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This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document (J Am Coll Cardiol 2017;70:1647-1672) addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

BACKGROUND: Trends in noninvasive diagnostic imaging (NDI) utilization rates have predominantly been reported in Medicare enrollees. To the authors’ knowledge, there has been no prior direct comparison of utilization rates between Medicare and commercially insured patients. PURPOSE: To analyze trends in NDI utilization rates by modality, comparing Medicare fee-for-service and commercially insured enrollees. MATERIALS AND METHODS: This study was a retrospective trend analysis of NDI performed between 2003 and 2016 as reported in claims databases for all adults enrolled in fee-for-service Medicare and for roughly 9 million commercially insured patients per year. The commercially insured patients were divided into two populations: those aged 18–44 years and those aged 45–64 years. The same procedure code definitions for NDI were applied to both Medicare and commercial claims, rates were calculated per 1000 enrollees, and trends were reported over time in aggregate followed by modality (CT, MRI, nuclear imaging, echocardiography, US, radiography). Join-point regression was used to model annual rates and to identify statistically significant (P < .05) changes in trends. RESULTS: In almost all instances, Medicare enrollees had the highest utilization rate for each modality, followed by commercially insured patients aged 45–64 years, then aged 18–44 years. All three populations showed utilization growth through the mid to late 2000s (images per 1000 enrollees per year for Medicare: 91 [95% confidence interval {CI}: 34, 148]; commercially insured patients aged 45–64 years: 158 [95% CI: 130, 186]; aged 18–44 years: 83 [95% CI: 69, 97]), followed by significant declining trends from the late 2000s through early 2010s (images per 1000 enrollees per year for Medicare: −301 [95% CI: −510, −92]; commercially insured patients aged 45–64 years: −54 [95% CI: −69, −39]; aged 18–44 years: −26 [95% CI: −31, −21]) coinciding with code-bundling events instituted by Medicare (CT, nuclear imaging, echocardiography). There were significant trend changes in modalities without code bundling (MRI, radiography, US), although flat trends mostly were exhibited. After the early 2010s, there were significant trend changes largely showing flat utilization growth. The notable exception was a significant trend change to renewed growth of CT imaging among commercially insured patients aged 45–64 years and Medicare enrollees after 2012, although at half the prior rate (images per 1000 enrollees per year for Medicare: 17 [95% CI: 6, 28]; commercially insured patients aged 45–64 years: 11 [95% CI: 2, 20]). CONCLUSION: Noninvasive diagnostic imaging utilization trends among commercially insured individuals are similar to those in Medicare enrollees, although at lower rates. Earlier rapid growth has ceased and, except for CT, utilization has stabilized since the early 2010s. © RSNA, 2019 See also the editorial by Hentel and Wolk in this issue.

John U. Doherty, MD, FACC, Co-Chair Gregory J. Dehmer, MD, MACC, Co-Chair Nicole M. Bhave, MD, FACC Stacie L. Daugherty, MD, MSPH, FACC Larry S. Dean, MD, FACC Milind Y. Desai, MBBS, FACC Claire S. Duvernoy, MD, FACC[∗][1] Linda D. Gillam, MD, FACC Praveen Mehrotra, MD, FACC Ritu

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines. A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology 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 the current understanding of the technical capabilities of the imaging modalities examined.

The American College of Cardiology Foundation (ACCF), in partnership with key specialty and subspecialty societies, conducted a review of common clinical scenarios where noninvasive vascular testing (venous ultrasound and physiological testing) is frequently considered. The indications (clinical

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging.

Steven R. Bailey, MD, FACC, FSCAI, FAHA, Moderator Andrea M. Russo, MD, FACC, FHRS, Writing Group Liaison [⁎][1] Suraj Kapa, MD, Writing Group Liaison Michael B. Alexander, MD, FACC[§][2] Steven R. Bailey, MD, FACC, FSCAI, FAHA[∥][3] Ulrika Birgersdotter-Green, MD, FHRS[∥][3] Alan S.

The past several decades have seen rapid and extensive changes in the practice of cardiology, especially in the innovation and utilization practices of imaging, interventional, and electrophysiology procedures. Enhanced radionuclide imaging techniques, evolution of echocardiography, development of

The American College of Cardiology Foundation, in collaboration with the Society for Cardiovascular Angiography and Interventions and key specialty and subspecialty societies, conducted a review of common clinical scenarios where diagnostic catheterization is frequently considered. The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of noninvasive imaging appropriate use criteria. The 166 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3). Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease with other procedure components (e.g., hemodynamic measurements, ventriculography) at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the use of coronary angiography at the discretion of the operator. Seventy-five indications were rated as appropriate, 49 were rated as uncertain, and 42 were rated as inappropriate. The appropriate use criteria for diagnostic catheterization have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research. © 2012 Wiley Periodicals, Inc.

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an update of the appropriate use criteria (AUC) for coronary revascularization frequently considered. In the initial document, 180 clinical scenarios were developed to mimic patient presentations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. This update provides a reassessment of clinical scenarios the writing group felt to be affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document, and the definition of appropriateness was unchanged. The technical panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate and likely to improve patients' health outcomes or survival. Scores of 1 to 3 indicate revascularization is considered inappropriate and unlikely to improve health outcomes or survival. Scores in the mid-range (4 to 6) indicate a clinical scenario for which the likelihood that coronary revascularization will improve health outcomes or survival is uncertain. In general, as seen with the prior AUC, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia is appropriate. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy are viewed less favorably. The technical panel felt that based on recent studies, coronary artery bypass grafting remains an appropriate method of revascularization for patients with high burden of coronary artery disease (CAD). Additionally, percutaneous coronary intervention may have a role in revascularization of patients with high burden of CAD. The primary objective of the appropriate use criteria is to improve physician decision making and patient education regarding expected benefits from revascularization and to guide future research.

ObjectivesThe aim of this study was to assess the feasibility of evaluation for appropriate use of radionuclide myocardial perfusion imaging (MPI) in multiple clinical sites and to determine use patterns as well as identify areas of apparent inappropriate use.BackgroundAlthough cardiac imaging is highly valued for decision-making, the growth and expense related to these procedures has raised questions regarding overuse. The publication of appropriate use criteria (AUC), including those for MPI, were designed to provide guidance in the rational use of testing. However, limited data regarding the implementation and evaluation of AUC are available.MethodsSix diverse clinical sites enrolled consecutive patients undergoing MPI, collecting point-of-service data entered into an online form. An automated algorithm assigned a specific indication from the AUC that was classified as appropriate, uncertain, or inappropriate. Site-specific feedback was later provided to each practice on ordering patterns.ResultsOf the 6,351 patients enrolled, 93% were successfully assigned an appropriateness level. Inappropriate use of MPI was found in 14.4% of patients, with a range of 4% to 22% among practices. Women and younger patients were more likely to undergo inappropriate MPI. Asymptomatic, low-risk patients accounted for 44.5% of inappropriate testing. Elimination of the 5 most common inappropriate use indications would reduce overall imaging volume by 13.2%. Inappropriate use by physicians from within the practice performing imaging was not greater than physicians outside of the practice. Educational feedback might have resulted in reduced inappropriate test ordering in 1 site.ConclusionsThe tracking of appropriate use is feasible in clinical practice, with an automated system that can readily identify practice patterns and targets for educational and quality improvement initiatives. This approach might provide an alternative to utilization management.

Advances in the therapeutic options for cardiovascular disease, coupled with improvements in imaging technology, have led to an explosive growth in the performance of cardiovascular imaging. Yet this growth is challenging to interpret as it may represent appropriate use, underuse (i.e., the failure

Objectives: We sought to evaluate the results of percutaneous coronary intervention (PCI) in elderly patients in contemporary practice.Background: Prior studies of PCI in the elderly popula...

Inherent in the doctor–patient relationship is the desire for physicians to use available knowledge and judgment to provide the best possible care to their patients. In return, physicians hope to earn the trust and respect of their patients and community. Physicians have the historical opportunity

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1 to 9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and 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 electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was 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 result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. 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 percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (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 prior to low-risk surgery also were 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.

Coronary artery calcification is part of the development of atherosclerosis; it occurs exclusively in atherosclerotic arteries and is absent in the normal vessel wall. Electron-beam computed tomography (EBCT), the focus of this document, is a highly sensitive technique for detecting coronary artery calcium and is being used with increasing frequency for the screening of asymptomatic people to assess those at high risk for developing coronary heart disease (CHD) and cardiac events, as well as for the diagnosis of obstructive coronary artery disease (CAD) in symptomatic patients. The use of EBCT has the greatest potential for further determination of risk, particularly in elderly asymptomatic patients and others at intermediate risk. The calcium score has been advocated by some as a potential surrogate for age in risk-assessment models. EBCT has also been proposed as a useful technique for assessing the progression or regression of coronary artery stenosis in response to treatment of risk factors such as hypercholesterolemia. EBCT uses an electron beam in stationary tungsten targets, which permits very rapid scanning times. Serial transaxial images are obtained in 100 ms with a thickness of 3 to 6 mm for purposes of detecting coronary artery calcium. Thirty to 40 adjacent axial scans are obtained during 1 to 2 breath-holding sequences. Current EBCT software permits quantification of calcium area and density. Histological studies support the association of tissue densities of 130 Hounsfield units (HU) with calcified plaque. However, a plaque vulnerable to fissure or erosion can be present in the absence of calcium. Also, sex differences play a role in the development of coronary calcium, the prevalence of calcium in women being half that of men until age 60 years. EBCT calcium scores have correlated with pathological examination of the atherosclerotic plaque. This American College of Cardiology (ACC)/American Heart Association (AHA) Writing Group reviewed …

Twenty-two years have elapsed since Andreas Gruentzig, MD, performed the first coronary angioplasty [(1,2)][1]. During that period, coronary angioplasty and its related procedures have evolved into a highly specialized cognitive and technical discipline, and the expectation of quality in coronary

Executive Summary I. Preamble…1077 II. Introduction…1077 Coding for Procedures and Services: Difficult and Dangerous Change and Ambiguity…1078 Complexity…1078 Financial Pressures…1078 Coding Versus Pricing Versus Billing…1078 Correct Coding Practices Speak the Language…1078

The pharmaceutical preparation sildenafil citrate (Viagra) is being widely prescribed as a treatment for male erectile dysfunction, a common problem that in the United States affects between 10 and 30 million men. The introduction of sildenafil has been a valuable contribution to the treatment of erectile dysfunction, which is a relatively common occurrence in patients with cardiovascular disease. This article is written to appropriately caution and not to unduly alarm physicians in their use of sildenafil in patients with heart disease. Reported cardiovascular side effects in the normal healthy population are typically minor and associated with vasodilatation (ie, headache, flushing, and small decreases in systolic and diastolic blood pressures). However, although their incidence is small, serious cardiovascular events, including significant hypotension, can occur in certain populations at risk. Most at risk are individuals who are concurrently taking organic nitrates. Organic nitrate preparations are commonly prescribed to manage the symptoms of angina pectoris. The coadministration of nitrates and Viagra significantly increases the risk of potentially life-threatening hypotension. Therefore, Viagra should not be prescribed to patients receiving any form of nitrate therapy. Although definitive evidence is currently lacking, it is possible that a precipitous reduction in blood pressure with nitrate use may occur over the initial 24 hours after a dose of Viagra. Thus, for patients who experience an acute cardiac ischemic event and who have taken Viagra within the past 24 hours, administration of nitrates should be avoided. In the event that nitrates are given, especially within this critical time interval, it is essential to have the capability to support the patient with fluid resuscitation and α-adrenergic agonists if needed. In patients with recurring angina after Viagra use, other nonnitrate antianginal agents, such as β-blockers, should be considered. Other patients in whom the use of Viagra is potentially hazardous include those …

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging.

The American College of Radiology (ACR) and the American College of Cardiology Foundation (ACCF) have jointly developed a method to define appropriate utilization of cardiovascular imaging. The primary role of this method is to create a series of documents to define the utility of cardiovascular imaging procedures in relation to specific clinical questions, with the aim of defining what, if any, imaging tests are indicated to help to determine diagnosis, treatment, or outcome. The methodology accomplishes this aim through the application of systematic evidence reviews integrated with expert opinion by means of a rigorous Delphi process. By obtaining broad input during the development process from radiologists, cardiologists, primary care physicians, and other stakeholders, these documents are intended to provide practical evidence-based guidance to ordering providers, imaging laboratories, interpreting physicians, patients, and policymakers as to optimal cardiovascular imaging utilization. This document details the history, rationale, and methodology for developing these joint documents for appropriate utilization of cardiovascular imaging.

Objectives This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993. Background The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons. Methods A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration. Results Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency. Conclusions Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment.

Perhaps the answer to the rhetorical question, “why aren't all cardiologists preventive?” lies in a quote attributed to American humorist W. C. Fields: “If at first you don't succeed, try again. Then quit. There's no use being a damn fool about it.” As usual, there is truth in Fields'

[Figure][1] Like so many Americans, I am concerned about the economy and our war on terrorism both at home and abroad. National polls indicate that jobs and the economy consistently rank high among voter priorities ([1][2]), but health care is not far behind. And when it comes to health care

“The times, they are a-changin'”—a familiar vocal refrain—is a sentiment that applies to the field of continuing medical education (CME). The provision of high quality CME to improve the care of patients with cardiovascular disease remains the core mission of the American College of

In one of my favorite books, the wonderful and wise The Little Prince, author Antoine de Saint-Exupery reveals an important secret of life. “One sees clearly only with the heart,” the little prince learns. “Anything essential is invisible to the eyes.” These words express my feelings this

Current procedural terminology codes generally do not distinguish between patients based on age or etiology of disease. As standardized payment schedules based upon such codes are being developed, the precise definition of a “typical” patient for each code becomes increasingly important. Since small size, young age, or presence of complex congenital disease could potentially render the work value of a physician's service different between children and adults, a study was jointly undertaken by the American College of Cardiology and the Cardiology Section of the American Academy of Pediatrics to compare relative work for the most commonly used Current Procedural Terminology codes in pediatric cardiology. A Technical Advisory Panel chose codes for evaluation and wrote clinical descriptors for each service. A separate rating panel of eight pediatric cardiologists (academic and private practice) and three adult cardiologists participated in a mail survey assigning work values to each service relative to current Health Care Financing Administration adult relative value units. The Panel then met and employed a modified Delphi process to arrive at consensus values. Of the 20 codes rated, only five were determined to be similar to adults. The pediatric median values were an average of 44% higher than the adult values (general cardiology codes 8% higher, echocardiography 90%, catheterization 49%, electrophysiology 35%). Thus, work values for cardiology were found to be different between children and adults in 75% of services assessed. The magnitude of these differences should be confirmed in a broader study. The Current Procedural Terminology Committee of the American Medical Association should consider, at a minimum, creating modifiers by specific age for certain procedures. Further study of the quantitative difference between services performed in adults and children is warranted.

The American College of Cardiology Foundation (ACCF), in partnership with key specialty and subspecialty societies, conducted a review of common clinical scenarios where noninvasive vascular testing (ultrasound and physiological testing) is frequently considered. The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC). The 159 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3).

The American College of Cardiology Appropriate Use Criteria (AUC) have been developed for guidance of utilization of myocardial perfusion SPECT (MPS), stress echocardiography (STE), and cardiac computed tomographic angiography (CCTA). To date, cardiologist application of AUC from a patient-based

The American College of Cardiology Appropriate Use Criteria (AUC) were developed to guide use of myocardial perfusion single-photon emission computed tomography (MPS), stress echocardiography, and cardiac computed tomographic angiography (CCTA). To date, cardiologist application of AUC from a patient-based multiprocedure perspective has not been evaluated. A Web-based survey of 15 clinical vignettes spanning a wide spectrum of indications for MPS, STE, and CCTA in coronary artery disease was administered to cardiologists who rated the ordered test as appropriate, inappropriate, or uncertain by AUC application and suggested a preferred alternative imaging procedure, if any. In total 129 cardiologists responded to the survey (mean age 49.5 years, board certification for MPS 65%, echocardiography 39%, CCTA 32%). Cardiologists agreed with published AUC ratings 65% of the time, with differences in all categories (appropriate, 50% vs 53%; inappropriate, 42% vs 20%; uncertain, 9% vs 27%, p

The American College of Cardiology Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonance appropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria.1 The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research. In an effort to respond to the need for the rational use of imaging services in the delivery of high-quality care, the ACCF has undertaken a process to determine the appropriate use of cardiovascular imaging for selected patient indications. Appropriate use criteria publications reflect an ongoing effort by the ACCF to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures …

The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac radionuclide imaging (RNI) is frequently considered. This document is a revision of the original Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) Appropriateness Criteria, published 4 years earlier, written to reflect changes in test utilization and new clinical data, and to clarify RNI use where omissions or lack of clarity existed in the original criteria. This is in keeping with the commitment to revise and refine appropriate use criteria (AUC) on a frequent basis. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Sixty-seven clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of cardiac RNI for diagnosis and risk assessment in intermediate- and high-risk patients with coronary artery disease (CAD) was viewed favorably, while testing in low-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Additionally, use for perioperative testing was found to be inappropriate except for high selected groups of patients. It is anticipated that these results will have a significant impact on physician decision making, test performance, and reimbursement policy, and will help guide future research.

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. The clinical scenarios were developed to mimic common situations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. Approximately 180 clinical scenarios were developed by a writing committee and scored by a separate technical panel on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization was considered appropriate and likely to improve health outcomes or survival. Scores of 1 to 3 indicate revascularization was considered inappropriate and unlikely to improve health outcomes or survival. The mid range (4 to 6) indicates a clinical scenario for which the likelihood that coronary revascularization would improve health outcomes or survival was considered uncertain. For the majority of the clinical scenarios, the panel only considered the appropriateness of revascularization irrespective of whether this was accomplished by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In a select subgroup of clinical scenarios in which revascularization is generally considered appropriate, the appropriateness of PCI and CABG individually as the primary mode of revascularization was considered. In general, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. It is anticipated that these results will have an impact on physician decision making and patient education regarding expected benefits from revascularization and will help guide future research.

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.

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.