Blog | Tuesday, December 17, 2013

QD: News Every Day--Appropriate-use criteria released for stable ischemic heart disease


Appropriate use criteria for tests used to diagnosis or evaluate stable ischemic heart disease assess 80 clinical scenarios, and are the first time that multiple tests have been rated side by side for the same clinical indication.

The criteria were meant to provide actionable standards that can be easily implemented in clinical settings. Changes include 37 clinical scenarios that are ranked differently than previous single-test appropriateness criteria, and 18 that were deemed Rarely Appropriate, the authors noted.

The appropriate use criteria identify common scenarios in clinical practice and considered the technology’s use based on a risk-benefit analysis. The criteria were published online Dec. 16 in the Journal of the American College of Cardiology.

According to the writing committee, including multiple test modalities leverages a greater knowledge base across the tests, optimizes decision making, and eliminates minor differences among single-test criteria.

“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 Michael J. Wolk, MD, FACP, 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 appropriate-use criteria examine 7 testing invasive and non-invasive modalities and rank their use as Appropriate, May Be Appropriate, or Rarely Appropriate. The tests include: exercise electrocardiogram (ECG), stress radionuclide imaging, stress echocardiography, stress cardiac magnetic resonance, calcium scoring, coronary computed tomography angiography (CCTA), and coronary angiography.

The paper is the first to incorporate exercise ECG, the authors noted. For the remaining modalities, new evidence and years of implementing appropriate-use criteria in clinical practice mean that some of the ratings have changed: 37 of the scenarios were rated differently from their previous single-test criteria and 6 ratings, all for asymptomatic patients, were lower than in previous documents.

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 2 years, or
3) coronary artery bypass grafting within 5 years.

Also included in this Rarely Appropriate group was preoperative testing for patients with:
1) good functional capacity,
2) prior normal testing within 1 year, or
3) those undergoing low-risk surgery.

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.

“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 10 medical societies that developed the document were the American College of Cardiology, 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.