The American College of Cardiology along with key specialty and subspecialty societies released appropriate use criteria for tests used in the diagnosis and/or evaluation of stable ischemic heart disease. The document assesses 80 potential clinical scenarios with the goal of assisting physician and patient decision-making.
The appropriate use criteria identify common scenarios in clinical practice and provide a level of appropriateness for the technology's use based on a risk-benefit analysis.
The criteria are specifically designed to provide actionable standards that can be easily implemented in clinical settings. Appropriate Use Criteria serve as the foundation for efforts to educate patients through programs like the Choosing Wisely campaign and to engage physicians with ongoing decision support through quality-improvement registries. Establishment of the criteria also facilitates proactive partnerships with purchasers and policymakers to reduce the costs and risks of overuse, audits, and prior authorization.
The release of the 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease marks the first time that multiple tests for stable ischemic heart disease have been rated side by side for the same clinical indication. According to the document's writing committee, the inclusion of multiple testing modalities leverages a greater knowledge base across the tests, promoting optimized decision making. Consolidation is also meant to eliminate minor differences among the prior single-test criteria.
Partners in development of the document were, the ACC, 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.
"The goal of the document is not to rank order diagnostic tests but to help guide physicians and patients when it comes to making reasonable testing choices amongst the available testing modalities," said Dr. Michael J. Wolk, Professor of Clinical Medicine at Weill Cornell Medical College and the chair of the writing committee. "These ratings help ensure that tests with the highest potential to benefit are being utilized, while tests are avoided that can cause unnecessary concern and complicated follow-up."
The AUC examine seven testing modalities-both invasive and non-invasive-and ranks their use as "Appropriate," "May Be Appropriate," or "Rarely Appropriate." The tests included are: exercise electrocardiogram (ECG), stress radionuclide imaging (RNI), stress echocardiography (Echo), stress cardiac magnetic resonance (CMR), calcium scoring, coronary computed tomography angiography (CCTA), and invasive coronary angiography.
While the current document is the first AUC to incorporate exercise ECG, the other modalities have previously been addressed in their own respective AUC. According to the writing committee, however, new evidence and years of implementing AUC in clinical practice mean that some of the ratings have changed, and the current document should supersede earlier ratings.
Thirty-seven of the scenarios were rated differently from their previous single-test AUC documents. For example, six ratings-all for asymptomatic patients-were lower than in previous documents. In the current document, testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate- and high-risk patients.
Of the 80 scenarios reviewed, 18 were determined to be Rarely Appropriate across all tests. Included among these was follow-up testing-if the individual does not have new symptoms-after: 1) a prior test, 2) PCI within two years, or 3) CABG within five years. Preoperative testing for patients with: 1) good functional capacity, 2) prior normal testing within one year, or 3) those undergoing low-risk surgery was also included in this Rarely Appropriate group.
Many tests in the initial evaluation of patients with symptoms of stable ischemic heart disease were found to be Appropriate or May Be Appropriate for those with an intermediate or high probability of heart disease. Cardiac catheterization and CCTA were found to be Appropriate for patients to confirm disease and determine treatment options after a previous abnormal stress imaging test. A test rated as Appropriate is a reasonable option but is not required to be done for all patients given the specific circumstances unique to each patient.
The writing committee noted that these criteria blend clinical experience with evidence-based information to guide high-quality patterns of care while reducing resource use when patient benefit is unlikely.
"In addition to offering guidance for individual patient cases, the application of these criteria will yield insights into patterns of procedure use over time and increase the opportunity for quality improvement," Dr. Wolk said. "It should further be understood that procedures that have been rated Appropriate or May Be Appropriate should be reimbursed when applied in the suitable clinical scenario."
The ACC has developed decision-support tools and performance modules for physicians, as well as educational materials for patients to help encourage a dialogue about when and how these tests should be used based on these ratings. These resources can be found at: www.cardiosource.org/focus.
Full text of the report is published online on the ACC website (www.cardiosoure.org) and in the print issue (TBD) of the Journal of the American College of Cardiology.