Criteria Released for Evaluating Tests for Stable Ischemic Heart Disease
New recommendations compare seven tests to diagnose or evaluate disease
WASHINGTON (Dec. 16, 2013)— The American College of Cardiology along with nine key specialty and subspecialty societies today 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 The 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 rank their use as “Appropriate,” “May Be Appropriate,” or “Rarely Appropriate.” The tests include: exercise electrocardiogram (ECG), stress radionuclide imaging (RNI), stress echocardiography (Echo), stress cardiac magnetic resonance (CMR), calcium scoring, coronary computed tomography angiography (CCTA), and 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) Percutaneous coronary intervention within two years, or 3) Coronary artery bypass grafting 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 will be published online today at today on the ACC website (www.cardiosoure.org) and in a future print issue Journal of the American College of Cardiology.
ACC: Rachel Cagan, rcagan [at] acc [dot] org, 202.375.6395
AHA: Darcy Spitz, darcy [dot] spitz [at] heart [dot] org, 212.878.5940
ASE: Cathy Kerr, Ckerr [at] asecho [dot] org, 919.297.7156
HFSA: Michele Blair, mblair [at] hfsa [dot] org, 301.718.4800
HRS: Kennesha Baldwin, Kbaldwin [at] hrsonline [dot] org, 202.464.3464
SCAI: Kathy Boyd David, kbdavid [at] scai [dot] org, 717.422.1181
SCCT: Debra Fernandez, dfernandez [at] scct [dot] org, 703.766.1706
STS: Cassie Brasseur, cbrasseur [at] sts [dot] org, 312.202.5865
About the American College of Cardiology
The mission of the American College of Cardiology is to transform cardiovascular care and improve heart health. The College is a 40,000-member medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers. The College is a leader in the formulation of health policy, standards and guidelines. The ACC provides professional education, operates national registries to measure and improve quality of care, disseminates cardiovascular research, and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more information, visit www.cardiosource.org.
About the American Heart Association
The American Heart Association is devoted to saving people from heart disease and stroke – America’s No. 1 and No. 4 killers. We team with millions of volunteers to fund innovative research, fight for stronger public health policies, and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. To learn more or to get involved, call 1-800-AHA-USA1, visit heart.org or call any of our offices around the country. Follow us on Facebook and Twitter.
About the American Society of Echocardiography
As the largest global organization for cardiovascular ultrasound imaging, the American Society of Echocardiography is the leader and advocate, setting practice standards and guidelines. Comprised of over 16,000 physicians, sonographers and scientists, ASE is a strong voice, providing guidance, expertise and education to its members, with a commitment to improving the practice of ultrasound and imaging of the heart and cardiovascular system for better patient outcomes. For more information about ASE, visit www.asecho.org or ASE’s public information site, www.SeeMyHeart.org.
About the American Society of Nuclear Cardiology
The American Society of Nuclear Cardiology (ASNC) is the leader in education, advocacy, and quality for the field of nuclear cardiology. ASNC is the voice of more than 4,600 physicians, technologists, and scientists worldwide who are dedicated to the science and practice of nuclear cardiology. Since 1993, ASNC has been establishing the standard for excellence in cardiovascular imaging through the development of clinical guidelines, professional education, and research development. To learn more about ASNC, visit www.asnc.org.
About the Heart Failure Society of America
The Heart Failure Society of America, Inc. (HFSA) represents the first organized effort by heart failure experts from the Americas to provide a forum for all those interested in heart function, heart failure, and congestive heart failure (CHF) research and patient care. HFSA represents more than 1400 heart failure multi-disciplinary experts.
About the Heart Rhythm Society
The Heart Rhythm Society is the international leader in science, education and advocacy for cardiac arrhythmia professionals and patients, and the primary information resource on heart rhythm disorders. Its mission is to improve the care of patients by promoting research, education and optimal health care policies and standards. Incorporated in 1979 and based in Washington, DC, it has a membership of more than 5,800 heart rhythm professionals in more than 72 countries around the world. For more information, visit www.HRSonline.org.
About the Society for Cardiovascular Angiography and Interventions
The Society for Cardiovascular Angiography and Interventions is a 4,000-member professional organization representing invasive and interventional cardiologists in approximately 70 nations. SCAI's mission is to promote excellence in invasive/interventional cardiovascular medicine through physician education and representation, and advancement of quality standards to enhance patient care. SCAI's public education program, Seconds Count, offers comprehensive information about cardiovascular disease. For more information about SCAI and Seconds Count, visit http://www.SCAI.org/or www.SecondsCount.org. Follow @SCAI and @SCAINews on Twitter for the latest heart health news.
About the Society of Cardiovascular Computed Tomography
(SCCT) is the professional society devoted exclusively to cardiovascular computed tomography (CCT). With an expanding global membership, it is acknowledged and recognized as the representative and advocate for research, education, and clinical excellence in the use of cardiovascular computed tomography. For more information on the Society’s Mission and Goals, please see the SCCT Website at: www.SCCT.org.
About The Society of Thoracic Surgeons
Founded in 1964, STS is a not-for-profit organization representing more than 6,800 cardiothoracic surgeons, researchers, and allied health care professionals worldwide who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. The Society’s mission is to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research and advocacy. www.sts.org