Table 13

Inappropriate Indications (Median Score 1 to 3)

IndicationAppropriateness Score (1–9)
Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome or Anginal Equivalent
1.
  • Low pre-test probability of CAD

  • ECG interpretable AND able to exercise

I (3)
Detection of CAD: Symptomatic—Acute Chest Pain
8.
  • High pre-test probability of CAD

  • ECG ST-elevation

I (1)
Detection of CAD and Risk Assessment: Asymptomatic (Without Chest Pain Syndrome or Anginal Equivalent)—General Patient Populations
11.
  • Low CHD risk (Framingham risk criteria)

I (1)
12.
  • Moderate CHD risk (Framingham)

  • ECG interpretable

I (3)
Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—Valvular Heart Disease Requiring Valve Surgery
16.
  • Moderate CHD risk (Framingham)

I (3)
Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—New-Onset Atrial Fibrillation
17.
  • Low CHD risk (Framingham)

  • Part of the evaluation

I (2)
Risk Assessment With Prior Test Results—Asymptomatic OR Stable Symptoms, Normal Prior Stress Imaging Study
20.
  • High CHD risk

  • Repeat stress echo study annually

I (2)
Risk Assessment With Prior Test Results—Known CAD: Asymptomatic OR Stable Symptoms, Abnormal Catheterization OR Abnormal Prior Stress Imaging Study
22.
  • Assessment of severity of ischemia (CAD)

  • Less than 1 year to evaluate medically managed patients

I (2)
Risk Assessment With Prior Test Results—Asymptomatic, Prior Coronary Calcium Agatston Score
26.
  • Agatston score less than 100

I (1)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—Low-Risk Surgery
28.
  • Preoperative evaluation for noncardiac surgery risk assessment

  • Minor or intermediate clinical risk predictors

I (1)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—Intermediate-Risk Surgery
29.
  • Poor exercise tolerance (less than or equal to 4 METs)

  • Minor or no clinical risk predictors

I (2)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—High-Risk Nonemergent Surgery
32.
  • Asymptomatic up to 1 year after normal catheterization, noninvasive test, or previous revascularization

I (1)
Risk Assessment: Following Acute Coronary Syndrome—Asymptomatic Post-Revascularization (PCI or CABG)
34.
  • Routine evaluation prior to hospital discharge

I (1)
Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic
36.
  • Less than 5 years after CABG

I (2)
39.
  • Asymptomatic (e.g., silent ischemia) prior to previous revascularization

  • Less than 2 years after PCI

I (3)
40.
  • Symptomatic prior to previous revascularization

  • Less than 2 years after PCI

I (2)
Stress Study for Hemodynamics (Includes Doppler During Stress)—Valvular Stenosis
46.
  • Severe aortic or mitral stenosis

I (2)
48.
  • Severe AI or MR

  • Symptomatic or with severe LV enlargement or LV systolic dysfunction

I (2)
Contrast Use–Use of Contrast With Stress Echo
50.
  • Routine use of contrast

  • All segments visualized on noncontrast images

I (1)
  • The ranking of this indication as inappropriate is different from that given to similar but not identical indications in previously published appropriateness criteria. The ratings were done in accordance with established ACCF methodology. Furthermore, the Technical Panel for each modality operated independently without allowance and with discouragement for intermodality comparisons. Discrepant scores may be related to rating variability, differing Technical Panel composition, maturation of the appropriateness criteria process, or perceived differences in appropriateness.