Journal of the American College of Cardiology
ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress EchocardiographyA Report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine
Author + information
- stress echocardiography
- appropriateness criteria
- cardiac imaging
- coronary artery disease
- diagnostic testing
Technical Panel Members
Eric D. Peterson, MD, MPH, FACC, FAHA, Moderator
Robert C. Hendel, MD, FACC, FAHA, Methodology Liaison
Raymond F. Stainback, MD, FACC, FASE, Writing Group Liaison†
Michael Blaivas, MD, RDMS, FACEP‡
Roger D. Des Prez, MD, FACC§
Linda D. Gillam, MD, FACC, FAHA, FASE
Terry Golash, MD
Loren F. Hiratzka, MD, FACC, FAHA, FACS∥
William G. Kussmaul, MD, FACC¶
Arthur J. Labovitz, MD, FACC, FAHA, FASE, FCCP†
JoAnn Lindenfeld, MD, FACC#
Frederick A. Masoudi, MD, MSPH, FACC
Paul H. Mayo, MD, FCCP⁎⁎
David Porembka, DO, FCCM††
John A. Spertus, MD, MPH, FACC
L. Samuel Wann, MD, MACC‡‡
Susan E. Wiegers, MD, FACC, FASE†
ACCF Appropri- ateness Criteria Task Force
Ralph G. Brindis, MD, MPH, FACC, Chair
Pamela S. Douglas, MD, MACC, FAHA, FASE
Robert C. Hendel, MD, FACC, FAHA
Manesh R. Patel, MD
Eric D. Peterson, MD, MPH, FACC, FAHA
Michael J. Wolk, MD, MACC
Joseph M. Allen, MA
Table of Contents
Abstract......1128
Preface......1129
Introduction......1130
Methods......1130
General Assumptions for Stress Echocardiography......1130
Abbreviations......1130
Results of Ratings......1131
Stress Echocardiography Appropriateness Criteria (by Indication)......1131
Table 1. Detection of CAD/Risk Assessment: Symptomatic......1131
Detection of CAD/Risk Assessment: Symptomatic
Table 2. Detection of CAD and Risk Assessment: Asymptomatic (Without Chest Pain Syndrome or Anginal Equivalent)......1132
Detection of CAD and Risk Assessment: Asymptomatic (Without Chest Pain Syndrome or Anginal Equivalent)
Table 3. Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities......1132
Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities
Table 4. Risk Assessment With Prior Test Results......1132
Risk Assessment With Prior Test Results
Table 5. Risk Assessment: Preoperative Evaluation for Noncardiac Surgery......1133
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery†
Table 6. Risk Assessment: Following Acute Coronary Syndrome......1133
Risk Assessment: Following Acute Coronary Syndrome
Table 7. Risk Assessment: Post-Revascularization (PCI or CABG)......1133
Risk Assessment: Post-Revascularization (PCI or CABG)
Table 8. Assessment of Viability/Ischemia......1133
Assessment of Viability/Ischemia
Table 9. Stress Study for Hemodynamics (Includes Doppler During Stress)......1134
Stress Study for Hemodynamics (Includes Doppler During Stress)
Table 10. Contrast Use......1134
Contrast Use
Stress Echocardiography Appropriateness Criteria (by Appropriateness Category)......1134
Table 11. Appropriate Indications (Median Score 7 to 9)......1134
Appropriate Indications (Median Score 7 to 9)
Table 12. Uncertain Indications (Median Score 4 to 6)......1136
Uncertain Indications (Median Score 4 to 6)
Table 13. Inappropriate Indications (Median Score 1 to 3)......1137
Inappropriate Indications (Median Score 1 to 3)
General Discussion......1138
Appendix A: Stress Echocardiography Definitions......1139
Determining Pre-Test Probability of CAD......1139
Determining Pre-Test Risk Assessment for Risk Stratification......1140
Evaluating Perioperative Risk for Noncardiac Surgery......1141
Appendix B: Methods......1143
Panel Selection......1143
Development of Indications......1143
Rating Process......1143
Relationships With Industry......1144
Literature Review......1144
Appendix C: ACCF Appropriateness Criteria Task Force and Technical Panels......1144
Stress Echocardiography Writing Group......1144
Stress Echocardiography Technical Panel......1144
ACCF Appropriateness Criteria Task Force......1145
Appendix D: ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR Stress Echocardiography Appropriateness Criteria Writing Group, Technical Panel, Task Force, and Indication Reviewers—Relationships With Industry (in Alphabetical Order)......1145
Comparing Pre-Test Likelihoods of CAD in Low-Risk Symptomatic Patients With High-Risk Symptomatic Patients—Duke Database (15)
Men: 10-Year CHD Risk According to Framingham Risk Score
Women: 10-Year CHD Risk According to Framingham Risk Score
ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR Stress Echocardiography Appropriateness Criteria Writing Group, Technical Panel, Task Force, and Indication Reviewers—Relationships With Industry (In Alphabetical Order)
References......1147
Abstract
The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain.
The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.
Preface
In an effort to respond to the need for the rational use of imaging services in the delivery of high quality care, the American College of Cardiology Foundation (ACCF) has undertaken a process to determine the appropriateness of cardiovascular imaging for selected patient indications.
Appropriateness criteria publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on a current understanding of the technical capabilities of the imaging modalities examined. Although not intended to be entirely comprehensive, the indications are meant to identify common scenarios encompassing the majority of contemporary practice. Given the breadth of information they convey, the indications do not directly correspond to the Ninth Revision of the International Classification of Diseases (ICD-9) system.
The ACCF believes that careful blending of a broad range of clinical experiences and available evidence-based information will help guide a more efficient and equitable allocation of health care resources in cardiovascular imaging. The ultimate objective of appropriateness criteria is to improve patient care and health outcomes in a cost-effective manner but is not intended to ignore ambiguity and nuance intrinsic to clinical decision making. Local parameters, such as the availability or quality of equipment or personnel, may influence the selection of appropriate imaging procedures. Thus, appropriateness criteria should not be considered substitutes for sound clinical judgment and practice experience.
The ACCF appropriateness criteria process itself is also evolving. In the current iteration, Technical Panel members were asked to rate indications for stress echocardiography in a manner independent and irrespective of prior ACCF ratings for similar diagnostic stress imaging modalities such as single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) (1), cardiac computed tomography (CT), or cardiac magnetic resonance (2). Given the iterative nature of the process, readers are counseled not to compare too closely the individual appropriateness ratings among modalities rated at different times over the past 2 years. A “cross-modality” evaluation of the appropriateness of multiple imaging techniques will be undertaken in the near future. This evaluation should more directly answer questions about the strengths of each modality relative to alternatives for various clinical scenarios.
In developing these criteria the Appropriateness Criteria Technical Panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate; they were provided the following definition of appropriateness:
An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences⁎by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.
The Technical Panel scores each indication as follows:
Score 7 to 9
Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).
Score 4 to 6
Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). (Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.)
Score 1 to 3
Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).
The contributors acknowledge that the division of these scores into 3 categories of appropriateness is somewhat arbitrary and that the numeric designations should be viewed as a continuum. The contributors also recognize diversity in clinical opinion for particular clinical scenarios. Therefore, scores in the intermediate level of appropriateness should be labeled “uncertain,” as critical patient or research data are lacking and should be a prompt to the field to conduct definitive research investigation. It is anticipated that the appropriateness criteria reports will require updates as further data are generated and information from the implementation of the criteria is accumulated.
To prevent bias in the scoring process, the Technical Panel deliberately was not comprised solely of specialists in the particular procedure under evaluation. Specialists, while offering important clinical and technical insights, might have a natural tendency to rate the indications within their specialty as more appropriate than nonspecialists. In addition, care was taken in providing objective, nonbiased information, including guidelines and key references, to the Technical Panel.
We are grateful to the Technical Panel, a professional group with a wide range of skills and insights, for a thoughtful and thorough deliberation of the merits of stress echocardiography for various indications. In addition to our thanks to the Technical Panel for their dedicated work and review, we would like to offer special thanks to William Armstrong, MD, Christopher Kramer, MD, Robert McNamara, MD, and Catherine Otto, MD, for reviewing the draft indications; to Peggy Christiansen, the ACC librarian for her comprehensive literature searches; to Karen Caruth, who continually drove the process forward, and to ACCF Past President Pamela Douglas, MD, MACC, FAHA, FASE, for her insight and leadership.
Eric D. Peterson, MD, MPH, FACC, FAHA Moderator, Stress Echocardiography Technical Panel
Ralph G. Brindis, MD, MPH, FACC Chair, ACCF Appropriateness Criteria Task Force
Introduction
This report addresses the appropriateness of stress echocardiography. The improvement in the test characteristics of stress echocardiography in recent years has increased its utility for detection and risk assessment of ischemic heart disease. Similar to other forms of stress imaging testing, stress echocardiography can help more clearly define cardiovascular risk for a patient, but also creates opportunities for overuse and misuse in patients who may not obtain a benefit, or who could have been medically managed effectively without the addition of the test. In particular, inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up. Concerns about inappropriate use exist among those who pay for these services and clinical leaders who evaluate the effectiveness of testing.
Methods
The indications included in this review are purposefully broad, and they comprise a wide array of cardiovascular signs and symptoms as well as clinical judgment as to the likelihood of cardiovascular findings.
A detailed description of the methods used for ranking of the selected clinical indications is outlined in Appendix B and is also found more generally in a previous publication, “ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging” (3). Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise. The panel first rated indications independently. Then the panel was convened for a face-to-face meeting for discussion of each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers’ scores. After the consensus meeting, panel members were then asked to independently provide their final scores for each indication.
The level of agreement among panelists as defined by RAND (4) was analyzed based on the BIOMED rule for a panel of 14 to 16. As such, agreement was defined as an indication where 4 or fewer panelists’ ratings fell outside the 3-point region containing the median score. Disagreement was defined as where at least 5 panelists’ ratings fell in both the appropriate and the inappropriate categories.
General Assumptions for Stress Echocardiography
To prevent any nuances of interpretation, all indications were considered with the following important assumptions:
1. All indications are assumed to apply to adult patients (18 years of age or older).
2. The test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique (5–8).
The indications were constructed by echocardiography experts and modified on the basis of discussions among the Task Force and feedback from independent reviewers and the Technical Panel. Wherever possible, indications were mapped to relevant clinical guidelines and key publications/references (Online Appendix at http://content.onlinejacc.org).
The Technical Panel was comprised of clinician experts, some with backgrounds in cardiac imaging and others with experience in general cardiovascular medicine, cardiac surgery, critical care medicine, emergency medicine, health services research, and health plan administration.† Panelists were instructed to incorporate in their deliberations several assumptions specifically for stress echocardiography, including:
1. All standard echocardiographic techniques for image acquisition, including imaging protocols, are available for each indication, and stress echocardiography has a sensitivity and specificity similar to those found in the published literature.
2. For all stress imaging, the mode of stress testing is assumed to be exercise for patients able to exercise. For patients unable to exercise, it is assumed that dobutamine is used for echocardiographic stress testing. Further background on the rationale for the assumption of exercise stress is available in the ACC/AHA 2002 Guideline Update for Exercise Stress Testing (9). Any indications including a specific mode of stress are labeled as such.
3. Preoperative evaluation includes procedures such as organ transplantation.
Abbreviations
ACS = acute coronary syndrome
AI =aortic insufficiency
CABG = coronary artery bypass grafting surgery
CAD =coronary artery disease
CHD = coronary heart disease
CT = computed tomography
ECG = electrocardiogram
HF = heart failure
LV = left ventricular
MET = estimated metabolic equivalents of exercise
MI = myocardial infarction
MR = mitral regurgitation
PCI = percutaneous coronary intervention
SPECT MPI = single-photon emission computed tomography myocardial perfusion imaging
UA/NSTEMI = unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI)
Results of Ratings
The final ratings for stress echocardiography (Tables 1 to 10) are listed by indication sequentially as obtained from second round rating sheets submitted by each panelist. Additionally, the indications are presented by Appropriateness Category (Tables 11 to 13).
Definitions used by the Technical Panel can be found in Appendix A. Supplemental tables, including documentation of the mean absolute deviation from the median and level of agreement of rankings for each indication, can be found in the Online Appendix at http://content.onlinejacc.org.
For the 51 indications for the use of stress echocardiography, 22 were found to be appropriate, 10 were uncertain, and 19 were considered inappropriate.
Typically, there was greater variability in scores of indications defined as uncertain, suggesting wide variation in opinion. A number of indications failed to meet the above definition of agreement. Still, there were no uncertain indications where the panel held such opposing viewpoints that the indication was labeled as one for which the panel disagreed. There was generally less variation for the indications labeled as either appropriate or inappropriate, with 68.8% and 79.0%, respectively, showing agreement as previously defined. Disagreement did not occur for any of the indications ultimately defined as appropriate or inappropriate. Finally, as prior research has found that, in general, the test operating characteristics of stress echocardiography and SPECT MPI imaging are similar, we also provide the readers with an asterisk where there were discordances between similar indications rated inappropriate for stress echocardiography and those previously rated uncertain for SPECT MPI.
Stress Echocardiography Appropriateness Criteria (by Indication)
Stress Echocardiography Appropriateness Criteria (by Appropriateness Category)
General Discussion
The appropriateness criteria in this report provide an estimate of the reasonableness of the use of stress echocardiography for the particular clinical scenarios presented in each of the 51 indications considered. They are expected to be useful for clinicians, health care facilities, and third-party payers engaged in the delivery of cardiovascular imaging. Experience with already published appropriateness criteria (1,2) has shown their value across a broad range of situations, guiding care of individual patients, educating caregivers, and informing policy decisions regarding reimbursement for cardiovascular imaging.
Appropriateness criteria represent the first component of the chain of quality recommended for cardiovascular imaging (11). After ensuring proper test selection, the achievement of quality in imaging includes adherence to best practices in image acquisition, image interpretation, and results communication, as well as incorporation of findings into clinical care. All components are important for optimal patient care, although not all are addressed in this report. The development of appropriateness criteria and their ranking by the Technical Panel assumes that other quality standards are adequately met. It also is assumed that when considering the appropriateness of ordering a repeat or annual test that the prior image and report can be obtained and are of sufficient quality as outlined above.
Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient. For example, the rating of an indication as inappropriate should not preclude a provider from performing stress echocardiographic procedures when there are patient- and condition-specific data to support that decision. Indeed this may be the correct clinical pathway if supported by mitigating characteristics of the patient. Likewise, uncertain indications often require individual physician judgment and understanding of the patient to better determine the usefulness of a test for a particular scenario. As such, the ranking of an indication as uncertain (score 4 to 6) should not be viewed as limiting the use of stress echocardiography for such patients. Finally, there may be clinical situations in which the use of stress echocardiography for an indication considered to be appropriate does not always represent reasonable practice, such as a patient in whom another diagnostic imaging test might be scheduled or has already been performed.
The indications contained in this report are purposefully broad to capture the range of situations in which clinicians find value in stress echocardiography information. However, as with the appropriateness criteria for other imaging modalities, they are not exhaustive because of the complexity and number of the potential clinical situations. For example, neither the use of stress echocardiography prior to organ transplantation nor all forms of perioperative echocardiography were included as separate indications but are assumed to be covered by the more general perioperative guidelines (10).
Stress echocardiography tests, like many imaging tests, may provide additional useful information beyond the primary purpose outlined by the indication. The appropriateness criteria for stress echocardiography were not developed to quantify the incremental information obtained by performing the test for reasons beyond those stated in an individual indication. For example, the additional information available with a stress echocardiogram, including the assessment of resting ejection fraction or the identification of concomitant valve disease, was not considered when determining the appropriateness rankings. Thus, members of the Technical Panel were asked specifically not to consider implicit or additional information outside the scope of an individual indication in their rankings. As such, the entire list of indications from this document and those published separately for transthoracic and transesophageal echocardiography (12) should be reviewed to assess a broader range of potential reasons for ordering a stress echocardiogram for an individual patient.
In addition, panelists were asked specifically not to consider comparisons to other imaging procedures or other appropriateness criteria documents while completing their rankings. While stress CT and MR are newer modalities which have not been extensively studied, stress echocardiography and stress SPECT MPI have similar bodies of evidence to support their use. The overwhelming majority of final ratings of stress echocardiography and stress SPECT MPI were concordant for similar clinical indications. However, a small number of the final scores and rating categories reported in this document differ from those previously published for stress SPECT MPI. Readers should note, however, that the categorical summaries tend to accentuate differences that sometimes are slight. For example, small fluctuations in a median rating (e.g., 4 vs. 3) will cause an indication to switch appropriateness categories (e.g., from uncertain to inappropriate).
There are several potential reasons for these discordant occurrences. The most likely reason for this is a simple variation in rating by the different panel members, whether due to composition, different levels of clinical experience, or different interpretations of data. The RAND process has documented that the interpretation of the literature by different sets of experts can yield slightly different final ratings (4). For example, one panel may contain a slightly higher percentage of “modality experts” than another panel. The Appropriateness Criteria Task Force has subsequently examined this influence of specialty and made every effort to provide a balance of expertise. Another source of potential variation is timing. As appropriateness criteria gain more exposure, Technical Panel members have greater familiarity with the indications and implementation requirements than the panels of prior modules. Inconsistency in wording of indications for the stress echocardiography and stress nuclear panels may have also contributed to differences in some scenarios. For example, stress echocardiography indications combined CAD detection and risk assessment into single indications, whereas the criteria for stress SPECT separated these indications.
The indications were developed and rated prior to the release of the ACC/AHA 2007 Perioperative Guidelines (10). As such, in addition to the Online Appendix (http://content.onlinejacc.org), the reader should refer to the 2007 version of the guidelines for further discussion of the use of noninvasive testing prior to surgery.
There are many potential applications for appropriateness criteria. Clinicians could use the ratings as a decision support or educational tool when ordering a test or providing a referral to another qualified physician. The criteria also may be used to facilitate discussion with referring clinicians who have patterns of ordering tests for inappropriate indications. Facilities and payers may choose to use the criteria either prospectively in the design of protocols, automated order entry, and pre-authorization procedures, or retrospectively for quality reports. It is hoped that payers will use this document as the basis to inform rational strategies to ensure that their members receive the highest-quality, cost-effective cardiovascular care.
As outlined in the original methodology by the ACCF (3), it is expected that services performed for appropriate indications will receive reimbursement. In contrast, services performed for inappropriate indications will likely require additional documentation to justify payment because of unique circumstances or the clinical profile of the patient. Payers should note that the Technical Panel and clinical community do not consider uncertain indications as those that should not be performed or reimbursed. Rather, the uncertain indications are those where the opinions of the panel vary and the data may be conflicting. In many of these areas, additional research is clearly desirable. Indications with high clinical volume that are rated as uncertain identify areas for increased focus and research.
When used to assess performance, appropriateness criteria should be applied in conjunction with systems that support quality improvement. Ordering forms containing essential information for determining appropriateness along with periodic feedback reports to providers may help educate providers on their ordering patterns. Prospective pre-authorization procedures, if put in place, are most effective once a retrospective review has identified a pattern of potential inappropriate use. Because the criteria are based on current scientific evidence and the deliberations of the Technical Panel, they should be used prospectively to generate future discussions about reimbursement, but should not be applied retrospectively to cases completed prior to issuance of this report.
The primary objective of this report is to provide guidance regarding the perceived suitability of stress echocardiography for diverse clinical scenarios. As with previous appropriateness criteria documents, consensus among the raters was desirable, but any attempt to achieve complete agreement within this diverse panel would have been artificial and not necessarily of clinical value. Two rounds of ratings with lively discussion between the ratings did lead to some consensus among panelists. However, further attempts to drive consensus would have diluted true differences in opinion among panelists and, therefore, was not undertaken.
Future research analyzing patient outcomes utilizing indications rated appropriate would help ensure the equitable and efficient allocation of resources for diagnostic studies. Review of medically necessary care may also improve the understanding of regional variations in imaging utilization. Further exploration of the indications rated as “uncertain” will help generate the data required to further define the appropriateness of stress echocardiography. Finally, it will be necessary to periodically assess and update the indications and criteria as technology evolves and new data and field experience become available.
Appendix A Stress Echocardiography Definitions
Determining Pre-Test Probability of CAD
Angina: as defined by the ACC/AHA Guidelines on Exercise Testing (9)
• Typical Angina (Definite) (13):
1. Substernal chest pain or discomfort that is
2. provoked by exertion or emotional stress and
3. relieved by rest and/or nitroglycerin.
• Atypical Angina (Probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina (13).
Nonanginal Chest Pain: Chest pain or discomfort that meets one or none of the typical angina characteristics (13).
Chest Pain Syndrome or Anginal Equivalent: Any constellation of symptoms that the physician feels may represent a complaint consistent with obstructive CAD. Examples of such symptoms include, but are not exclusive to, chest pain, chest tightness, burning, dyspnea, shoulder pain, palpitations, syncope, breathlessness, and jaw pain.
Pre-Test Probability of CAD: Once the physician determines the presence of symptoms that may represent obstructive CAD (chest pain syndrome or anginal equivalent present), then the pre-test probability of CAD should be determined. There are a number of risk algorithms (14,15) available that can be used to calculate this probability. Clinicians should become familiar with those that pertain to the populations they encounter most often. In scoring the indications, the following probabilities as calculated from any of the various available algorithms should be applied.
• Low pre-test probability: Less than 10% pre-test probability of CAD
• Intermediate pre-test probability: Between 10% and 90% pre-test probability of CAD
• High pre-test probability: Greater than 90% pre-test probability
The method recommended by the ACC/AHA Guidelines for Chronic Stable Angina (16) is provided below as 1 example of a method used to calculate pre-test probability and is a modification of a previously published literature review (17). Please refer to definitions of angina and Table A1. Please note that the following table only predicts pre-test probability in patients without other complicating history or ECG findings. History and electrocardiographic evidence of prior infarction dramatically affect pre-test probability. Detailed nomograms are available that incorporate the effects of a history of prior infarction, electrocardiographic Q waves, electrocardiographic ST- and T-wave changes, diabetes, smoking, and hypercholesterolemia (9) (Table A2 presents 1 example).
Determining Pre-Test Risk Assessment for Risk Stratification
Risk Assessment
The rating sheets on risk assessment include indications in patients with suspected CAD.
It is assumed that clinicians will use echocardiography studies in addition to standard methods of risk assessment as presented in the AHA/ACC Scientific Statement: Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations (19). See the scientific statement to determine Framingham Risk Score (Tables A3 and A4)⇑⇑ to calculate CHD risk percentage. As noted in the scientific statement, these scores should be modified on the basis of additional relevant factors shown to affect risk such as obesity, physical inactivity, psychosocial factors, family history of premature CHD, ethnic characteristics (especially South Asians in the United States), and hypertriglyceridemia.
CHD Risk‡
(Based on the AHA/ACC Scientific Statement on Cardiovascular Risk Assessment [19])
• CHD Risk–Low
Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CHD risk less than 10%.
• CHD Risk–Moderate
Defined by the age-specific risk level that is average or above average. In general, moderate risk will correlate with a 10-year absolute CHD risk between 10% to 20%.
• CHD Risk–High
Defined as a 10-year absolute CHD risk of greater than 20% or the presence of diabetes mellitus.†
Evaluating Perioperative Risk for Noncardiac Surgery§
Method for Determining Perioperative Risk
(Based on the recommendations from the ACC/AHA Perioperative Cardiovascular Evaluation for Noncardiac Surgery [20])
Review Figure A1, “Stepwise Approach to Preoperative Cardiac Assessment.” Based on the algorithm, once it is determined that the patient does not require urgent surgery, and that there has not been revascularization within the last 5 years, the clinician should determine the patient’s perioperative risk predictors (see definitions in the following text). If major risk predictors are present, Figure A1 suggests consideration of coronary angiography and postponing or canceling noncardiac surgery. Once perioperative risk predictors are assessed based on the algorithm, then the surgical risk and patient’s functional status should be used to establish the need for noninvasive testing.
Perioperative Risk Predictors∥
• Major risk predictors
Unstable coronary syndromes, decompensated HF, significant arrhythmias, and severe valve disease.
• Intermediate risk predictors
Mild angina, prior MI, compensated or prior HF, diabetes, or renal insufficiency.
• Minor risk predictors
Advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of cerebrovascular accident, and uncontrolled hypertension.
Surgical Risk Categories∥
• High-Risk Surgery–cardiac death or MI greater than 5%
Emergent major operations (particularly in the elderly), aortic and peripheral vascular surgery, prolonged surgical procedures associated with large fluid shifts and/or blood loss.
• Intermediate-Risk Surgery–cardiac death or MI equal to 1% to 5%
Carotid endarterectomy, head and neck surgery, surgery of the chest or abdomen, orthopedic surgery, prostate surgery.
• Low-Risk Surgery–cardiac death or MI less than 1%
Endoscopic procedures, superficial procedures, cataract surgery, breast surgery.
ECG–Uninterpretable
Refers to ECGs with resting ST-segment depression (greater than or equal to 0.10 mV), complete left bundle-branch block, pre-excitation (Wolf-Parkinson-White syndrome), or paced rhythm.
Appendix B Methods
Panel Selection
Stakeholders were given the opportunity to participate in the appropriateness criteria process by submitting nominees from their organizations through a Call for Nominations released in the summer of 2006. From this list of nominees, the Task Force selected panel members to ensure an appropriate balance with respect to expertise in the specific modality, referring physicians, academic versus private practice, health services research, and specialty training.
Development of Indications
The process for creating a robust set of indications involved consulting current literature and previously published guidelines and clinical policy statements. The indications capture the majority of scenarios faced by cardiologists or referring physicians, but are not meant to be inclusive of all potential indications for which a stress echocardiography imaging study may be performed. Review was done by the Task Force, including additional comments from external reviewers. As a result of the meeting of the Technical Panel prior to the second round of rating, a number of the indications were clarified and modified. A final set of indications comprised the list of possible clinical scenarios that were rated for appropriateness by the panelists and compiled for this report.
Rating Process
The Technical Panel was instructed to follow the process outlined in the document, “ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging” (3). The appropriateness method combines expert clinical judgment with the scientific literature in evaluating the benefits and risks of medical procedures. Each panel member has equal weight in producing the final result for the set of indications they are asked to rate and the method does not force consensus.
The rating process includes a modified Delphi process involving 2 rounds of ratings and an intervening face-to-face meeting. At the face-to-face meeting, each panelist received a personalized rating form that indicated his or her rating for each indication and the distribution of de-identified ratings of other members of the panel. In addition, the moderator received a summary rating form with similar information (including panelist identification), along with other statistics that measured the level of agreement among panel members. A measure of the level of disagreement was applied to each score after both the first and second round scoring was completed. This project employed the BIOMED Concerted Action on Appropriateness definition for a panel size of 14 to 16. As defined in the RAND/UCLA manual (4) upon which the ACCF ratings method is based, the BIOMED rule for agreement (+) is that no more than 4 panelists rate the indication outside the 3-point region containing the median; for disagreement (−), at least 5 panelists rate in each extreme rating region (i.e., 1 to 3 and 7 to 9). Measures of agreement and the dispersion of ratings (mean absolute deviation from the median) may highlight areas where definitions are not clear or ratings are inconsistent, where panelist perceptions of the “average” patient may differ, or where various specialty groups or individual panelists may have differences of clinical opinion. In cases of obvious disagreement or outlier scores, the indication was highlighted in a summary table and identification of the outlier raters brought to the attention of the moderator. This information was used by the moderator to guide the panel’s discussion.
Relationships With Industry
The ACCF and its partnering organizations rigorously avoid any actual, perceived, or potential conflicts of interest that may arise as a result of an outside relationship or personal interest of a member of the Technical Panel. Specifically, all panelists are asked to provide disclosure statements of all relationships that may be perceived as real or potential conflicts of interest. These statements were reviewed by the ACCF Appropriateness Criteria Task Force, discussed with all members of the Technical Panel at the face-to-face meeting, and updated and reviewed as necessary. A table of disclosures of the Technical Panel and Task Force Members can be found in the Appendix D.
Literature Review
The Technical Panel members were asked to refer to the relevant guidelines for a summary of the relevant literature, guideline recommendation tables, and reference lists provided for each indication table when completing their ratings (Online Appendix at http://content.onlinejacc.org). Lastly, they were provided Web links to the previously published materials pertaining to the appropriateness criteria work (1–3).
Appendix C ACCF Appropriateness Criteria Task Force and Technical Panels
Stress Echocardiography Writing Group
Pamela S. Douglas, MD, MACC, FAHA, FASE–Lead Author, Appropriateness Criteria for Stress Echocardiography–Past President, ACC; Past President, ASE; Ursula Geller Professor of Research in Cardiovascular Diseases, Duke University Medical Center, Durham, NC
Bijoy Khandheria, MD, FASE, FACC–Professor of Medicine and Chair, Division of Cardiovascular Disease, Mayo Clinic, Scottsdale, AZ
Raymond F. Stainback, MD, FACC, FASE–Assistant Professor of Medicine (Clinical), Baylor College of Medicine; Medical Director, Noninvasive Cardiac Imaging and Adult Echocardiography Laboratories, St. Luke’s Episcopal Hospital, Texas Heart Institute; Partner, Hall-Garcia Cardiology Associates, Houston, TX
Neil J. Weissman, MD, FACC, FASE–Professor of Medicine, Georgetown University Medical Center, Washington, DC; Director of Cardiac Ultrasound, Cardiovascular Research Institute, Washington Hospital Center, Washington, DC
Stress Echocardiography Technical Panel
Eric D. Peterson, MD, MPH, FACC, FAHA–Moderator of the Technical Panel–Professor of Medicine and Director, Cardiovascular Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
Robert C. Hendel, MD, FACC, FAHA–Methodology Liaison for the Technical Panel–Midwest Heart Specialists, Fox River Grove, IL
Raymond F. Stainback, MD, FACC, FASE–Writing Group Liaison for the Technical Panel–Assistant Professor of Medicine (Clinical), Baylor College of Medicine; Medical Director, Noninvasive Cardiac Imaging and Adult Echocardiography Laboratories, St. Luke’s Episcopal Hospital, Texas Heart Institute; Partner, Hall-Garcia Cardiology Associates, Houston, TX
Michael Blaivas, MD, RDMS, FACEP–Associate Professor of Emergency Medicine; Chief, Emergency Ultrasound; and Director, Emergency Ultrasound Fellowship Program, Medical College of Georgia, Augusta, GA
Roger D. Des Prez, MD, FACC–Oklahoma Heart Institute, Tulsa, OK
Linda D. Gillam, MD, FACC, FAHA, FASE–Assistant Professor of Medicine and Medical Director, Cardiac Valve Program, Columbia University, New York, NY
Terry Golash, MD–Medical Director, Aetna Health, Inc., New York, NY
Loren F. Hiratzka, MD, FACC, FAHA, FACS–Medical Director, Cardiac Surgery, TriHealth, Inc. (Bethesda North and Good Samaritan Hospitals), Cincinnati, OH
William G. Kussmaul, MD, FACC–Associate Professor of Medicine, Drexel University College of Medicine; Cardiology Consultants of Philadelphia, Philadelphia, PA
Arthur J. Labovitz, MD, FACC, FAHA, FASE, FCCP–Professor of Internal Medicine, Director, Division of Cardiology, Director, Fellowship Program, and Director, Echocardiography Lab, Saint Louis University School of Medicine, St. Louis, MO
JoAnn Lindenfeld, MD, FACC–Professor of Medicine and Director, Heart Transplantation Program, University of Colorado at Denver and Health Sciences Center, Denver, CO
Frederick A. Masoudi, MD, MSPH, FACC–Associate Professor of Medicine, Denver Health Medical Center and University of Colorado at Denver and Health Sciences Center, Denver, CO
Paul H. Mayo, MD, FCCP–Professor of Clinical Medicine, Albert Einstein College of Medicine, Bronx, NY; Director, MICU, Beth Israel Medical Center, New York, NY
Todd D. Miller, MD, FACC, FAHA–Professor of Medicine and Co-Director, Nuclear Cardiology Laboratory, Mayo Clinic, Rochester, MN
David Porembka, DO, FCCM–Professor of Anesthesiology, Surgery, and Internal Medicine, Adjunct Professor of United States Air Force Aerospace Medicine, Cincinnati, OH
John A. Spertus, MD, MPH, FACC–Professor, University of Missouri–Kansas City School of Medicine, Director of Cardiovascular Education and Outcomes Research, Mid America Heart Institute of St. Luke’s Hospital, Kansas City, MO
L. Samuel Wann, MD, MACC–Chairman, Department of Cardiovascular Medicine, Wisconsin Heart Hospital, Wauwatosa, WI
Susan E. Wiegers, MD, FACC, FASE–Associate Professor of Medicine, Director, Clinical Echocardiography and Co-Director, Cardiovascular Fellowship, University of Pennsylvania School of Medicine, Philadelphia, PA
ACCF Appropriateness Criteria Task Force
Ralph G. Brindis, MD, MPH, FACC–Chair, Task Force–Regional Senior Advisor for Cardiovascular Disease, Northern California Kaiser Permanente; Clinical Professor of Medicine, University of California at San Francisco; Chief Medical Officer and Chairman, NCDR Management Board, American College of Cardiology, Washington, DC
Pamela S. Douglas, MD, MACC, FAHA, FASE–Past President, ACC; Past President, ASE; Ursula Geller Professor of Research in Cardiovascular Diseases, Duke University Medical Center, Durham, NC
Robert C. Hendel, MD, FACC, FAHA–Midwest Heart Specialists, Fox River Grove, IL
Manesh R. Patel, MD–Assistant Professor of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC
Eric D. Peterson, MD, MPH, FACC, FAHA–Professor of Medicine and Director, Cardiovascular Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
Michael J. Wolk, MD, MACC–Past President, ACC; Clinical Professor of Medicine, Weill-Cornell Medical School, New York, NY
Joseph M. Allen, MA–Director, TRIP (Translating Research Into Practice), American College of Cardiology, Washington, DC
Appendix D
Staff
American College of Cardiology Foundation
John C. Lewin, MD, Chief Executive Officer
Joseph M. Allen, MA, Director, TRIP (Translating Research Into Practice)
Karen Cowdery Caruth, MBA, Senior Specialist, Appropriateness Criteria
Erin A. Barrett, Senior Specialist, Clinical Policy and Guidelines
Appendix
Stress Echocardiography Second Round Ratings (Confidential and Embargoed)
Appropriateness Criteria for Echocardiography Related Guideline Recommendations and References for Stress Echocardiography
[S0735109707039629_mmc1.pdf]Footnotes
↵† American Society of Echocardiography Representative
↵† American Society of Echocardiography Representative
↵‡ American College of Emergency Physicians Representative
↵§ American Society of Nuclear Cardiology Representative
↵∥ American Heart Association Representative
↵¶ Society for Cardiovascular Angiography and Interventions Representative
↵# Heart Failure Society of America Representative
↵⁎⁎ American College of Chest Physicians Representative
↵†† Society of Critical Care Medicine Representative
↵‡‡ Society of Cardiovascular Computed Tomography Representative
↵§ Note: Todd D. Miller, MD, FACC, FAHA,§ also contributed to the panel ratings but not to the final document§
↵⁎ Negative consequences include the risks of the procedure (i.e., radiation or contrast exposure) and the downstream impact of poor test performance such as delay in diagnosis (false negatives) or inappropriate diagnosis (false positives).
↵† Full detail about the backgrounds of the members of the Technical Panel can be found in Appendix C.
↵‡ Grundy et al. (19) cite Framingham when assigning patients with diabetes mellitus to a category of high short-term risk because these patients typically have multiple risk factors and have poor prognoses if they develop CHD.
↵§ Definitions and algorithms cited were current at the time of the technical panel and are those reviewed by the technical panel at time of rating. See 2007 ACC/AHA Perioperative Guidelines for updated content (10).
↵∥ As defined by the ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation of Non-Cardiac Surgery (20).
This document was approved by the American College of Cardiology Board of Trustees in November 2007. When citing this document, the American College of Cardiology would appreciate the following citation format: Douglas PS, Khandheria B, Stainback RF, Weissman NJ. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography. J Am Coll Cardiol 2008;51:1127–47.
This article has been copublished in the March 18, 2008, issue of Circulation and e-published in Catheterization and Cardiovacular Interventions.
Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints{at}elsevier.com.
Permissions: Modification, alteration, enhancement and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at healthpermissions{at}elsevier.com.
Note: Todd D. Miller, MD, FACC, FAHA,§ also contributed to the panel ratings but not to the final document
↵⁎ Developed in accordance with the principles and methodology outlined by ACCF: Patel MR, Spertus JA, Brindis RG, Hendel RC, Douglas PS, Peterson ED, Wolk MJ, Allen JM, Raskin IE. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol 2005;46:1606–13.
- American College of Cardiology Foundation
References
Stepwise Approach to Preoperative Cardiac Assessment
Steps are discussed in the text. Definitions and algorithms cited were current at the time of the technical panel and are those reviewed by the technical panel at time of rating. See 2007 ACC/AHA Perioperative Guidelines for updated content (10). *Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care. CHF = congestive heart failure; ECG = electrocardiogram; MET = metabolic equivalent; MI = myocardial infarction.
Figures in Article
Figures
Tables
Supplementary Materials
- Online Appendix
Stress Echocardiography Second Round Ratings (Confidential and Embargoed)
Appropriateness Criteria for Echocardiography Related Guideline Recommendations and References for Stress Echocardiography
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