingcoronary CT angiography was considered inappropri-ate, as was repeat coronary calcium testing. Repeat CTangiography in asymptomatic patients or patients withstable symptoms with prior test results was broadlyconsidered inappropriate.

• Within heart failure, CT angiography was appropriateor uncertain as a test across both normal (new to thisdocument) and abnormal left ventricular ejection frac-tion, although the only appropriate scenarios werewith reduced left ventricular ejection fraction with lowor intermediate pretest CAD probability.

• As part of the preoperative evaluation, CT angiogra-phy was viewed as a potential option among patientsundergoing heart surgery for noncoronary indications(e.g., valve replacement surgery or atrial septal defectclosure) when the pretest CAD risk was either inter-mediate (appropriate) or low (uncertain). In compari-son, there were no appropriate indications for coronaryCT angiography as part of the preoperative evaluationfor noncardiac surgery.

• The evaluation of coronary stents was considered as afunction of patient symptom status, time from revas-cularization, and stent size. Only with larger stents(�3 mm in diameter) after long time periods (�2years) was stent imaging considered uncertain, andonly with left main stents was imaging of stentsconsidered appropriate.

• A strength of cardiac CT imaging is the evaluation ofcardiac structure and function. Appropriate indicationsinclude coronary anomalies, congenital heart disease,evaluation of right ventricular function, evaluation ofleft ventricular ejection fraction when images fromother techniques are inadequate, or evaluation ofprosthetic heart valves. New to this document is theuse of CCT for evaluation of myocardial viability when
other modalities are inadequate or contraindicated


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(uncertain), and in suspected arrhythmogenic rightventricular dysplasia (appropriate).

• The use of CCT was appropriate prior to electrophys-iological procedures for anatomic mapping, or prior torepeat sternotomy in reoperative cardiac surgery.

• There was disagreement on the panel in 2 of theclinical scenarios: 1) detection of CAD in the settingof a low pretest probability for CAD when the ECGis interpretable and the patient is able to exercise(Indication 1); and 2) preoperative coronary assess-ment prior to noncoronary cardiac surgery in thesetting of a low pretest probability for CAD (Indica-tion 30). Both of these indications were ranked in theuncertain category.

.2. Application of Criteria

here are many potential applications for appropriate useriteria. Clinicians could use the ratings for decision supportr an educational tool when considering the need for CCTmaging. Moreover, these criteria could be used to facilitateiscussion with patients and/or referring physicians about

igure A1. Stepwise Approach to Perioperative Cardiac Assess

ardiac evaluation and care algorithm for noncardiac surgery based on active clinica
ears of age. HR indicates heart rate; LOE, level of evidence; and MET, metabolic equivale

he need for CCT imaging. Facilities and payers may chooseo use these criteria either prospectively in the design ofrotocols and preauthorization procedures, or retrospec-ively for quality reports. It is hoped that payers would usehese criteria as the basis for the development of rationalayment management strategies.These criteria were developed with the intent that they be

onsidered in both the delivery and in the policy positionsor these services, including reimbursement. In contrast,ervices performed for inappropriate indications shouldikely require additional documentation to justify reimburse-

ent because of the unique circumstances or the clinicalrofile that must exist in such a patient. It is critical tomphasize that the writing group, technical panel, Appro-riate Use Criteria Task Force, and clinical community doot believe an uncertain rating is grounds to deny reim-ursement for CCT imaging. Rather, uncertain ratings arehose where expert opinion or the available data vary or areapidly evolving. The opinions of the technical panel oftenaried for these indications reflecting that additional re-earch is needed. By the same right, appropriate indications

t

itions, known cardiovascular disease, or cardiac risk factors for patients �50

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ay still benefit from further clinical trials and evidenceevelopment.In conclusion, this document represents the current

nderstanding of the net clinical benefit of CCT imagingith respect to the balance between benefit and risk to

he patient as assessed under the ACCF’s appropriate useriteria methodology. It is intended to provide a practicaluide and perspective to clinicians and patients whenonsidering CCT imaging and promote more appropriateest utilization including avoidance of either under- orverutilization. As with other appropriate use criteria,ome of these ratings will require research and furthervaluation to provide the greatest information and benefito clinical decision making. Finally, it will be necessary toeriodically assess and update the indications and criterias technology evolves and new data and field experienceecome available.

ppendix A: Additional Cardiacomputed Tomography Definitions

ngina: As defined by the ACC/AHA Guidelines onxercise Testing (9)

• Typical Angina (Definite):1. Substernal chest pain, or an ischemic equivalent

discomfort that isa. provoked by exertion or emotional stress andb. relieved by rest and/or nitroglycerin (17).

• Atypical Angina (Probable): Chest pain or discomfortwith two characteristics of definite or typical angina (17).

• Nonanginal Chest Pain: Chest pain or discomfort thatmeets one or none of the typical angina characteristics (17).

cute Coronary Syndrome: As defined by the ACC/AHAuidelines for the Management of Patients With ST-levation Myocardial Infarction, patients with an acute

oronary syndrome include those whose clinical presenta-ions cover the following range of diagnoses: unstablengina, MI without ST-elevation (NSTEMI), and myocar-ial infarction with ST-elevation (STEMI) (18).

valuating Perioperative Risk for Noncardiac Surgery

ETHOD FOR DETERMINING PERIOPERATIVE RISK

eview Figure A1, “Stepwise Approach to Perioperativeardiac Assessment,” from the ACC/AHA 2009 Periop-

rative Guidelines (19). Based on the algorithm, once it isetermined that the patient does not require urgent surgery,he clinician should determine the patient’s active cardiaconditions and/or perioperative risk predictors—see defini-ions in the following text. If any active cardiac conditionsTable A1) and/or major risk predictors (Table A2) areresent, Figure A1 suggests consideration of coronary an-iography and postponing or canceling noncardiac surgery.nce perioperative risk predictors are assessed based on the

lgorithm, then the surgical risk and patient’s functional*n


tatus should be used to establish the need for noninvasiveesting.

CG—Uninterpretable: Refers to electrocardiograms withesting ST-segment depression (�0.10 mV), complete leftundle-branch block, pre-excitation (Wolff-Parkinson-

hite syndrome), or paced rhythm.

ble to Exercise: Able to complete a diagnostic exercisereadmill examination.

ppendix B: Additional Methods

ee the Methods section for a description of panel selection,ndication development, scope of indications, and ratingrocess.

elationships With Industry and Other Entities

list of all individuals participating in the development andeview of this document and their institutional and/or

able A1. Active Cardiac Conditions for Which the Patienthould Undergo Evaluation and Treatment Before Noncardiacurgery (Class I, Level of Evidence: B)

Condition Examples

nstable coronary syndromes Unstable or severe angina*(CCS class III or IV)†

Recent MI‡

ecompensated HF (NYHAfunctional class IV;worsening or new-onset HF)

ignificant arrhythmias High-grade atrioventricular block

Mobitz II atrioventricular block

Third-degree atrioventricular heart block

Symptomatic ventricular arrhythmias

Supraventricular arrhythmias (includingatrial fibrillation) with uncontrolledventricular rate (HR �100 bpm atrest)

Symptomatic bradycardia

Newly recognized ventricular tachycardia

evere valvular disease Severe aortic stenosis (mean pressuregradient �40 mm Hg, aortic valvearea �1.0 cm2, or symptomatic)

Symptomatic mitral stenosis(progressive dyspnea on exertion,exertional presyncope, or HF)

According to Campeau (20); †May include “stable” angina in patients who are unusuallyedentary; ‡The American College of Cardiology National Database Library defines recent MI as7 days but �1 month (within 30 days). Reprinted from Fleisher (19).CCS indicates Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI,yocardial infarction; and NYHA, New York Heart Association.

able A2. Perioperative Clinical Risk Factors*

History of ischemic heart diseaseHistory of compensated or prior heart failureHistory of cerebrovascular diseaseDiabetes mellitus (requiring insulin)Renal insufficiency (creatinine �2.0)

As defined by the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care foroncardiac surgery (1). Note that these are not standard coronary artery disease risk factors.



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rganizational affiliations is presented in Appendix C. TheCCF and its partnering organizations rigorously avoid any

ctual, perceived, or potential conflicts of interest that mightrise as a result of an outside relationship or personal interestf a member of the technical panel. Specifically, all panelembers are asked to provide disclosure statements of all

elationships that might be perceived as real or potentialonflicts of interest. These statements were reviewed by theppropriate Use Criteria Task Force, discussed with allembers of the technical panel at the face-to-face meeting,

nd updated and reviewed as necessary. A table of disclo-ures by the technical panel and oversight task force mem-ers can be found in Appendix D.

iterature Review

he technical panel members were asked to refer to theelevant literature provided for each indication table whenompleting their ratings (Online Appendix at http://ontent.onlinejacc.org/cgi/content/full/j.jacc.2010.07.005/C1).

ppendix C: ACCF/SCCT/ACR/AHA/ASE/SNC/SCAI/SCMR 2010 Appropriate Useriteria for Cardiac Computed Tomographyarticipants

ardiac Computed Tomography Writing Group

llen J. Taylor, MD, FACC, FAHA—Chair, Appropriatese Criteria for Cardiac Computed Tomography Writingroup, Co-Director Noninvasive Imaging, Washingtonospital Center, Washington, DCManuel Cerqueira, MD, FACC, FASNC—Chairman ofolecular and Functional Imaging, Cleveland Clinic Foun-

ation, Cleveland, OHJohn McB. Hodgson, MD, FACC, FSCAI—Chairman,epartment of Cardiology Geisinger Health System, Dan-

ille, PADaniel Mark, MD, MPH, FACC, FAHA—Professor ofedicine, Duke Clinical Research Institute, Duke Univer-

ity, Durham, NCJames Min, MD, FACC—Assistant Professor of Medi-

ine, Weil Cornell Medical College, New York, NYPatrick O’Gara, MD, FACC, FAHA—Associate Pro-

essor of Medicine, Harvard University School of Medicine,irector of Clinical Cardiology, Brigham & Women’sospital, Boston, MAGeoffrey D. Rubin, MD, FSCBTMR—Professor of

adiology, Associate Dean for Clinical Affairs, Chief ofardiovascular Imaging, Stanford University School ofedicine, Palo Alto, CA

ardiac Computed Tomography Technical Panel

hristopher M. Kramer, MD, FACC, FAHA—Moderator
f the Technical Panel, Professor of Radiology and Medi- B

ine, and Director, Cardiovascular Imaging Center, Univer-ity of Virginia Health System, Charlottesville, VA

Allen J. Taylor, MD, FACC, FAHA—Writing Groupiaison, Appropriate Use Criteria for Cardiac Computedomography Technical Panel, Co-Director of Noninvasive

maging, Washington Hospital Center, Washington, DCDaniel Berman, MD, FACC—Director of Cardiac Im-

ging, Cedars-Sinai Medical Center Department of Imag-ng, Los Angeles, CA

Alan Brown, MD, FACC, FAHA, FNLA—Clinicalssociate Professor of Medicine, Loyola Stritch School ofedicine, Maywood, IL; Medical Director of Midwesteart Disease Prevention Center, Midwest Heart Special-

sts, Edward Heart Hospital, Naperville, ILFarooq A. Chaudhry, MD, FACC, FAHA, FASE—

ssociate Professor of Medicine, Columbia University Col-ege of Physicians and Surgeons, Associate Chief of Cardi-logy, Director of Echocardiography, New York, NYRicardo C. Cury, MD—Director of Cardiac Imaging,

aptist Hospital of Miami and Baptist Cardiac and Vascu-ar Institute, Miami, FL

Milind Y. Desai, MD, FACC—Cardiologist, Section ofardiovascular Imaging, Cleveland Clinic, Cleveland, OHAndrew J. Einstein, MD, PhD, FACC, FAHA,

ASNC—Assistant Professor of Clinical Medicine, Direc-or, Cardiac CT Research, Co-Director, Cardiac CT and

RI, Columbia University, New York, NYAntoinette S. Gomes, MD, FAHA, FSIR—Professor of

adiology and Medicine, David Geffen School of Medicinet UCLA, Los Angeles, CA

Robert Harrington, MD, FACC, FAHA, FSCAI—rofessor of Medicine, Duke University, Director of Dukelinical Research Institute, Durham, NCUdo Hoffmann, MD, MPH—Director of Cardiac MR,

ET, and CT program, Massachusetts General Hospital,oston, MARahul Khare, MD—Instructor, Department of Emer-

ency Medicine, Northwestern University, Feinberg Schoolf Medicine, Chicago, ILJohn Lesser, MD, FACC—Director of Cardiovascular

T and MRI, Minneapolis Heart Institute, Minneapolis, MNChristopher McGann, MD, FACC—Associate Profes-

or of Medicine, Division of Cardiology, University of Utahedical Center, Salt Lake City, UTAlan Rosenberg, MD, FACC—Vice President of Med-

cal Policy and Credentialing Programs, WellPoint, Inc.,hicago, ILRobert Schwartz, MD, FACC—Cardiolgist, Minneap-

lis Heart Institute, Minneapolis, MNMarc Shelton, MD, FACC—President, Prairie Cardio-

ascular Consultants, Ltd., Springfield, ILGerald W. Smetana, MD—Associate Professor of Medi-

ine, Harvard University School of Medicine, Internal Medi-ine Physician, Division of General Medicine & Primary Care,
eth Israel Deaconess Medical Center, Boston, MA

http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.07.005/DC1




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Sidney C. Smith, Jr., MD, FACC, FAHA—Professor ofedicine, Director of Center for Cardiovascular Science andedicine, University of North Carolina, Chapel Hill, NC

xternal Reviewers of the Appropriate Use Criteriandications

ichael Atalay, MD, PhD, FACC—Director CardiacRI and CT, Assistant Professor of Diagnostic Imaging

nd Cardiology Warren Alpert School of Medicine atrown University, Rhode Island Hospital, Providence, RIMatthew Budoff, MD, FACC—Program Director, Di-

ision of Cardiology, Los Angeles Biomedical Researchnstitute, Torrance, CA

Tracy Callister, MD, FACC—Director, Tennesseeeart and Vascular Institute, Hendersonville, TNJeffrey Carr, MD, FACC—Cardiologist, Cardiovascular

ssociates of East Texas, PA, Tyler, TXSu Min Chang, MD, FACC—Assistant Professor ofedicine, Weill Cornell Medical College, Associate Direc-

or of the Cardiac Computed Tomography Laboratory—he Methodist DeBakey Heart & Vascular Center, Hous-

on, TXBenjamin Cheong, MD, FACC—Attending Physician,

linical Director, Cardiovascular MR and CT, St. Luke’spiscopal Health System/The Texas Heart Institute, Hous-

on, TXKavitha Chinnaiyan, MD, FACC—Director, Cardiovas-

ular Imaging Education, William Beumont Hospital,oyal Oak, MIPhilip Costello, MD—Chair of Radiology, Medical Uni-

ersity of South Carolina, Charleston, SCE. Gordon DePuey, MD, FACC—Director of Nuclearedicine, St. Luke’s-Roosevelt Hospital Professor of Ra-

iology, Columbia University, New York, NYAndrew J. Einstein, MD, PhD, FACC, FAHA,

ASNC—Assistant Professor of Clinical Medicine, Direc-or, Cardiac CT Research, Co-Director, Cardiac CT and

RI, Columbia University, New York, NYLee Fleisher, MD, FACC—Professor of Anesthesiology,

niversity of Pennsylvania Department of Anesthesiology,hiladelphia, PAMario Garcia, MD, FACC—Director of Cardiovascular

maging, Mount Sinai Hospital Cardiovascular Institute,ew York, NYThomas Gerber, MD, FACC—Professor of Radiology

nd Medicine, Jacksonville, FLRaymond Gibbons, MD, FACC—Professor of Medi-

ine, Co-Director of Nuclear Cardiology Lab, Mayo Clinic,ochester, MNHarvey Hecht, MD, FACC, FSCCT—Director of Car-

iovascular CT, Lenox Hill Heart and Vascular Institute ofew York, New York, NYMilena Henzlova, MD, FACC—Director of Nuclear

ardiology, Mount Sinai Medical Center, New York, NY Ccontent.onlinejacDownloaded from

Jill Jacobs, MD—Associate Professor of Radiology, Chieff Cardiac Imaging, NYU Langone Medical Center, Nework, NYScott Jerome, DO, FACC—Assistant Professor of Med-

cine, Cardiology Division, University of Maryland Medicalenter, Finksburg, MDNorman Kato, MD, FACC—Cardiothoracic Surgeon,

ardiac Care Medical Group, Encino, CARichard Kovacs, MD, FACC—Professor of Clinical Med-

cine, Krannert Institute of Cardiology, Indianapolis, INMichael Lauer, MD, FACC—Director, Division of

ardiovascular Sciences, National Heart, Lung, and Bloodnstitute, Bethesda, MD

John Mahmarian, MD, FACC—Professor of Medicine,he Methodist Hospital Organization, Houston, TXDavid Malenka, MD—Professor of Medicine, Dart-outh Hitchcock Medical Center Section of Cardiology,ebanon, NHFrederick A. Masoudi, MD, MSPH, FACC, FAHA—

ssociate Professor of Medicine, Denver Health Center,enver, COJulie Miller, MD, FACC—Assistant Professor of Med-

cine, Johns Hopkins University, Baltimore, MDDebabrata Mukherjee, MD, FACC—Chief, Cardiovas-

ular Medicine, Professor of Medicine, Texas Tech Univer-ity, El Paso, TX

Meagan Murphy, MD—Internist, Massachusetts Gen-ral Hospital, Boston, MA

Jagat Narula, MD, FACC—Professor of Medicine,hief of Division of Cardiology, University of California,

rvine, Orange, CAJohn Nixon, MD, FACC, FAHA—Professor of Medi-

ine, Medical College of Virginia, Richmond, VAE. Magnus Ohman, MD, FACC—Professor of Medi-

ine, Duke University Medical Center; Associate Director,uke Heart Center-Ambulatory Care; Director, Program

or Advanced Coronary Disease, Duke Clinical Researchnstitute, Durham, NC

Michael H. Picard, MD, FACC, FAHA, FASE—irector of Echocardiography, Massachusetts Generalospital, Boston, MAMichael Poon, MD, FACC—Professor of Medicine and

adiology, Stony Brook School of Medicine, Stony Brook, NYMiguel Quinones, MD, FACC—Professor of Medicine,eill Cornell Medical College; Chairman, Department of

ardiology, The Methodist Hospital Physician Organiza-ion, Houston, TX

Daniel Rader, MD—Cooper-McClure Professor of Med-cine, Director of Preventive Cardiovascular Medicine andipid Clinic, University of Pennsylvania, Philadelphia, PARita Redberg, MD, FACC—Professor of Medicine,

niversity of California San Francisco, San Francisco, CAU. Joseph Schoepf, MD, FAHA, FSCBT-MR,

SCCT—Professor of Radiology and Medicine, Directorf Cardiovascular Imaging, Medical University of South
arolina, Charleston, SC


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Samuel Wann, MD—Cardiologist, Wheaton Franciscanedical Group, Wauwatosa, WIWilliam Guy Weigold, MD, FACC—Director of CT,ashington Hospital Center, Washington, DCJonathan Weinsaft, MD, FACC—Director of CardiacRI Program, New York Presbyterian Hospital, Cornelledical Center, New York, NYWilliam Weintraub, MD, FACC—Chief of Cardiology,

hristiana Care Health System, Newark, DEKim Allan Williams, MD, FACC, FAHA, FASNC—

hair, Division of Cardiology, Wayne State Universitychool of Medicine, Detroit, MI

CCF Appropriate Use Criteria Task Force

ichael J. Wolk, MD, MACC—Chair, Task Force, Pastresident, American College of Cardiology Foundation andlinical Professor of Medicine, Weill-Cornell Medicalchool, New York, NYSteven Bailey, MD, FACC, FSCAI—Chair, Division of

ardiology, Professor of Medicine and Radiology, Janeyriscoe Distinguished Chair, University of Texas Healthciences Center, San Antonio, TXPamela S. Douglas, MD, MACC, FAHA, FASE—Past

resident, American College of Cardiology Foundation;ast President, American Society of Echocardiography; andrsula Geller Professor of Research in Cardiovasculariseases and Chief, Cardiovascular Disease, Duke Univer-

ity Medical Center, Durham, NC F


Robert C. Hendel, MD, FACC, FAHA, FASNC—hair, Appropriate Use Criteria for Radionuclide Imagingriting Group—Director of Cardiac Imaging and Outpa-

ient Services, Division of Cardiology, Miami Universitychool of Medicine, Miami, FLChristopher M. Kramer, MD, FACC, FAHA—

rofessor of Medicine and Radiology and Director, Cardio-ascular Imaging Center, University of Virginia Healthystem, Charlottesville, VAJames Min, MD, FACC—Assistant Professor of Medi-

ine, Weil Cornell Medical College, New York, NYManesh R. Patel, MD, FACC—Assistant Professor ofedicine, Division of Cardiology, Duke University Medi-

al Center, Durham, NCLeslee Shaw, PhD, FACC, FASNC—Professor of Med-

cine, Emory University School of Medicine, Atlanta, GARaymond F. Stainback, MD, FACC, FASE—Medicalirector of Noninvasive Cardiac Imaging, Texas Heart

nstitute at St. Luke’s Episcopal Hospital, Houston,X; Clinical Associate Professor of Medicine, Baylorollege of Medicine; President-Elect, Intersocietalommission for the Accreditation of Echocardiographyaboratories (ICAEL); Hall-Garcia Cardiology Associ-tes, Houston, TX

Joseph M. Allen, MA—Director, TRIP (Translatingesearch into Practice), American College of Cardiology
oundation, Washington, DC


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PPENDIX D. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 CARDIAC COMPUTED TOMOGRAPHYPPROPRIATE USE CRITERIA WRITING GROUP, TECHNICAL PANEL, TASK FORCE, AND INDICATION REVIEWERS—ELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (IN ALPHABETICAL ORDER)

CommitteeMember

ResearchGrant Speaker

StockOwnership Salary

Board ofDirectors

Consulting Fees/Honoraria

ExpertWitness

Cardiac Computed Tomography Use Criteria Writing Group

anuelCerqueira

● PerceptiveInformatics, Inc.

● GE Healthcare● Astellas

None None None ● Astellas● GE Healthcare● MDS Nordion● Siemens

None

ohn McB.Hodgson

● BostonScientific

● RADI● Volcano Corp

None ● GuardianVPM

None None ● Volcano Corp ● Myocardialinfarct

● Review ofcaredelivered topatient withprostheticvalveendocarditis

aniel Mark None None None None None None None

ames Min None ● GE Healthcare None None None None None

atrick O’Gara ● Lantheus None None None None None None

eoffery D.Rubin

None None ● Terarecon None None ● Fovia● Medtronic● Trivascular 2

None

llen J. Taylor ● Abbott● Resverlogix

None None None None ● Abbott None

Cardiac Computed Tomography Appropriate Use Criteria Technical Panel

aniel Berman ● Siemens● GE/Amersham● Astellas● Lantheus

None None None None ● Bracco● Cedars Sinai

Medical Center-software royalties

● Floura Pharma● Lantheus● Spectrum

Dynamics

None

lan Brown ● Astellas● GlaxoSmithKline● Siemens

None None None None ● AstraZeneca● Merck● Merck/Schering-

Plough● Pfizer● Reliant

None

arooq A.Chaudhry

● Lantheus ● Lantheus None None None None None

icardo C. Cury ● AstellasPharma

● Pfizer Inc.

None None None ● Society ofCardiovascularComputedTomography

● Astellas Pharma None

ilind Y. Desai None ● Philips None None None None None

ndrew J.Einstein

● SpectrumDynamics

None None None None None None

ntoinette S.Gomes

None None None None None None None



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CommitteeMember



Board ofDirectors


ExpertWitness

obertHarrington

● AstraZeneca● Bristol-Myers

Squibb● GlaxoSmithKline● Merck● Millenium● Portola● Schering-Plough● The Medicines

Company

None None None None ● AstraZeneca● Baxter● CSL Behring● Eli Lilly● Heart.org● Luitpold● Merck● Novartis● Otsuka Maryland

Research Institute● Regado● Schering-Plough● WebMD

None

do Hoffmann None None None None None None None

ahul Khare None None None None None None None

hristopher M.Kramer

● Astellas● GlaxoSmithKline● Siemens


ohn Lesser None ● SiemensMedicalSystems

None None None ● Vital Images None

hristopherMcGann


lan Rosenberg None None None ● WellPointInc.

None None None

obert Schwartz None None None None None None None

arc Shelton None None None None None None None

erald W.Smetana

None None ● AnvitaHealth

None None None None

idney C. Smith,Jr.


llen J. Taylor ● Abbott● Resverlogix

None None None None ● Abbott None

Cardiac Computed Tomography Appropriate Use Criteria Task Force

oseph M. Allen None None None None None None None

teven Bailey ● BostonScientificCorporation

● Data SafetyMonitoringBoard

None None None None ● Volcano None

amela S.Douglas

● Abiomed● Amgen● Atritech● Edwards

Lifesciences● MAP

Pharmaceuticals● Medtronic● Osiris● Viacor

None ● CardioDX

● Elsevier

None ● TranslationalResearch inOncology

● 23andME● BG Medicine● CancerGuideDX● Heart.org● Institute of

Medicine● National Institutes

of Health● Novartis● Pappas Ventures● Veterans

Administration● WebMD● Xceed Molecular

None



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CommitteeMember



Board ofDirectors


ExpertWitness

obert C.Hendel

● GE Healthcare ● Astellas None None None ● PHx Health● United Healthcare

None

hristopher M.Kramer

● Astellas● GlaxoSmithKline● Siemens


ames Min None ● GE Healthcare None None None None None

anesh R. Patel ● Genzyme None None None None None None

eslee Shaw ● Astellas● Bracco

Diagnostics


aymond F.Stainback


ichael J. Wolk None None None None None None None

Cardiac Computed Tomography Appropriate Use Criteria Indication Reviewers

ichael Atalay None None None None None None None

atthew Budoff None ● General Electric None None None None ● CT scanning

racy Callister None ● GE Healthcare None None None None None

efferey Carr None None None None None None None

u Min Chang ● LantheusImaging


enjaminCheong

● Bracco Inc.● St. Jude

Medical


avithaChinnaiyan

● BayerHealthcare


hilip Costello None None None None None None None

. GordonDePuey


ndrew J.Einstein

● SpectrumDynamics


ee Fleisher None None None None None ● AstraZeneca ● Preoperativestroke

ario Garcia ● SpectrumDynamics

None ● Pfizer None ● IntersocietalAccreditationCouncil

● BG Medicine● MD Imaging● TheHeart.org

None

homas Gerber None None None None None None None

aymondGibbons

● Velomedix None None None None ● CardiovascularClinical Studies

● Lantheus MedicalImaging

● Medscape(Heart.org)

● Molecular InsightPharmaceuticals

● TherOx (WomenStudy)

None

arvey Hecht ● Philips MedicalSystems

● Philips MedicalSystems

None None None None None

ilena Henzlova None None ● Astellas None None None None



J

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CommitteeMember



Board ofDirectors


ExpertWitness

ill Jacobs ● SiemensMedical

● GE Healthcare None None None None None

cott Jerome ● Astellas ● Astellas None None None None None

orman Kato None None None None None None None

ichard Kovacs None None None None None ● Abbott● BG Medicine● Biomedical

Systems● Cook Inc-Med

Institute● ECG Scanning

Services● Eli Lilly● Endocyte● Essentials● XenoPort

None

ichael Lauer None None None None None None None

ohn Mahmarian None None None None None None None

avid Malenka ● Abbott Vascular● St. Jude

MedicalFoundation


rederick A.Masoudi

None None None ● AmericanCollege ofCardiology

● OklahomaFoundationforMedicalQuality

None ● United Healthcare(previous)

None

ulie Miller ● Toshiba MedicalSystems


ebabrataMukherjee


eagan Murphy None None None None None None None

agat Narula None None None None None None None

ohn Nixon None None None None None None None

. MagnusOhman

● Bristol-MyersSquibb

● CV Therapeutics● Daiichi Sankyo● Datascope● Eli Lilly● Sanofi-Aventis● Schering-Plough● The Medicines

Company

● Gilead Sciences None None None ● Abiomed● AstraZeneca● CV Therapeutics● Datascope● Gilead Sciences● Liposcience● Northpoint

Domain● Pozen, Inc.● Response

Biomedical● The Medicines

Company● WebMD

None

ichael H.Picard


ichael Poon None None None None None None None



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Tctoi

S

AJJsLCSCEC

R


CommitteeMember



Board ofDirectors


ExpertWitness

iguel Quinones None None None None None None None

aniel Rader ● Abbott● AstraZeneca● Bristol-Myers

Squibb● Merck● Otsuka

● AstraZeneca● Merck/

Schering-Plough

● Merck None None ● IsisPharmaceuticals

None

ita Redberg None None None None None None None

. JosephSchoepf

● Bayer-Schering● Bracco● GE● Medrad● Siemens

● Bayer● Bracco● GE● Medrad● Merck● Siemens

None None None ● Bayer-Schering● Bracco● GE● Medrad● Siemens

None

amuel Wann None None None None None None None

illiam GuyWeigold

● Philips MedicalSystems


onathanWeinsaft


illiamWeintraub

● Abbott● AstraZeneca● Bristol-Myers

Squibb● Otsuka● Sanofi-Aventis

None None None None ● AstraZeneca● Bayer● Bristol-Myers

Squibb● Cardionet● Eli Lilly● Pfizer● Sanofi-Aventis● Shionogi

● Celebrexlitigation

● Quetiapinelitigation

im AllanWilliams

● Bristol-MyersSquibb

● PGx Inc.

● Astellas None None None ● Astellas None

his table represents the relationships of the writing group, technical panel, task force, and indication reviewers with industry and other entities. These relationships were reviewed and updated inonjunction with all meetings and/or conference calls of the writing committee and technical panel during the document development process. The table does not necessarily reflect relationships athe time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership
f $10 000 or more of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship
ships in
s considered to be modest if it is less than significant under the preceding definition. Relation
taff

merican College of Cardiology Foundationohn C. Lewin, MD, Chief Executive Officeroseph M. Allen, MA, Director, TRIP (Translating Re-earch Into Practice)indsey Law, MHS, Senior Specialist, Appropriate Useriteriatarr Webb, MPH, Senior Specialist, Appropriate Useriteriarin A. Barrett, MPS, Senior Specialist, Science andlinical Policy

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ey Words: ACCF Appropriate Use Criteria y coronary artery bypassraft surgery y coronary artery disease y coronary heart disease yoronary calcium score y computed tomography y computedomographic angiography y electrocardiogram y heart failure ystimated metabolic equivalents of exercise y myocardial infarction y
ercutaneous coronary intervention y perioperative evaluation.


doi:10.1016/j.jacc.2010.07.005 published online Oct 25, 2010; J. Am. Coll. Cardiol.

and Geoffrey D. Rubin Manuel Cerqueira, John McB. Hodgson, Daniel Mark, James Min, Patrick O'Gara,

Interventions, Society for Cardiovascular Magnetic Resonance, Allen J. Taylor, Society of Nuclear Cardiology, Society for Cardiovascular Angiography and

American Heart Association, American Society of Echocardiography, American Radiology,Society of Cardiovascular Computed Tomography, American College of

American College of Cardiology Foundation Appropriate Use Criteria Task Force, Criteria for Cardiac Computed Tomography

ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 Appropriate Use

This information is current as of October 26, 2010

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