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The American College of Cardiology, along with several specialty societies, has released updated criteria for the appropriate use of cardiac computed tomography ( CT ). Of 93 possible clinical scenarios, 35 were considered appropriate uses of the imaging modality and 58 inappropriate or of uncertain appropriateness, according to the guidelines crafted by a writing group chaired by Allen Taylor, MD, of the Washington (D.C.) Hospital Center.

The criteria were published online in the Journal of the American College of Cardiology.

The guidelines were developed in a collaborative effort by the ACC, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance.

In general, using cardiac CT for diagnosis, for risk assessment in patients at low or intermediate risk, or as a pretest for probability of coronary artery disease was labeled appropriate usage by the guidelines. The evaluation of cardiac structure and function was another use deemed favorable.

Appropriate uses of cardiac CT also included noncontrast CT for calcium scoring among intermediate-risk patients or low-risk patients who have a family history of premature coronary heart disease, as well as for testing prior to electrophysiological procedures for anatomic mapping, or prior to a repeat sternotomy in reoperative cardiac surgery.

The use of cardiac CT was generally deemed inappropriate or of uncertain value for high-risk patients, for repeat testing, for general screening of asymptomatic patients, and for preoperative risk assessment for noncardiac surgery in patients who do not have a cardiac condition.

"These criteria are expected to be useful for clinicians, healthcare facilities, and third-party payers engaged in the delivery of cardiovascular imaging services," the authors wrote.

Appropriateness criteria for the use of cardiac CT were first issued in 2006. The current update expands from 39 to 93 the number of common clinical scenarios in which cardiac CT may be considered.

General scenario categories included: acute and chronic chest pain; testing symptomatic and asymptomatic patients; heart failure; preoperative risk assessment before both cardiac and noncardiac surgery; testing in the setting of prior test results; prior revascularization; and the evaluation of cardiac structure and function.

Thirty-one scenarios were carried over from the 2006 guidelines; 23 had unchanged appropriateness ratings and eight moved up a level -- either from inappropriate to uncertain or from uncertain to appropriate based on the most current data.

The writing group developed all of the scenarios, which were then scored for appropriateness on a scale of 1 to 9 by a separate technical panel. The list was not meant to be comprehensive, according to the authors, but a sampling of the most common scenarios clinicians are likely to encounter when considering cardiac CT.

The ratings generally were interpreted as follows:

• An appropriate rating means that the use of cardiac CT is generally acceptable and is a reasonable approach.
• An uncertain rating means that cardiac CT may be acceptable and reasonable.
• An inappropriate rating means that cardiac CT is not generally acceptable and is not a reasonable approach.
• The authors of the guidelines stressed that an uncertain rating should not be used to limit the use of or reimbursement for cardiac CT in that situation.

"Rather, uncertain ratings are those where expert opinion or the available data vary or are rapidly evolving," they wrote, adding that physician judgment should be used in individual cases to determine whether cardiac CT would be appropriate.

Source: ACC

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