In the Journals

Report establishes new appropriate use criteria for multimodality imaging

A multisociety task force has released new appropriate use criteria for evaluation and utilization of multimodality imaging in the diagnosis and management of nonvalvular heart disease.

The purpose of the publication, which was approved 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, is to “provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities,” the task force wrote.

‘Dizzying array of options

“Improvements in noninvasive cardiovascular imaging technologies and their broader application to cardiovascular diagnosis and therapy have led to a dizzying array of imaging options for the clinician,” John U. Doherty, MD, FACC, FAHA, FACP, of the Jefferson Heart Institute and ACC representative, and colleagues wrote.

The 102 clinical scenarios, many of which were developed based on the most current ACC/AHA clinical practice guidelines, were scored by a separate rating panel on a scale of 1 to 9, with 1 to 3 representing rarely appropriate care, 4 to 6 being possibly appropriate care and 7 to 9 considered appropriate for the scenario.

In the initial evaluation of an asymptomatic patient, transthoracic echocardiography (TTE) was endorsed in almost all scenarios, whereas strain rate imaging may be appropriate for specific indications. Cardiac MRI and CTA may be appropriate for specific cardiac indications and were rated appropriate for the evaluation of the thoracic aorta.

TTE was deemed appropriate for most scenarios involving the initial evaluation of a patient with clinical signs or symptoms of cardiac disease, whereas coronary angiography was appropriate in evaluating patients with sustained ventricular tachycardia or ventricular fibrillation.

Appropriate use for evaluating cardiac structure and function in patients who have undergone prior testing included cardiac MRI, CTA and transesophageal echocardiography (TEE) in the evaluation of the aortic sinuses and ascending aorta. Cardiac MRI was also ranked appropriate for diagnoses such as sarcoidosis and amyloidosis, researchers wrote.

Researchers identified many modalities were rarely appropriate in the evaluation of sequential or follow-up testing of asymptomatic or stable symptoms. In the scenario involving patients imaged after undergoing therapy with potentially cardiotoxic agents, repeat imaging in less than 1 year was appropriate for TEE, strain imaging and radionuclide ventriculography, Doherty and colleagues wrote.

When evaluating the sequential or follow-up testing when a diagnosis was established in new or worsening symptoms or to guide therapy, TTE was endorsed as appropriate for most of the scenarios and cardiac MRI and CTA were appropriate for some of them.

MRI and CTA were endorsed in scenarios involving the assessment of intracranial arteries, whereas assessment of extracranial arteries is appropriate with carotid Doppler in addition to MRI and CTA, the authors wrote.

Transthoracic and transesophageal echo each received endorsement for preprocedural guidance for closure of patent foramen ovale or atrial septal defect, whereas cardiac MRI and CTA are appropriate for atrial septal defect. Standard and 3D TEE, intracardiac echo and fluoroscopy were both appropriate for intraprocedural guidance for closure of PFO and atrial septal defect.

In the preprocedural assessment of patients with left atrial appendage occlusion, transthoracic and TEE and CTA were endorsed as appropriate, whereas TEE was endorsed in all scenarios of intraprocedural guidance in patients with left atrial appendage occlusion.

TEE was also endorsed for postprocedural assessment for patient surveillance at 45 days as mandated by the FDA.

Broad spectrum of scenarios

“Some of these scenarios replicate those of prior documents, but many are new, specifically structural interventions that were not in the armamentarium of clinicians when prior, single-modality documents were published,” Doherty and colleagues wrote. “We believe the multimodality approach more replicates clinical decision-making and will be useful. Future documents will not provide single-source guidance for appropriateness of a single imaging modality in all disease states.” – by Earl Holland Jr.

Disclosures: Doherty reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

A multisociety task force has released new appropriate use criteria for evaluation and utilization of multimodality imaging in the diagnosis and management of nonvalvular heart disease.

The purpose of the publication, which was approved 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, is to “provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities,” the task force wrote.

‘Dizzying array of options

“Improvements in noninvasive cardiovascular imaging technologies and their broader application to cardiovascular diagnosis and therapy have led to a dizzying array of imaging options for the clinician,” John U. Doherty, MD, FACC, FAHA, FACP, of the Jefferson Heart Institute and ACC representative, and colleagues wrote.

The 102 clinical scenarios, many of which were developed based on the most current ACC/AHA clinical practice guidelines, were scored by a separate rating panel on a scale of 1 to 9, with 1 to 3 representing rarely appropriate care, 4 to 6 being possibly appropriate care and 7 to 9 considered appropriate for the scenario.

In the initial evaluation of an asymptomatic patient, transthoracic echocardiography (TTE) was endorsed in almost all scenarios, whereas strain rate imaging may be appropriate for specific indications. Cardiac MRI and CTA may be appropriate for specific cardiac indications and were rated appropriate for the evaluation of the thoracic aorta.

TTE was deemed appropriate for most scenarios involving the initial evaluation of a patient with clinical signs or symptoms of cardiac disease, whereas coronary angiography was appropriate in evaluating patients with sustained ventricular tachycardia or ventricular fibrillation.

Appropriate use for evaluating cardiac structure and function in patients who have undergone prior testing included cardiac MRI, CTA and transesophageal echocardiography (TEE) in the evaluation of the aortic sinuses and ascending aorta. Cardiac MRI was also ranked appropriate for diagnoses such as sarcoidosis and amyloidosis, researchers wrote.

Researchers identified many modalities were rarely appropriate in the evaluation of sequential or follow-up testing of asymptomatic or stable symptoms. In the scenario involving patients imaged after undergoing therapy with potentially cardiotoxic agents, repeat imaging in less than 1 year was appropriate for TEE, strain imaging and radionuclide ventriculography, Doherty and colleagues wrote.

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When evaluating the sequential or follow-up testing when a diagnosis was established in new or worsening symptoms or to guide therapy, TTE was endorsed as appropriate for most of the scenarios and cardiac MRI and CTA were appropriate for some of them.

MRI and CTA were endorsed in scenarios involving the assessment of intracranial arteries, whereas assessment of extracranial arteries is appropriate with carotid Doppler in addition to MRI and CTA, the authors wrote.

Transthoracic and transesophageal echo each received endorsement for preprocedural guidance for closure of patent foramen ovale or atrial septal defect, whereas cardiac MRI and CTA are appropriate for atrial septal defect. Standard and 3D TEE, intracardiac echo and fluoroscopy were both appropriate for intraprocedural guidance for closure of PFO and atrial septal defect.

In the preprocedural assessment of patients with left atrial appendage occlusion, transthoracic and TEE and CTA were endorsed as appropriate, whereas TEE was endorsed in all scenarios of intraprocedural guidance in patients with left atrial appendage occlusion.

TEE was also endorsed for postprocedural assessment for patient surveillance at 45 days as mandated by the FDA.

Broad spectrum of scenarios

“Some of these scenarios replicate those of prior documents, but many are new, specifically structural interventions that were not in the armamentarium of clinicians when prior, single-modality documents were published,” Doherty and colleagues wrote. “We believe the multimodality approach more replicates clinical decision-making and will be useful. Future documents will not provide single-source guidance for appropriateness of a single imaging modality in all disease states.” – by Earl Holland Jr.

Disclosures: Doherty reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.