ACC releases new Appropriate Use Criteria for multimodality imaging of nonvalvular heart disease

The American College of Cardiology (ACC) and several other partnering societies, including the American Heart Association and American Society of Nuclear Cardiology, released on Monday, Jan. 7 its 2019 Appropriate Use Criteria (AUC) for multimodality imaging in the diagnosis and management of cardiac structure in nonvalvular heart disease.  

The new guidelines accompany the 2017 AUC, according to an ACC news release. The goal of the new AUC is to determine "the range of modalities that may or may not be reasonable for specific indications rather than the determination of a single best test for each indication or a rank order,” according to the release.  

The new criteria are divided into three sections: initial evaluation of cardiac structure and function, evaluation in patients with prior testing, and evaluation in patients undergoing transcatheter intervention for structural heart disease. 

The following are takeaways from the new guidelines: 

  • Transthoracic echocardiography (TTE) is considered “appropriate” for the initial cardiac evaluation of a known systemic, congenital or acquired disease that could be associated with structural heart disease.  
  • TTE, cardiac MRI or radionuclide ventriculography is considered appropriate evaluation after appropriate time interval following revascularization and/or optimal medical therapy to determine candidacy for implantable cardioverter-defibrillator/cardiac resynchronization therapy and/or to determine optimal choice of device. 
  • TTE, transesophageal echocardiography (TEE), cardiac MRI or cardiac CT is considered “appropriate” for initial evaluation of cardiac mass, suspected tumor or thrombus or potential cardiac source of emboli. 
  • TEE, cardiac MRI, or cardiac CT is considered “appropriate” for comprehensive further evaluation of dilated aortic sinuses or ascending aorta identified by TTE. 
  • TEE or intracardiac echocardiography (ICE) and fluoroscopy are considered “appropriate” for intraprocedural guidance for closure of patent foramen ovale or atrial septal defect. 
  • TEE and fluoroscopy are considered “appropriate” for intraprocedural guidance for left atrial appendage occlusion; ICE “may be appropriate” in this situation. 

Additionally, modalities should not be considered in a rank order and should be used relative to individual patient circumstances based on the balance of risk versus benefit, the authors explained. They also noted that TTE was considered the best modality for initial evaluation because its non-invasive, doesn’t require radiation and costs less than CT, MRI and nuclear medicine procedures.  

“Clinical benefit should always be considered first, and cost should be considered in relationship to these benefits when determining net value. For example, a procedure with moderate clinical efficacy for a given AUC indication should not be scored as more appropriate than a procedure with a high clinical efficacy solely because of lower cost,” the AUC read. 

The 2019 AUC was developed with representatives from the American College of Cardiology AUC Task Force, the American Association for Thoracic Surgery, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Heart Rhythm Society, the Society for Cardiovascular Angiography and Interventions, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance and the Society of Thoracic Surgeons.