ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease

A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

Indication Development

The indications have been developed by a diverse writing committee composed of experts in both invasive and noninvasive diagnostic cardiac testing as well as general cardiology. Within each main indication category, a standardized approach has been used to capture the majority of clinical scenarios for which patients are referred for testing. Still, the writing committee recognizes that patient presentations vary widely and not all clinical factors are fully captured by these standardized scenarios. Indications were modified based on feedback from independent reviewers composed of both cardiovascular experts as well as those in general practice or in related specialty fields.

Rating Process and Scoring

Once the indications were finalized, a rating panel scored the indications independently. To ensure a diversity of expertise in the scoring process, the rating panel deliberately comprised individuals with a diversity of expertise, among which <50% regularly performed the particular procedures under evaluation. Wherever possible, indications have been mapped to relevant ACCF/AHA and subspecialty clinical practice guidelines and key publications/references (Online Appendix 1).

In scoring these criteria, the rating panel was asked to assess whether the use of the test for each indication is Appropriate, May Be Appropriate, or Rarely Appropriate, and was provided the following definition of appropriate use:

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 rating panel scored each indication as follows:

Median Score 7 to 9: Appropriate Care

An appropriate option for management of patients in this population because of benefits generally outweighing risks; effective option for individual care plans although not always necessary depending on physician judgment and patient-specific preferences (i.e., procedure is generally acceptable and is generally reasonable for the indication).

Median Score 4 to 6: May Be Appropriate Care

At times an appropriate option for management of patients in this population due to variable evidence or agreement regarding the benefit/risk ratio, potential benefit based on practice experience in the absence of evidence, and/or variability in the population; effectiveness for individual care must be determined by a patient’s physician in consultation with the patient, based on additional clinical variables and judgment along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the indication).

Median Score 1 to 3: Rarely Appropriate Care

Rarely an appropriate option for management of patients in this population due to the lack of a clear benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally acceptable and is not generally reasonable for the indication).

After independent rating, 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. Panel members had the opportunity to suggest modifications to the indications based on the discussion. After the 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 Concerted Action on Appropriateness 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. Any indication having disagreement was categorized as uncertain, regardless of the final median score. Indications that meet neither definition for agreement or disagreement are in a third, unlabeled, category.

General Assumptions/Considerations

• 1. Each test is performed in compliance with published criteria for quality cardiac diagnostic testing as provided by national laboratory accreditation “standards” (i.e., Intersocietal Accreditation Commission, American College of Radiology) and societal “quality” guidelines documents, and interpreted by physicians who are qualified to do so.

  Stress echocardiography (echo) (5–7)

  Radionuclide myocardial perfusion imaging (MPI) (8–11)

  Cardiac magnetic resonance (CMR) (12–15)

  Coronary computed tomography angiography (CCTA) (16–19)

  Invasive coronary angiography (cath) (20,21)

  Radiation (22–24)

  Although geographic differences may exist in the availability or quality of the different modalities, raters were asked to make determinations based on published diagnostic and prognostic performance of the testing modalities. In other words, the rater should assume that each modality is locally available and performed on appropriate equipment, and is interpreted by individuals with acceptable training and expertise, when scoring each indication.

• 2. The clinical status of the patient should be assumed to be valid as stated in the indication (e.g., a thorough history and physical exam have occurred such that an asymptomatic patient is truly asymptomatic for the condition in question).

• 3. Evaluation of all indications is taking place under nonurgent circumstances.

• 4. All patients are receiving optimal standard care, including guideline-based risk factor modification for primary or secondary prevention of ischemic heart disease unless specifically noted.

• 5. In the event of an ambiguous angiogram, either intravascular ultrasound or fractional flow reserve may be performed as needed.

• 6. If the patient’s characteristics are captured under more than 1 indication, the patient should be categorized according to the hierarchy provided in Figure 1.

• 7. Indications that describe routine or surveillance imaging imply that the test is being considered, not because of any change in clinical circumstances or any need to consider a change in therapy, but rather, solely because a period of time has elapsed.

• 8. For certain indications, emphasis has been placed upon the patient’s ability to exercise and achieve 85% of their age-predicted maximal heart rate (220 − age). When the patient’s ability to exercise is not explicitly stated, it should be assumed that the patient can exercise to a symptomatic endpoint or ≥85% of their age-predicted maximal heart rate. Similarly, it should be assumed that the electrocardiogram (ECG) is interpretable unless otherwise stated.

• 9. The mode of stress testing is assumed to be exercise (e.g., treadmill, bicycle) for patients able to exercise for the modalities for which some form of “stress” is required. For patients unable to exercise, it is assumed that pharmacological stress may be performed using the appropriate agent and/or with or without low level exercise. For CMR, it is assumed that vasodilator stress perfusion is the technique used.

• 10. Selection for and monitoring of contrast use is assumed to be in accord with published standards documents, when available (14,24).

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Figure 1

Hierarchy of Potential Test Ordering Based on Clinical Presentation

For those patients who may be classified into more than 1 of the clinical indication tables and/or algorithms, this flowchart places clinical conditions into a hierarchy to aid in assessing appropriateness. Patients sent for testing for purposes of pre-operative cardiac assessment who are rated Rarely Appropriate for testing based on surgery alone may be considered for testing for other reasons (e.g., symptomatic). CABG = coronary artery bypass graft; CAD = coronary artery disease; CV = cardiovascular; PCI = percutaneous coronary intervention.

Multimodality-Specific Assumptions/Considerations

Definitions for All Sections

Symptomatic (includes potentially ischemic equivalents as relevant): Chest Pain Syndrome or Anginal Equivalent

Patients may present with any constellation of clinical findings that the physician feels is consistent with coronary artery disease (CAD). Examples of such findings include, but are not limited to, chest pain, chest tightness, chest burning, epigastric pain, shoulder pain, jaw pain, or other symptoms/findings suggestive of CAD. Non-chest pain symptoms (e.g., dyspnea or reduced/worsening effort tolerance) or signs (e.g., new electrocardiographic abnormalities) that are thought to be consistent with CAD may also be considered to be an ischemic equivalent. Symptomatic patients described in the tables with certain pre-test probabilities are assumed to present only with the relevant symptomatology (e.g., low pre-test probability patients may present with atypical or nonanginal chest pain, but not typical chest pain or tightness).

Indication

A set of patient-specific conditions defines an indication. The term clinical indication does not necessarily mean that any test is warranted. In other words, for some clinical indications, all modalities may be rated as Rarely Appropriate.

Unable to Exercise

Patient inability to exercise is assumed to be due to noncardiovascular issues such as arthritis and not cardiovascular issues that would inherently increase a patient’s risk.

Definitions for Section 1

ECG: Uninterpretable

This refers to ECGs with resting abnormalities such as ST-segment depression (≥0.10 mV), complete left bundle branch block, pre-excitation (Wolff-Parkinson-White syndrome), digoxin use, or ventricular paced rhythm that would make the exercise ECG difficult to interpret.

Definitions for Section 1: Table 1.1

Pre-Test Probability of CAD: Symptomatic (Ischemic Equivalent) Patients

When symptoms are present, and there is sufficient suspicion of heart disease to warrant cardiac evaluation, the clinician should make a probability estimate of the likelihood of CAD prior to selecting testing. There are a number of validated risk assessment models (26,27) available that can be used to calculate this probability. Clinicians should be familiar with those algorithms that pertain to the populations they encounter most often. In scoring the indications, the following probabilities, as calculated from any of the various available validated algorithms, should be applied.

• • Low pre-test probability: <10% pre-test probability of CAD;

• • Intermediate pre-test probability: Between 10% and 90% pre-test probability of CAD;

• • High pre-test probability: >90% pre-test probability of CAD.

The method recommended by the ACCF/AHA Guidelines for Stable Ischemic Heart Disease (28) is provided as 1 example of a method used to calculate pre-test probability and is a modification of a previously published literature review (29). Please refer to Table A and the definition of angina characteristics. It is important to note that other factors or ECG findings (e.g., prior infarction) can affect pre-test probability, although these factors are not accounted for in Table A. Similarly, although not incorporated into the algorithm, other CAD risk factors may also affect pre-test likelihood of CAD. Detailed nomograms are available that incorporate the effects of a history of prior infarction, ECG Q waves, and ST- and T-wave changes, diabetes, and other cardiac risk factors (30). Patients with multiple established coronary risk factors not accounted for in Table A are likely not to have <10% likelihood of coronary artery disease and may require reclassification.

Angina

• • Typical Angina (Definite): Defined as 1) substernal chest pain or discomfort that is 2) provoked by exertion or emotional stress and 3) relieved by rest and/or nitroglycerin (31).

• • Atypical Angina (Probable): Chest pain or discomfort that lacks one of the characteristics of definite or typical angina.

• • Nonanginal Chest Pain: Chest pain or discomfort that meets one or none of the typical angina characteristics.

Definitions for Section 1: Table 1.2 and Section 2: Table 2.2

Global CAD Risk

It is assumed that clinicians will use current standard methods of global risk assessment such as those presented in the National Heart, Lung, and Blood Institute report on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) (32), PROCAM (33), or similar national guidelines.

• • When applying a global risk score for asymptomatic patients, risk is defined as the probability of experiencing a CAD event over a given time period. The ATP III report specifies CAD event risk over the next 10 years among asymptomatic individuals. CAD risk refers to 10-year risk for myocardial infarction or CAD death. However, acknowledging that global risk scores may be miscalibrated in certain populations (e.g., women, younger men), clinical judgment may be used to document an exception to the AUC. Moreover, important clinical risk factors, such as family history of premature CAD, though not included in global risk scoring, also may be influential considerations in clinical judgment.

• • Low global CAD risk

  Defined by an age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk <6%.

• • Intermediate global CAD risk

  Intermediate risk is defined as a 10-year CAD risk from 10% to 20%. Among women and younger men, an expanded intermediate-risk range of 6% to 20% may be appropriate.

• • High global CAD risk

  High risk is defined as a 10-year CAD risk of >20%. CAD equivalents (e.g., diabetes mellitus, peripheral arterial disease) can also define high risk.

Definitions for Section 1: Table 1.3

Heart Failure

Refer to stages B, C, and D heart failure as defined by the ACCF/AHA Guideline for the Management of Heart Failure (33a).

Ventricular Tachycardia

A cardiac arrhythmia of 3 or more consecutive complexes in duration that emanates from the ventricles at a rate of >100 beats/min (cycle length <600 ms).

Sustained Ventricular Tachycardia

Ventricular tachycardia (VT) that is >30 seconds in duration and/or requires termination due to hemodynamic compromise in <30 seconds (34,35).

Nonsustained VT

Three or more consecutive beats of VT that self-terminate in <30 seconds.

Frequent Premature Ventricular Contractions

More than 30 premature ventricular contractions (PVCs) per hour (36).

Syncope

Transient loss of consciousness due to global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery (37), not lightheadedness or dizziness alone.

Definitions for Section 2: All Tables

Nonobstructive Invasive Coronary Angiogram

Less than 50% luminal diameter narrowing, by visual assessment, of an epicardial or left main stenosis measured in the “worst view” angiographic projection.

Definitions for Section 3: All Tables

Evaluating Perioperative Risk for Noncardiac Surgery

Method for Determining Perioperative Risk

See Figure 2, “Stepwise Approach to Perioperative Cardiac Assessment,” from the ACCF/AHA 2009 perioperative guidelines (38). On the basis of the algorithm, once it is determined that the patient does not require urgent surgery, the clinician should determine the patient’s active cardiac conditions (see Table B) and/or perioperative risk predictors (see Table C). If any active cardiac conditions and/or major risk predictors are present, Figure 2 suggests a directed workup of the underlying condition, 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.

Condition	Examples
Unstable coronary syndromes	Unstable or severe angina∗ (CCS class III or IV)†
	Recent MI‡
Decompensated HF (NYHA functional class IV; worsening or new-onset HF)
Significant arrhythmias	High-grade atrioventricular block
	Mobitz II atrioventricular block
	Third-degree atrioventricular heart block
	Symptomatic ventricular arrhythmias
	Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR >100 beats/min at rest)
	Symptomatic bradycardia
	Newly recognized ventricular tachycardia
Severe valvular disease	Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm2, or symptomatic)
	Symptomatic mitral stenosis (progressive dyspnea on exertion, exertional presyncope, or HF)

Reprinted from Fleisher et al. (38).

CCS = Canadian Cardiovascular Society; HF = heart failure; HR = heart rate; MI = myocardial infarction; NYHA = New York Heart Association.

↵∗ According to Campeau (39).

↵† may include “stable” angina in patients who are unusually sedentary.

↵‡ the American College of Cardiology National Database Library defines recent MI as >7 days but ≤1 month (within 30 days).

Table B

Active Cardiac Conditions for Which the Patient Should Undergo Evaluation and Treatment Before Non-Emergent Noncardiac Surgery (Class I, Level of Evidence: B)

• History of ischemic heart disease

• History of compensated or prior heart failure

• History of cerebrovascular disease

• Diabetes mellitus

• Renal insufficiency (creatinine >2.0)

Reprinted from Fleisher et al. (38).

ACCF = American College of Cardiology Foundation; AHA = American Heart Association.

↵∗ As defined by the ACCF/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care For Noncardiac Surgery. Note that these are not standard coronary artery disease risk factors.

Table C

Perioperative Clinical Risk Factors^∗

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Figure 2

Stepwise Approach to Perioperative Cardiac Assessment

Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients ≥50 years of age. ACC = American College of Cardiology; AHA = American Heart Association; HR = heart rate; LOE = level of evidence; MET = metabolic equivalent.

Modified from Fleisher et al. (38).

Section 1. Detection of CAD/Risk Assessment

Table 1.1

Symptomatic

Table 1.2

Asymptomatic (Without Symptoms or Ischemic Equivalent)

Table 1.3

Other Cardiovascular Conditions

Section 2. Prior Testing or Procedure

Section 2.1. Prior Testing Without Intervening Revascularization (If Intervening Revascularization Since Most Recent Test, Refer to Section 2.2)

Table 2.0

Sequential Testing (≤90 Days): Abnormal Prior Test/Study)

Table 2.1

Sequential or Follow-Up Testing (≤90 Days): Uncertain Prior Results

Table 2.2

Follow-Up Testing (>90 Days): Asymptomatic or Stable Symptoms

Table 2.3

Follow-Up Testing: New or Worsening Symptoms

Section 2.2. Post-Revascularization (PCI or CABG)

Table 2.4

Symptomatic (Ischemic Equivalent)

Table 2.5

Asymptomatic (Without Ischemic Equivalent)

Section 3. Pre-Operative Evaluation for Noncardiac Surgery

Table 3.1

Moderate-to-Good Functional Capacity (≥4 METs) OR No Clinical Risk Factors

Table 3.2

Asymptomatic AND < 1 Year Post Any of the Following: Normal CT or Invasive Angiogram, Normal Stress Test for CAD, or Revascularization

Table 3.3

Poor or Unknown Functional Capacity (<4 METs)

Section 4. Determine Exercise Level Prior to Initiation of Exercise Prescription or Cardiac Rehabilitation

Table 4.1

Exercise Prescription

Table 4.2

Prior to the Initiation of Cardiac Rehabilitation (As a Stand-Alone Indication): Able to Exercise

Clinical Scenarios

The clinical scenarios represented in the document cover a range of typical patient presentations, which represent a range of appropriateness for each procedure. The use of several modalities of testing in the initial evaluation of patients with symptoms representing SIHD or ischemic equivalents (i.e., newly diagnosed heart failure, arrhythmias, or syncope) was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise ECG. Testing for the evaluation of new or worsening symptoms following a prior test or procedure was also found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior test result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing intermediate or vascular surgery with 1 or more clinical risk factors or prior to an organ transplant. Exercise ECG was rated as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes.

By comparison to symptomatic patients, testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate- and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or PCI within 2 years or within 5 years after CABG in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or those undergoing low-risk surgery also was found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.

Rating Changes From Prior Documents

This document supersedes prior AUC documents that cover the same or similar clinical scenarios for individual procedures (e.g., for the various stress imaging modalities and anatomic procedures) (40–43).

Thirty-seven of the indications were rated differently in the current document than they were rated in the prior relevant documents (Online Appendix 4). Of these divergences, 18 could be reasonably expected by virtue of the fact that modalities were rated in tandem by 1 panel. The current document incorporated slight wording changes within the definitions and/or the indications sections relative to previous documents in order to remove inconsistencies. Other rating differences may be attributed to the changing practice environment and evolution in cumulative clinical experience with these procedures, and maturation of the field since the original documents’ publication. For instance, in this document, ratings for stress CMR were more often in accord with the ratings for stress RNI, stress echo, and exercise treadmill testing. This may reflect the simultaneous rating of modalities and the growing body of evidence supporting the utility and accuracy of stress CMR (44–49). Of the remaining 19 divergent ratings, all but 1, in stress echo, were for CCTA, coronary calcium scoring, and invasive coronary angiography.

Six ratings were lower than previous documents, and all were among asymptomatic patients. Despite supporting evidence, these lower ratings for asymptomatic patients may reflect concern, voiced by many physicians, that the previous Appropriate Use ratings could have been misinterpreted as a recommendation to use these tests to screen a broad swath of the U.S. population. Although the general ratings are lower in the current document relative to prior documents, both coronary artery calcium and exercise ECG were rated as May Be Appropriate for asymptomatic patients of intermediate global risk. As such, 1 of these tests can be an option for further evaluation of potential SIHD in an individual patient when deemed reasonable by the patient’s physician. For instance, prior clinical practice guidelines have supported the role of coronary artery calcium with a Class IIa, Level of Evidence B recommendation for identifying at-risk individuals who may qualify for risk detection and targeted prevention efforts including altered medical therapeutic regiments and/or lifestyle modifications.

For CCTA, there were 7 additional differences, 4 of which recognized the value of CCTA in sequential or follow-up testing. The improved rating of CCTA following an abnormal stress imaging study may reflect the evolution of the evidence base since prior ratings (50–52). Notably, there were also a few indications where the ratings of CCTA decreased, specifically for symptomatic patients or in the pre-operative setting, ratings that are consistent with the perioperative guidelines and recent SIHD guidelines (28,38).

Another important difference from prior documents is the May Be Appropriate rating for stress echo among symptomatic patients with low pre-test probability and an ability to exercise and an interpretable ECG, a presentation also reviewed in the recent SIHD guideline (28). However, stress echo was less strongly supported for this scenario than exercise treadmill testing. In fact, although not a rating choice, “no testing at all” may also be considered an option in such low-risk cases since the low pre-test probability alone limits the value of a positive test in determining likelihood of disease and often could then potentially lead to further testing. This is in keeping with the concept that because a test was rated Appropriate or May Be Appropriate, this does not indicate that a test must be performed. If testing is considered, several studies and an expert consensus statement have reviewed the utility of exercise treadmill testing in this population, which is largely composed of women <60 years old with atypical and nonanginal presentations based on pre-test probability calculations (53,54). An ECG treadmill test can serve as an effective initial test and significantly reduce the number of patients who proceed to further stress imaging or other testing (53). Despite the fact that ST-segment depression and the ECG reading portion of the test have been shown to be less reliable in women, the ability to integrate multiple parameters (exercise capacity, chronotropic response, heart rate response, blood pressure response, and Duke Treadmill Score) from an exercise ECG can provide physicians with the necessary diagnostic accuracy, especially given the excellent negative predictive value of the test (55).

Interpretation, Assumptions, and Future Directions

There are a number of important considerations in interpreting and applying the standards contained in this document.

These new AUC are intended to provide guidance for patients and clinicians when it comes to making a reasonable testing choice amongst the available testing modalities for SIHD detection or risk assessment. Although the various modality ratings for each indication are presented together, the ratings are not intended to be comparative or indicate a “best test” for a given indication. Rather, each rating should be interpreted as a summary of the available evidence supplemented by expert opinion for an individual stress test or anatomic procedure. For example, just because 2 stress imaging modalities are rated as Appropriate and the third as May Be Appropriate, it may still be reasonable to choose the third modality for a particular patient due to his/her individual characteristics. In performing the ratings, the technical panel was instructed not to compare modalities with one another for any given indication. Rather, each test was to be rated individually for each scenario based upon the quality of the published evidence as well as the expert opinion of the rating panel. In the absence of robust comparative effectiveness evidence, a comparative rating approach would be both premature and misleading. Thus, although these ratings reflect the existing evidence base supplemented by expert consensus, there is no doubt that more research is needed to further identify, not only when to use any given modality, but also when to favor one over another. Importantly, there are a number of ongoing large randomized trials that may provide sufficient evidence to allow for comparative ratings in future documents (56,57).

The contributors also acknowledge that the division of these scores into 3 rating categories of appropriate use is often somewhat arbitrary and that the category designations should be viewed instead as a continuum. At the same time, the AUC process is intended to be transparent for users. Accordingly, the technical panel’s numerical scores may be found online, Appendix 3. However, the categorical ratings only, which are shown in the tables in the preceding text, are intended for clinical use. The contributors also recognize diversity in clinical opinion for particular clinical scenarios. As such, the criteria can inform procedure use, but physician judgment is required for individual patient decisions. Furthermore, the clinical scenario list is intended to be relatively comprehensive, without being exhaustive. Accordingly, some patients encountered in clinical practice may have extenuating features such that they may not fit exactly into any of the clinical scenarios presented.

It is understood that procedures whose use is Appropriate or May Be Appropriate should be reimbursed when applied in the suitable clinical scenario. In certain clinical settings, procedures that are Rarely Appropriate may be justifiable based on that patient’s particular clinical characteristics. These exceptions should be clearly documented.

Additionally, it is assumed that the evaluation for SIHD in these clinical scenarios occurs in a nonurgent setting. Thus, despite the recent publication of 3 randomized comparative effectiveness trials of the use of CCTA in the emergency department evaluation of low risk but acute chest pain (58–60), the use of CCTA for this specific clinical scenario is not addressed in this document because the intended focus is for the outpatient evaluation of SIHD (61).

As with prior AUC documents, we anticipate that the interpretation and application of these criteria will yield insights into patterns of care and will help to inform future iterations of these criteria. The ratings in the present document will be re-evaluated on a regular basis as the modalities, the evidence base, and the clinical landscape evolve. In addition, future documents will rate clinical scenarios involving cardiac structure and function assessment.