Open Access, Peer-reviewed
pISSN 2508-707X
eISSN 2508-7088
    Cardiovasc Imaging Asia. 2017 Jul;1(3):156-165. English.
    Published online Jul 31, 2017.
    https://doi.org/10.22468/cvia.2017.00066
    Copyright © 2017 Asian Society of Cardiovascular Imaging
    Review

    2017 Multimodality Appropriate Use Criteria for Noninvasive Cardiac Imaging: Expert Consensus of the Asian Society of Cardiovascular Imaging

    ASCI Practice Guideline Working Group Kyongmin Sarah Beck,1,* Jeong A Kim,2,* Yeon Hyeon Choe,3 Sim Kui Hian,4 John Hoe,5 Yoo Jin Hong,6 Sung Mok Kim,3 Tae Hoon Kim,7 Young Jin Kim,6 Yun Hyeon Kim,8 Sachio Kuribayashi,9 Jongmin Lee,10 Lilian Leong,11 Tae-Hwan Lim,12 Bin Lu,13 Jae Hyung Park,14 Hajime Sakuma,15 Dong Hyun Yang,12 Tan Swee Yaw,16 Yung-Liang Wan,17 Zhaoqi Zhang,18 Shihua Zhao,13 and Hwan Seok Yong19
      • 1Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
      • 2Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea.
      • 3Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
      • 4Department of Cardiology, Sarawak General Hospital Heart Centre, Sarawak, Malaysia.
      • 5Department of Radiology, Mount Elizabeth Hospital, Singapore, Singapore.
      • 6Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
      • 7Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
      • 8Department of Radiology, Chonnam National University Hospital, Gwangju, Korea.
      • 9Department of Diagnostic Radiology, Keio University, Tokyo, Japan.
      • 10Department of Radiology, Kyungpook National University Hospital, Daegu, Korea.
      • 11Department of Radiology, Hong Kong College of Radiologists, Hong Kong, China.
      • 12Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
      • 13Department of Radiology, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, National Center for Cardiovascular Diseases, Beijing, China.
      • 14Department of Radiology, Myongji Hospital, Goyang, Korea.
      • 15Department of Radiology, Mie University Hospital, Mie, Japan.
      • 16Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.
      • 17Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Institute for Radiological Research, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
      • 18Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
      • 19Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.
    • Corresponding author: Hwan Seok Yong, MD, PhD. Department of Radiology, Korea University Guro Hospital, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea. Tel: 82-2-2626-1342, Fax: 82-2-863-9282, Email: yhwanseok@naver.com

      *These authors contributed equally to this work.
    Received May 16, 2017; Revised July 03, 2017; Accepted July 03, 2017.

    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Abstract

    In 2010, the Asian Society of Cardiovascular Imaging (ASCI) provided recommendations for cardiac CT and MRI, and this document reflects an update of the 2010 ASCI appropriate use criteria (AUC). In 2016, the ASCI formed a new working group for revision of AUC for noninvasive cardiac imaging. A major change that we made in this document is the rating of various noninvasive tests (exercise electrocardiogram, echocardiography, positron emission tomography, single-photon emission computed tomography, radionuclide imaging, cardiac magnetic resonance, and cardiac computed tomography/angiography), compared side by side for their applications in various clinical scenarios. Ninety-five clinical scenarios were developed from eight selected pre-existing guidelines and classified into four sections as follows: 1) detection of coronary artery disease, symptomatic or asymptomatic; 2) cardiac evaluation in various clinical scenarios; 3) use of imaging modality according to prior testing; and 4) evaluation of cardiac structure and function. The clinical scenarios were scored by a separate rating committee on a scale of 1–9 to designate appropriate use, uncertain use, or inappropriate use according to a modified Delphi method. Overall, the AUC ratings for CT were higher than those of previous guidelines. These new AUC provide guidance for clinicians choosing among available testing modalities for various cardiac diseases and are also unique, given that most previous AUC for noninvasive imaging include only one imaging technique. As cardiac imaging is multimodal in nature, we believe that these AUC will be more useful for clinical decision making.

    Keywords
    Appropriate use criteria; Multimodality; Noninvasive cardiac imaging

    INTRODUCTION

    Noninvasive cardiac imaging procedures provide essential information for the detection, diagnosis, and management of cardiovascular diseases and serve a vital role in risk assessment and clinical decision making. The range of diagnostic tools used to evaluate cardiovascular disease has expanded over the past decade; in particular, computed tomography (CT) and magnetic resonance (MR) have emerged as alternatives to echocardiography, exercise electrocardiography (ECG), and invasive angiography.

    Guidelines developed in the United States and Europe are often not applicable in Asian countries because of differences in healthcare systems, medical expenses, body habitus, and disease prevalence between Asian and Western countries. For this reason, the Asian Society of Cardiovascular Imaging (ASCI) separately developed ASCI appropriate use criteria (AUC) for cardiac CT and MR in 2010. Since the introduction of ASCI AUC in 2010, there has been further accumulation of scientific evidence and advances in imaging technology.

    Currently, there are many guidelines published by different cardiovascular societies led by various expert groups; as a consequence, there are various AUC for different modalities and diseases and from different countries. The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, published AUC for cardiac CT and cardiac MR (CMR) in 2006 [1]. In 2010, AUC for CT were published by the Society of Cardiovascular Computed Tomography (SCCT) as well as the ASCI [2, 3]. More recently, in 2015, the Korean Society of Radiology (KSR) also published AUC for CT [4]. AUC for CMR were also published by the ASCI in 2010 [5] and by the KSR in 2015 [6]. As for radionuclide imaging (RNI), the ACCF, along with key specialty and subspecialty societies, published AUC in 2009 [7], although they were limited to coronary artery disease only. Moreover, the ACCF and key specialty and subspecialty societies published AUC for echocardiography in 2011 [8]. There are also many guidelines for specific clinical scenarios, such as for appropriate utilization of various cardiac imaging modalities in the diagnosis and treatment of heart failure [9, 10], hypertrophic cardiomyopathy [11], and stable ischemic heart disease [12, 13]. However, few guidelines encompass various clinical scenarios, and to the best of our knowledge, there have been no multimodality AUC in Asia. Thus, we believe that multimodality AUC for different clinical scenarios would be relevant as an update for the previous ASCI CT and MR guidelines. The purpose of this document is to delineate the appropriate use of various noninvasive testing modalities for the diagnosis and evaluation of heart disease, as well as to update the previous 2010 ASCI AUC for cardiac CT and MR.

    METHODS

    Plans and approval for ASCI guideline update

    In March 2016, the need for an update of ASCI AUC was discussed at the ASCI Administration office-presidential office meeting. A steering committee was appointed among the board of directors in order to establish plans and a budget for the AUC update. In addition, a writing committee was to be appointed from the Korean members, a rating committee to be comprised of major speakers and researchers among the ASCI members, and a review committee to be comprised of previous presidents, vice-presidents, and congress presidents of the ASCI. The plan was approved at the annual ASCI meeting held in Singapore in August 2016.

    The working group consisted of the following committees:

    Steering committee

    • Yeon Hyeon Choe, Jongmin Lee, Yun Hyeon Kim, Bin Lu, Tae Hoon Kim

    Writing committee

    • Young Jin Kim, Jeong A Kim, Sung Mok Kim, Kyongmin Sarah Beck, Hwan Seok Yong, Dong Hyun Yang, Yoo Jin Hong

    Rating committee

    The number of technical panel members on the rating committee from each country was decided by the working group according to participation in the ASCI executive committee and ASCI annual meetings, as well as academic credentials of the investigators in the field. Thirty-three experts were nominated for the technical panel, taking into account the members' nationalities and areas of expertise, and all were approved by the working group in consensus. Twenty-two of the 33 technical panel members responded and participated in the consensus process according to the modified Delphi method.

    • Sung A Chang (Korea, Cardiology), Jin-Ho Choi (Korea, Cardiology), Sang-Chol Lee (Korea, Cardiology), Seung-Pyo Lee (Korea, Cardiology), Yeonyee Yoon (Korea, Cardiology), Kakuya Kitagawa (Japan, Radiology and Cardiology), Keiichiro Yoshinaga (Japan, Nuclear Medicine), Won Jun Kang (Korea, Nuclear Medicine), Jin Chul Paeng (Korea, Nuclear Medicine), Stephen Cheung (Hong Kong, Radiology), Akira Kurata (Japan, Radiology), Makoto Takamiya (Japan, Radiology), Whal Lee (Korea, Radiology), Sang IL Choi (Korea, Radiology), Eun Ju Chun (Korea, Radiology), Joon-Won Kang (Korea, Radiology), Sung Min Ko (Korea, Radiology), Jung Im Jung (Korea, Radiology), Ming-Ting Wu (Taiwan, Radiology), Wen-Yih Tseng (Taiwan, Radiology), Wen-Jeng Lee (Taiwan, Radiology), Masahiro Jinzaki (Japan, Radiology)

    Review committee

    • Yeon Hyeon Choe, John Hoe, Sachio Kuribayashi, Tae-Hwan Lim, Zhaoqi Zhang, Shihua Zhao, Lilian Leong, Sim Kui Hian, Jae Hyung Park, Hajime Sakuma, Oraporn See, Tan Swee Yaw

    Determining the methods for establishing AUC of multimodality cardiac imaging: adaptation and consensus methodology

    Because the ASCI CT and MR AUC were last published in 2010, we searched online databases for guidelines on noninvasive imaging published since 2010; if such guidelines were unavailable for certain modalities, we then searched for the most recently published guidelines instead. The following online databases were searched: Ovid-Medline, Ovid-Embase, National Guideline Clearing, and Guideline International Network. For development of this consensus document, we reviewed pre-existing utilization guidelines from countries worldwide. Eight pre-existing guidelines [3, 4, 5, 6, 7, 8, 9, 13] were finally selected for guideline adaptation: 1) ACCF cardiac radionuclide imaging guideline 2009 (7), 2) ASCI CMR guideline 2010 (5), 3) ASCI cardiac computed tomography angiography (CCTA) guideline 2010 (3), 4) ACCF echocardiography guideline 2011 (8), 5) ACCF multimodality guideline for stable ischemic heart disease 2013 (9), 6) ACCF cardiovascular imaging in heart failure 2013 (13), 7) Korean CMR guideline 2014 (6), 8) Korean CCTA guideline 2014 (4).

    The key questions were developed by the writing committee. To establish the key questions, the writing committee reviewed the previously published guidelines for each imaging modality as well as multimodality guidelines for ischemic heart disease and heart failure. After collecting all of the existing clinical questions from the guidelines, the writing committee classified the questions into four sections as follows: 1) detection of coronary artery disease, symptomatic or asymptomatic; 2) cardiac evaluation in various clinical scenarios; 3) use of imaging modality according to prior testing; and 4) evaluation of cardiac structure and function. Since questions in the previous guidelines varied by imaging modality, the writing committee selected questions common to each imaging method. Questions limited to a specific imaging method were changed or combined, conforming to more general clinical situations. Each question was modified based on feedback from independent reviewers who were cardiovascular experts. Finally, the writing committee established four sections comprised of 95 clinical scenarios for various noninvasive modalities.

    The appropriateness use criteria were defined with three ratings: appropriate (A), uncertain (U), and inappropriate (I). A questionnaire was emailed to the rating committee and then collected by the ASCI office after completion. The questionnaires were collected between December 2016 and February 2017 (22 of the 33 nominated members of the rating committee responded to the survey).

    The questionnaire had four sections with 95 clinical scenarios. A total of two rounds of consensus survey were conducted; for each round, the appropriateness of utilization was categorized with a 9-point response scale: 1–3 points as I, 4–6 points as U, and 7–9 points as A. For each round, different imaging modalities were separately scored for their appropriateness in a given scenario. When more than 50% of the panelists agreed on a category, the panel was considered to have reached a consensus for that particular clinical scenario. The questionnaire form included appropriateness criteria from other guidelines for each category and each noninvasive test modality [exercise ECG, echocardiography, positron emission tomography, single-photon emission computed tomography (SPECT), RNI, CMR, and CCTA], the 9-point response scale, and space for additional comments. In the second round, the median scores from the previous round and the scores originally given by the answering panelist were shown for the questions for which agreement had not been reached. The questions with agreement reached in the previous round were not shown in the following round.

    Of the 95 clinical scenarios-comprised of a total of 455 questions for different modalities-sent for the first round, consensus was reached on all modalities in 42 scenarios (197 questions). Of the other 53 scenarios (258 questions), 86 questions for which consensus was not reached were sent for the second round. The results of the consensus voting are included in the Supplementary (in the online-only Data Supplement).

    When interpreting the score, several specific assumptions should be considered. Presumably, each test is performed in compliance with published criteria for quality cardiac diagnostic testing, locally available, and interpreted by experts who are qualified to do so. For exercise ECG, it should be assumed that the patient can exercise to a symptomatic endpoint or 85% of their age-predicted maximal heart rate. For echocardiography, SPECT, and CMR in evaluation of coronary artery disease, it is assumed that pharmacological stress test is performed to identify the presence of myocardial ischemia. Each modality has inherent risks such as radiation exposure, contrast sensitivity, and interpretation error. It is assumed that each modality should be chosen after weighing the risks and benefits in the specific clinical scenario. It should be assumed that CCTA and SPECT are performed using contemporary dose-saving techniques conforming to the As Low As Reasonably Achievable (ALARA) principle. For reasonable use of cardiovascular modality, the As High As Reasonably Achievable (AHARA) principle was considered.

    The review committee, consisting of past-presidents, vice-presidents, and congress presidents, reviewed the AUC selected by consensus.

    The development of the current AUC was funded by the ASCI. However, the activities of the writing committee, the rating committee, and the review committee were independent of one another, and none of the three committees were influenced in any way by any of the funding for guideline development.

    These guidelines should be revised as needed, following advances in technology, changes in the healthcare environment, and further accumulation of scientific evidence.

    RESULTS

    The final AUC ratings for multimodality cardiac imaging are divided into four sections and listed by clinical scenarios sequentially (Table 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17).

    Table 1
    Symptomatic: non-acute chest pain suspected of stable coronary artery disease

    Table 2
    Symptomatic: acute chest pain suspected of acute coronary syndrome

    Table 3
    Asymptomatic (1)

    Table 4
    Asymptomatic (2): post-revascularization (PCI or CABG)

    Table 5
    Newly developed or suspected heart failure

    Table 6
    Cardiac evaluation prior to surgery

    Table 7
    Evaluation of arrhythmia or syncope without ischemic etiology

    Table 8
    Coronary revascularization

    Table 9
    Kawasaki disease

    Table 10
    Prior exercise ECG

    Table 11
    Prior SPECT

    Table 12
    Prior CCTA

    Table 13
    Congenital heart disease

    Table 14
    Valvular heart disease (native valve AND prosthetic valve)

    Table 15
    Cardiomyopathy (after ischemic etiology ruled out)

    Table 16
    Electrophysiology study, ablation, ICD/CRT

    Table 17
    Cardiac mass, pericardial disease, and aorta

    Section 1

    Detection of CAD: symptomatic or asymptomatic (Table 1, 2, 3, 4).

    Section 2

    Cardiac evaluation in various clinical scenarios (Table 5, 6, 7, 8, 9).

    Section 3

    Use of imaging modality according to prior testing (Table 10, 11, and 12).

    Section 4

    Evaluation of cardiac structure and function (Table 13, 14, 15, 16, 17).

    DISCUSSION

    These new ASCI multimodality AUC were developed in order to reflect the current status of noninvasive cardiac imaging in Asia. In the current document, we present a synthesis of clinical experience for all commonly employed noninvasive imaging procedures for diagnosis of various cardiovascular diseases.

    This document covers the same or similar clinical scenarios as the prior ASCI AUC for CT and MR and other modality guidelines for individual procedures. Overall, the AUC ratings for CT are higher than those of the previous guidelines. This difference might be attributable to advances in CT technology, which have resulted in reduced radiation exposure and more accurate evaluation of small structures with improvement in temporal resolution. In addition, wide availability of CT in Asian countries compared to CMR, which is less accessible, could be another cause of the improved rating of CT.

    These rating differences might also reflect the changing practice environment and evolution in cumulative clinical experience with these procedures, as well as maturation of the field since publication of the original documents.

    These new AUC are intended to provide guidance for clinicians when choosing among available testing modalities for various cardiac diseases. Each test was rated individually for each scenario based on the quality of the published evidence as well as the expert opinion of the rating panel. In the absence of robust evidence of comparative effectiveness, a comparative rating approach would be both premature and misleading. In addition, a larger number of radiologists in the writing and rating committees might have resulted in somewhat skewed ratings for certain modalities. Thus, although these ratings reflect existing evidence-based practice supplemented by expert consensus, further research is needed to identify not only when to use any given modality, but also when to favor one over another.

    Supplementary Materials

    The online-only Data Supplement is available with this article at https://doi.org/10.22468/cvia.2017.00066.

    Click here to view.(78K, docx)

    Notes

    This guideline has been published jointly by invitation and consent in both the Cardiovascular Imaging Asia and the Korean Journal of Radiology.

    Conflicts of Interest:The authors declare that they have no conflict of interest.

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