JACC publishes revised appropriate use criteria for radionuclide imaging

A task force of cardiology and radiology organizations has published revised appropriate use criteria for radionuclide imaging (RNI) in JACC. RNI was deemed appropriate as a test for possible ACS, but inappropriate for definite ACS.

In chest pain patients, RNI was deemed appropriate for those with an intermediate or high probability of coronary disease or in those with a low likelihood but an uninterpretable ECG. In asymptomatic patients, RNI was deemed appropriate  for those patients at high risk for coronary disease, and possibly appropriate if the ECG is uninterpretable.

Here is the ACC press release:

EMBARGOED FOR RELEASE:
2 p.m. ET
Monday, May 18, 2009

The ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine, will webpost today, Monday, May 18 at 2 p.m. ET, in the Journal of the American College of Cardiology (JACC) (http://content.onlinejacc.org). The Appropriate Use Criteria (AUC) for Cardiac Radionuclide Imaging, a revision of the original AUC document for SPECT-perfusion imaging, addresses accordance with best practice standards as delineated by subspecialty societies, and further refines appropriate use of pharmacologic versus exercise stress and updates recommendations regarding radionuclide imaging (RNI) in the perioperative setting to bring it in line with the 2007 ACC/AHA perioperative guidelines.

Key issues to recognize:

A panel of experts was queried regarding the appropriate use of RNI in 67 clinical situations, each of which was ranked 1-9, representing least to most appropriate and then grouped as inappropriate (1-3), uncertain (4-6), or appropriate (7-9). Overall, 33 indications were considered appropriate, 9 uncertain, and 25 inappropriate.

For patients presenting with “ischemic equivalent chest-pain syndrome,” RNI was considered an appropriate test in the presence of possible acute coronary syndrome (ACS), but inappropriate in the presence of definite ACS. For patients with chronic ischemic equivalent pain, RNI was considered appropriate for those with an intermediate/high pretest probability of CAD, and in those with a low pretest likelihood and an uninterpretable electrocardiogram (ECG), but inappropriate in those with an interpretable ECG and able to exercise.

For asymptomatic patients, RNI was considered inappropriate in those with a low coronary heart disease (CHD) risk (Framingham: Adult Treatment Panel 3) and appropriate for those with a high CHD risk. For those with an intermediate CHD risk, RNI was considered inappropriate if the ECG was interpretable, and uncertain if uninterpretable.

For perioperative evaluation, RNI was considered inappropriate for patients undergoing low-risk surgery or in intermediate-risk surgery with no risk factors and good functional capacity. RNI was considered appropriate for intermediate risk or vascular surgery in the presence of one or more risk factors and poor functional capacity.

Following revascularization, RNI was considered appropriate in symptomatic patients as well as in those with incomplete revascularization. In asymptomatic patients, RNI was considered inappropriate when performed <2 years from prior percutaneous revascularization (PCI) or <5 years after coronary artery bypass grafting (CABG) and uncertain >2 years after PCI, but appropriate >5 years post-CABG.