The newly updated appropriate use criteria (AUC) for stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD) were released Thursday by the American College of Cardiology (ACC) Foundation and several specialty and subspecialty societies.

The AUC focused on radionuclide imaging, stress echocardiography (echo), calcium scoring (coronary artery calcium [CAC]), coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR) and invasive coronary angiography.

This report was published by co-chairs David E. Winchester, MD, and David J. Maron, MD, and the Multimodality Writing Group for Chronic Coronary Artery Disease, along with the Rating Panel, in a report published Thursday online in the Journal of the American College of Cardiology.

This document evaluates the use of various invasive and noninvasive testing modalities (testing for CCD) in different patients scenarios, including patients with and without symptoms of ischemia, patients wishing to begin a physical exercise program or patients with other cardiovascular conditions.

The writing group was responsible for developing patient scenarios that would be similar to those conducted in a clinical setting. Reviewers were responsible for giving feedback to the writers and forwarding the scenarios to the rating panel. Members of the panel rated each scenario based on level of appropriateness, depending on the risk/benefit ratio for the patients, as “Appropriate,” meaning the benefits to the patient outweigh the risks; “May Be Appropriate,” meaning the option may be appropriate depending on the patient case;  and “Rarely Appropriate,” meaning there is not a clear benefit/risk advantage for this scenario.

The document’s introduction notes that preoperative testing scenarios were removed from this update to the AUC and says these will be added to a future AUC statement.

The writers gave some guidelines for the readers to limit inconsistencies in interpretation, including the fact that tests were performed, interpreted and reported while following national laboratory accreditation standards, the appropriate equipment was used, the clinical status of the patient in the scenario is valid, the patients in the scenario received optimal standards of care and a few more specifics about the individual tests themselves.

Definitions were given in the various tables included in the document. Some clinical scenarios included symptomatic patients with no known CCD and no prior testing, symptomatic patients without known CCD and with prior testing, symptomatic patients with prior myocardial infarction (MI) or revascularization, asymptomatic patients without known atherosclerotic cardiovascular disease, asymptomatic patients with prior revascularization or MI, asymptomatic patients undergoing assessment of an exercise program or cardiac rehabilitation and other cardiovascular conditions in patients without symptoms of ischemia.

The most substantial change to the rankings was the addition of a “No Test” column that could be ranked as an appropriate scenario. The primary purpose of this column was to inform physicians that testing could safely be delayed in these scenarios. The hierarchy of the summary flowchart was also rearranged to better follow the flow of clinical decision-making. Clinicians’ best judgment was recommended in cases with more than one designated appropriate scenario.

Overall, the document states that the writing group hopes the revisions will be useful in the day-to-day clinical practice of cardiovascular medicine. Though the interpretation of clinical scenarios is limited to what was in this document, patients will present in various unlisted ways. Clinicians should use their best judgement in these cases. The AUC criteria followed other contemporary guidelines, as well as scientific studies, with the goal of creating the most accurate and valid scenarios possible.

Source:

Winchester DE, Maron DJ, Blankstein R, et al. ACC/AHA/ASE/ASNC?ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Artery Disease. J Am Coll Cardiol. 2023 May 25 (Article in Press)

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