SAN FRANCISCO (EGMN)–A new report compiled by eight cardiology and imaging specialty organizations updates 4-year-old recommendations on when to use (or not use) cardiac CT imaging.

The eight societies hope that the recommendations not only will help inform clinicians and patients who are considering cardiac CT but will also guide insurers and third-party payers in setting rational reimbursement policies for cardiac CT.

The report, released by the American College of Cardiology, was endorsed by the ACC Foundation, 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.

The full report was published online Oct. 25 in the Journal of the American College of Cardiology, and is available at www.cardiosource.org. It will also be published in Circulation and in the Journal of Cardiovascular Computed Tomography.

The appropriate use criteria cover two tests: cardiac CT angiography using contrast, x-ray, or dye; and noncontrast CT scanning for calcium scoring, used to detect calcium deposits in the arteries.

In general, CT angiography was considered appropriate for diagnosis and risk assessment in patients with symptoms of possible heart disease who have a low to intermediate risk of a heart problem, or in situations where the diagnosis of heart disease is uncertain after other tests are performed.

Calcium scanning was considered appropriate in patients without heart symptoms who have an intermediate risk of heart disease, or in selected patients with low risk (especially women or younger men) with a family history of heart problems.

Cardiac CT would not be appropriate for general screening in asymptomatic patients, or in patients with known heart problems or a high risk for heart disease, or for routine repeat testing, the report concludes. Adding the test when patients have high risk for heart disease or existing heart problems does not add any useful clinical information, said Dr. Allen J. Taylor in a statement released by the ACC. Dr. Taylor is chair of the report’s writing committee and professor of medicine at Georgetown University, Washington.

The report also judged the usefulness of cardiac CT to be “uncertain” in some clinical scenarios, and the authors emphasized repeatedly that this does not mean that the test is inappropriate or that insurers should not reimburse for its use in these situations. An “uncertain” indication may require individual physician judgment and understanding of the patient to decide whether cardiac CT might help.

Tables in the report list 60 indications deemed to be appropriate, 52 rated as uncertain, and 55 indications that were considered inappropriate for cardiac CT. Clinical scenarios included acute and chronic chest pain, testing in symptomatic and asymptomatic patients, heart failure, preoperative risk assessment before either cardiac or noncardiac surgery, testing in the setting of prior test results (such as exercise testing, stress imaging procedures, or coronary calcium scores), prior revascularization, and evaluation of cardiac structure and function.

The document replaces the original 2006 criteria that were created when cardiac CT was relatively new (J. Am. Coll. Cardiol. 2006;48:1475-97).

The process that was used to create the new criteria combined evidence-based medicine and practice experience. A seven-member writing group developed clinical scenarios that were scored by a 19-member technical panel on a 1-9 scale to reflect their judgments of appropriate use of cardiac CT, inappropriate use, or uncertainty about the appropriateness of use.

In the real world, no physicians or facilities will have 100% of their cardiac CT procedure fall within the “appropriate” indications, the report notes. But if a physician or facility has a higher rate of inappropriate procedures than the national average, they may want to examine their patterns of care.

For the first time, the report considered CT angiography in patients with heart failure and normal, as well as abnormal, left ventricular ejection fraction (LVEF), with ratings of appropriate or uncertain. The only appropriate scenarios covered patients with reduced LVEF who had low or intermediate pretest probability of coronary artery disease.

CT angiography was considered a potential option as part of preoperative evaluations for patients undergoing heart surgery for noncoronary indications such as valve replacement, and was considered appropriate in patients with intermediate pretest risk for coronary artery disease, and of uncertain appropriateness if the pretest risk was low. Coronary CT angiography was never considered appropriate for evaluations before noncardiac surgery.

Imaging for evaluation of left main coronary stents was deemed appropriate, and was considered uncertain for any coronary stents measuring 3 mm in diameter or larger that had been in place at least 2 years.

The evaluation of cardiac structure and function is considered a strength of cardiac CT imaging. For the first time, the report rated cardiac CT as appropriate in patients with suspected arrhythmogenic right ventricular dysplasia, and as uncertain for evaluation of myocardial viability when other imaging modalities are inadequate or contraindicated.

Using cardiac CT before electrophysiologic procedures for anatomical mapping, or prior to repeat sternotomy in reoperative cardiac surgery, also was rated appropriate.

Disagreement among panelists over two clinical scenarios in particular left these two in the uncertain category: using cardiac CT to detect coronary artery disease in patients with a low probability of coronary artery disease when the ECG is interpretable and the patient is able to exercise, and using cardiac CT for coronary assessment prior to noncoronary cardiac surgery in patients with a low probability for coronary artery disease.

The report attempts to align its language and definitions with those in the ACC’s 2009 appropriate use criteria for cardiac radionuclide imaging (J. Am. Coll. Cardiol. 2009;53:2201-29).

Besides considering appropriate use of cardiac CT, clinicians should consider balancing the use of radiation dose–reduction techniques with the preservation of image quality, the report notes. A separate 2010 expert consensus document addressed issues of balancing those competing demands (J. Am. Coll. Cardiol. 2010;55:2663-99).

Dr. Matthew J. Budoff, president of the Society of Cardiovascular Computed Tomography, which helped develop the report, said that cardiologists will continue to increase their use of cardiac CT because of the very high negative predictive power of cardiac CT, whereby a negative test effectively rules out obstructive coronary artery disease. This obviates the need in these cases for the more expensive options of both nuclear imaging and invasive angiography. Using cardiac CT first (or early) in the course of patient management has been shown to be a more cost-effective algorithm for patient treatment, he added, noting that large HMOs like Kaiser are also incorporating cardiac CT into their practices, thus expediting cardiac work-ups with a more accurate and less expensive test.

“I think this report certainly helps the case for reimbursement,” as many radiology benefit managers who control approvals for certain payers (such as Blue Cross/Blue Shield) can incorporate these criteria into their approval process, said Dr. Budoff, professor of medicine at the University of California, Los Angeles, and director of cardiac CT at Harbor-UCLA Medical Center, Torrance, California.

Creation of the report was funded by the American College of Cardiology Foundation and by the other professional societies. Dr. Taylor reported having no pertinent conflicts of interest. He has been a consultant to Abbott Laboratories and has received research funds form Abbott and Resverlogix Corp. Others on the writing or technical committees and a panel of reviewers involved in the report declared potential conflicts of interest that are listed in the report. Dr. Budoff has been a speaker for General Electric and an expert witness in CT scanning.

Copyright (c) 2010 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

旧金山(EGMN)——10月25日，《美国心脏病学会杂志》(Journal of the American College of Cardiology)在线发布了心脏CT成像检查的最新适用标准，涉及2种检查：使用对比造影剂、X线的心脏CT血管造影和用于检测动脉钙沉积的非对比CT扫描。

 

一般而言，CT血管成像适用于有心脏病症状的心脏病低危或中危患者进行诊断和风险评估，在采用其他检查方法后仍无法确诊心脏病的情况下，也适合应用CT血管成像；钙扫描适用于无心脏症状的心脏病中危患者以及具有心脏病家族史的特定低危患者(特别是女性和年轻男性)。

 

该标准在如下临床情况对心脏CT的适用性进行了评定：急性和慢性胸痛、对症状性和无症状性患者的检查、心力衰竭、心脏手术和非心脏手术术前风险评估、此前检查(如运动试验、负荷显像、冠状动脉钙评分)结果基础上的检查、此前血运重建以及对心脏结构和功能的评价等。医生应根据患者具体情况考虑其适用性。心脏CT不适用于对无症状性患者的普查、对已知具有心脏病的患者或心脏病高危患者的检查以及常规复查。在该标准中，60种适应证适合应用心脏CT检查，52种适应证不确定是否适合应用此类检查，55种适应证不适合应用此类检查。

 

该标准首次考虑将CT血管造影应用于左室射血分数(LVEF)正常和异常的心力衰竭患者，但仅涉及曾检查出冠状动脉疾病风险低或中等的LVEF降低的患者。对于进行非冠状动脉心脏手术(如瓣膜置换术)的患者，CT血管造影可潜在作为术前检查的一部分。如果患者检查前的冠状动脉疾病风险为中等，则认为适用CT血管造影，如检查前风险为低，则认为不确定是否适用。冠状动脉CT血管造影不适用于非心脏手术的术前评价。成像技术适用于对左冠状动脉主干支架的评价，但对于已植入至少2年的直径≥3 mm的冠状动脉支架，则不确定是否适用。评价心脏结构和功能是心脏CT成像的强项。在该标准中，心脏CT首次被认为适用于疑似致心律失常性右心室发育不良的患者，并且在其他成像方法效果不理想或禁忌使用时，不确定是否适合使用心脏CT对心肌活力的评价。电生理操作前应用心脏CT进行解剖成像或在二次心脏手术中再次切开胸骨前适合行心脏CT检查。

 

对于冠状动脉疾病风险低的患者，如果其具备运动能力且ECG可解释，则不确定是否适用心脏CT。另外，对于行非冠状动脉心脏手术的冠状动脉疾病风险低的患者，也不确定心脏CT是否适用于术前对冠状动脉的评价。

 

对于不确定是否适用心脏CT的适应证，医生需根据患者实际情况进行判断，以决定是否进行心脏CT检查。

 

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