appropriateness criteria for stress echocardiography … for stress echo.pdferic d. peterson, md,...

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Journal of the American College of Cardiology Vol. 51, No. 11, 2008© 2008 by the American College of Cardiology Foundation ISSN 0735-1097/08/$34.00P

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ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR APPROPRIATENESS CRITERIA

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008Appropriateness Criteria for Stress Echocardiography*A Report of the American College of Cardiology Foundation AppropriatenessCriteria Task Force, American Society of Echocardiography, American Collegeof Emergency Physicians, American Heart Association, American Society ofNuclear Cardiology, Society for Cardiovascular Angiography and Interventions,Society of Cardiovascular Computed Tomography, and Society forCardiovascular Magnetic ResonanceEndorsed by the Heart Rhythm Society and the Society of Critical Care Medicine

ublished by Elsevier Inc. doi:10.1016/j.jacc.2007.12.005

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the principles and methodology outlined by ACCF: Patel MR, Spertus JAsed method for evaluating the appropriateness of cardiovascular imaging. J

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aymond F. Stainback, MD, FACC, FASE†eil J. Weissman, MD, FACC, FASE†

American Society of Echocardiography Representative

TechnicalPanelMembers

ric D. Peterson, MD, MPH, FACC, FAHA,Moderator

obert C. Hendel, MD, FACC, FAHA,Methodology Liaison

aymond F. Stainback, MD, FACC, FASE,Writing Group Liaison†

ichael Blaivas, MD, RDMS, FACEP‡oger D. Des Prez, MD, FACC§inda D. Gillam, MD, FACC, FAHA, FASEerry Golash, MDoren F. Hiratzka, MD, FACC, FAHA,FACS�illiam G. Kussmaul, MD, FACC¶

rthur J. Labovitz, MD, FACC, FAHA,

oAnn Lindenfeld, MD, FACC#rederick A. Masoudi, MD, MSPH, FACCaul H. Mayo, MD, FCCP**avid Porembka, DO, FCCM††

ohn A. Spertus, MD, MPH, FACC. Samuel Wann, MD, MACC‡‡usan E. Wiegers, MD, FACC, FASE†

American Society of Echocardiography Representative; ‡Americanollege of Emergency Physicians Representative; §American Society ofuclear Cardiology Representative; �American Heart Association Rep-

esentative; ¶Society for Cardiovascular Angiography and Inter-entions Representative; #Heart Failure Society of America Rep-esentative; **American College of Chest Physicians Representative;†Society of Critical Care Medicine Representative; ‡‡Society ofardiovascular Computed Tomography Representative

ote: Todd D. Miller, MD, FACC, FAHA,§ also contributed to the
anel ratings but not to the final document
ACCFAppropri-atenessCriteriaTask Force

alph G. Brindis, MD, MPH, FACC, Chair

amela S. Douglas, MD, MACC, FAHA,FASE

anesh R. Patel, MDric D. Peterson, MD, MPH, FACC, FAHAichael J. Wolk, MD, MACC

oseph M. Allen, MA

, Brindis RG, Hendel RC, Douglas PS, Peterson ED, Wolk MJ, AllenAm Coll Cardiol 2005;46:1606–13.

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2 Douglas et al. JACC Vol. 51, No. 11, 2008Appropriateness Criteria for Echocardiography March 18, 2008:000–000

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TABLE OF CONTENTS

bstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

reface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ethods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

General Assumptions for Stress Echocardiography . . .XXXX

bbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

esults of Ratings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

tress Echocardiography Appropriateness Criteria(by Indication) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 1. Detection of CAD/Risk Assessment:Symptomatic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 2. Detection of CAD and Risk Assessment:Asymptomatic (Without Chest Pain Syndromeor Anginal Equivalent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 3. Detection of CAD/Risk Assessment:Without Chest Pain Syndrome or AnginalEquivalent in Patient Populations WithDefined Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 4. Risk Assessment With Prior Test Results . .XXXX

Table 5. Risk Assessment: Preoperative Evaluationfor Noncardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 6. Risk Assessment: Following AcuteCoronary Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 7. Risk Assessment: Post-Revascularization(PCI or CABG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 8. Assessment of Viability/Ischemia . . . . . . . . . .XXXX

Table 9. Stress Study for Hemodynamics(Includes Doppler During Stress) . . . . . . . . . . . . . . . . .XXXX

Table 10. Contrast Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

This document was approved by the American College of Cardiology Board ofrustees in November 2007. When citing this document, the American College ofardiology would appreciate the following citation format: Douglas PS, Khandheria, Stainback RF, Weissman NJ. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/CMR 2008 appropriateness criteria for stress echocardiography. J Am Coll Cardiol008;51:XXX–XX.This article has been copublished in the March 18, 2008, issue of Circulation and

-published in Catheterization and Cardiovacular Interventions.Copies: This document is available on the World Wide Web site of the Americanollege of Cardiology (www.acc.org). For copies of this document, please contactlsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected]: Modification, alteration, enhancement and/or distribution of this

ocument are not permitted without the express permission of the American College

tf Cardiology Foundation. Please contact Elsevier’s permission department [email protected].

content.onlinejaDownloaded from

tress Echocardiography Appropriateness Criteria(by Appropriateness Category) . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 11. Appropriate Indications (Median Score7 to 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 12. Uncertain Indications (Median Score4 to 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Table 13. Inappropriate Indications (Median Score1 to 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

eneral Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ppendix A: Stress EchocardiographyDefinitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Determining Pre-Test Probability of CAD . . . . . . . . . . . . .XXXX

Determining Pre-Test Risk Assessment for RiskStratification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Evaluating Perioperative Risk for NoncardiacSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ppendix B: Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Panel Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Development of Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Rating Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Relationships With Industry . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

ppendix C: ACCF Appropriateness CriteriaTask Force and Technical Panels . . . . . . . . . . . . . . . . . . . .XXXX

Stress Echocardiography Writing Group . . . . . . . . . . . . . .XXXX

Stress Echocardiography Technical Panel . . . . . . . . . . . .XXXX

ACCF Appropriateness Criteria Task Force . . . . . . . . . . .XXXX

ppendix D: ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR Stress Echocardiography AppropriatenessCriteria Writing Group, Technical Panel, Task Force,and Indication Reviewers—Relationships WithIndustry (in Alphabetical Order). . . . . . . . . . . . . . . . . . . . . . .XXXX

eferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XXXX

bstract

he American College of Cardiology Foundation (ACCF)nd the American Society of Echocardiography (ASE) to-ether with key specialty and subspecialty societies, conductedn appropriateness review for stress echocardiography. Theeview assessed the risks and benefits of stress echocardiogra-hy for several indications or clinical scenarios and scored themn a scale of 1 to 9 (based upon methodology developed by theCCF to assess imaging appropriateness). The upper range (7

o 9) implies that the test is generally acceptable and is a by on March 3, 2008 cc.org

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3JACC Vol. 51, No. 11, 2008 Douglas et al.March 18, 2008:000–000 Appropriateness Criteria for Echocardiography

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easonable approach, and the lower range (1 to 3) implies thathe test is generally not acceptable and is not a reasonablepproach. The midrange (4 to 6) indicates a clinical scenario forhich the indication for a stress echocardiogram is uncertain.The indications for this review were drawn from common

pplications or anticipated uses, as well as from current clinicalractice guidelines. Use of stress echocardiography for riskssessment in patients with coronary artery disease (CAD) wasiewed favorably, while routine repeat testing and generalcreening in certain clinical scenarios were viewed less favor-bly. It is anticipated that these results will have a significantmpact on physician decision making and performance, reim-ursement policy, and will help guide future research.

reface

n an effort to respond to the need for the rational use ofmaging services in the delivery of high quality care, themerican College of Cardiology Foundation (ACCF) hasndertaken a process to determine the appropriateness ofardiovascular imaging for selected patient indications.

Appropriateness criteria publications reflect an ongoingffort by the ACCF to critically and systematically create,eview, and categorize clinical situations where diagnostic testsnd procedures are utilized by physicians caring for patientsith cardiovascular diseases. The process is based on a currentnderstanding of the technical capabilities of the imagingodalities examined. Although not intended to be entirely

omprehensive, the indications are meant to identify commoncenarios encompassing the majority of contemporary practice.iven the breadth of information they convey, the indications

o not directly correspond to the Ninth Revision of thenternational Classification of Diseases (ICD-9) system.

The ACCF believes that careful blending of a broadange of clinical experiences and available evidence-basednformation will help guide a more efficient and equitablellocation of health care resources in cardiovascular imaging.he ultimate objective of appropriateness criteria is to improveatient care and health outcomes in a cost-effective manner buts not intended to ignore ambiguity and nuance intrinsic tolinical decision making. Local parameters, such as the avail-bility or quality of equipment or personnel, may influence theelection of appropriate imaging procedures. Thus, appropri-teness criteria should not be considered substitutes for soundlinical judgment and practice experience.

The ACCF appropriateness criteria process itself is alsovolving. In the current iteration, Technical Panel membersere asked to rate indications for stress echocardiography inmanner independent and irrespective of prior ACCF

atings for similar diagnostic stress imaging modalities suchs single-photon emission computed tomography myocar-ial perfusion imaging (SPECT MPI) (1), cardiac com-uted tomography (CT), or cardiac magnetic resonance (2).iven the iterative nature of the process, readers are

ounseled not to compare too closely the individual appro-ed


riateness ratings among modalities rated at different timesver the past 2 years. A “cross-modality” evaluation of theppropriateness of multiple imaging techniques will bendertaken in the near future. This evaluation should moreirectly answer questions about the strengths of each mo-ality relative to alternatives for various clinical scenarios.In developing these criteria the Appropriateness Criteria

echnical Panel was asked to assess whether the use of the testor each indication is appropriate, uncertain, or inappropriate;hey were provided the following definition of appropriateness:

An appropriate imaging study is one in which the expectedncremental information, combined with clinical judgment,xceeds the expected negative consequences* by a sufficientlyide margin for a specific indication that the procedure is

enerally considered acceptable care and a reasonable ap-roach for the indication.

The Technical Panel scores each indication as follows:

Score 7 to 9Appropriate test for specific indication (test is generally

cceptable and is a reasonable approach for the indication).

Score 4 to 6Uncertain for specific indication (test may be generally

cceptable and may be a reasonable approach for thendication). (Uncertainty also implies that more researchnd/or patient information is needed to classify the indica-ion definitively.)

Score 1 to 3Inappropriate test for that indication (test is not generally

cceptable and is not a reasonable approach for the indication).

The contributors acknowledge that the division of thesecores into 3 categories of appropriateness is somewhatrbitrary and that the numeric designations should beiewed as a continuum. The contributors also recognizeiversity in clinical opinion for particular clinical scenarios.herefore, scores in the intermediate level of appropriate-ess should be labeled “uncertain,” as critical patient oresearch data are lacking and should be a prompt to the fieldo conduct definitive research investigation. It is anticipatedhat the appropriateness criteria reports will require updatess further data are generated and information from themplementation of the criteria is accumulated.

To prevent bias in the scoring process, the Technical Paneleliberately was not comprised solely of specialists in thearticular procedure under evaluation. Specialists, while offer-ng important clinical and technical insights, might have aatural tendency to rate the indications within their specialty asore appropriate than nonspecialists. In addition, care was

aken in providing objective, nonbiased information, includinguidelines and key references, to the Technical Panel.

Negative consequences include the risks of the procedure (i.e., radiation or contrast
xposure) and the downstream impact of poor test performance such as delay iniagnosis (false negatives) or inappropriate diagnosis (false positives).
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We are grateful to the Technical Panel, a professionalroup with a wide range of skills and insights, for ahoughtful and thorough deliberation of the merits of stresschocardiography for various indications. In addition to ourhanks to the Technical Panel for their dedicated work andeview, we would like to offer special thanks to Williamrmstrong, MD, Christopher Kramer, MD, Robert Mc-amara, MD, and Catherine Otto, MD, for reviewing the

raft indications; to Peggy Christiansen, the ACC librarianor her comprehensive literature searches; to Karen Caruth,ho continually drove the process forward, and to ACCFast President Pamela Douglas, MD, MACC, FAHA,ASE, for her insight and leadership.

Eric D. Peterson, MD, MPH, FACC, FAHAModerator, Stress Echocardiography Technical Panel

Ralph G. Brindis, MD, MPH, FACCChair, ACCF Appropriateness Criteria Task Force

ntroduction

his report addresses the appropriateness of stress echocar-iography. The improvement in the test characteristics oftress echocardiography in recent years has increased itstility for detection and risk assessment of ischemic heartisease. Similar to other forms of stress imaging testing,tress echocardiography can help more clearly define cardio-ascular risk for a patient, but also creates opportunities forveruse and misuse in patients who may not obtain aenefit, or who could have been medically managed effec-ively without the addition of the test. In particular, inap-ropriate use may be costly and may prompt potentiallyarmful and costly downstream testing and treatment suchs unwarranted coronary revascularization or unnecessaryepeat follow-up. Concerns about inappropriate use existmong those who pay for these services and clinical leadersho evaluate the effectiveness of testing.

ethods

he indications included in this review are purposefullyroad, and they comprise a wide array of cardiovascularigns and symptoms as well as clinical judgment as to theikelihood of cardiovascular findings.

A detailed description of the methods used for ranking ofhe selected clinical indications is outlined in Appendix Bnd is also found more generally in a previous publication,ACCF Proposed Method for Evaluating the Appropriate-ess of Cardiovascular Imaging” (3). Briefly, this processombines evidence-based medicine and practice experiencey engaging a technical panel in a modified Delphi exercise.he panel first rated indications independently. Then theanel was convened for a face-to-face meeting for discussionf each indication. At this meeting, panel members wererovided with their scores and a blinded summary of their
eers’ scores. After the consensus meeting, panel members
†f


ere then asked to independently provide their final scoresor each indication.

The level of agreement among panelists as defined byAND (4) was analyzed based on the BIOMED rule for aanel of 14 to 16. As such, agreement was defined as anndication where 4 or fewer panelists’ ratings fell outside the-point region containing the median score. Disagreementas defined as where at least 5 panelists’ ratings fell in both

he appropriate and the inappropriate categories.

eneral Assumptions for Stress Echocardiography

o prevent any nuances of interpretation, all indicationsere considered with the following important assumptions:

. All indications are assumed to apply to adult patients (18years of age or older).

. The test is performed and interpreted by qualifiedindividuals in facilities that are proficient in the imagingtechnique (5–8).

The indications were constructed by echocardiography ex-erts and modified on the basis of discussions among the Taskorce and feedback from independent reviewers and theechnical Panel. Wherever possible, indications were mapped

o relevant clinical guidelines and key publications/referencesOnline Appendix at http://content.onlinejacc.org).

The Technical Panel was comprised of clinician experts,ome with backgrounds in cardiac imaging and others withxperience in general cardiovascular medicine, cardiac sur-ery, critical care medicine, emergency medicine, health ser-ices research, and health plan administration.† Panelists werenstructed to incorporate in their deliberations several assump-ions specifically for stress echocardiography, including:

. All standard echocardiographic techniques for image acqui-sition, including imaging protocols, are available for eachindication, and stress echocardiography has a sensitivity andspecificity similar to those found in the published literature.

. For all stress imaging, the mode of stress testing is assumedto be exercise for patients able to exercise. For patientsunable to exercise, it is assumed that dobutamine is used forechocardiographic stress testing. Further background onthe rationale for the assumption of exercise stress is availablein the ACC/AHA 2002 Guideline Update for ExerciseStress Testing (9). Any indications including a specificmode of stress are labeled as such.

. Preoperative evaluation includes procedures such as or-gan transplantation.

bbreviations

CS � acute coronary syndromeI �aortic insufficiencyABG � coronary artery bypass grafting surgeryAD �coronary artery disease

Full detail about the backgrounds of the members of the Technical Panel can beound in Appendix C.




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HD � coronary heart diseaseT � computed tomographyCG � electrocardiogramF � heart failureV � left ventricularET � estimated metabolic equivalents of exerciseI � myocardial infarctionR � mitral regurgitation

CI � percutaneous coronary interventionPECT MPI � single-photon emission computed tomog-aphy myocardial perfusion imagingA/NSTEMI � unstable angina (UA) and non-ST-

levation myocardial infarction (NSTEMI)

esults of Ratings

he final ratings for stress echocardiography (Tables 1 to0) are listed by indication sequentially as obtained fromecond round rating sheets submitted by each panelist.dditionally, the indications are presented by Appropriate-ess Category (Tables 11 to 13).Definitions used by the Technical Panel can be found in


f the mean absolute deviation from the median and level ofgreement of rankings for each indication, can be found inhe Online Appendix at http://content.onlinejacc.org.

For the 51 indications for the use of stress echocardiog-aphy, 22 were found to be appropriate, 10 were uncertain,nd 19 were considered inappropriate.

Typically, there was greater variability in scores of indi-ations defined as uncertain, suggesting wide variation inpinion. A number of indications failed to meet the aboveefinition of agreement. Still, there were no uncertainndications where the panel held such opposing viewpointshat the indication was labeled as one for which the panelisagreed. There was generally less variation for the indica-ions labeled as either appropriate or inappropriate, with8.8% and 79.0%, respectively, showing agreement as pre-iously defined. Disagreement did not occur for any of thendications ultimately defined as appropriate or inappropri-te. Finally, as prior research has found that, in general, theest operating characteristics of stress echocardiography andPECT MPI imaging are similar, we also provide theeaders with an asterisk where there were discordancesetween similar indications rated inappropriate for stresschocardiography and those previously rated uncertain for

ppendix A. Supplemental tables, including documentation SPECT MPI.

tress Echocardiography Appropriateness Criteria (by Indication)

able 1. Detection of CAD/Risk Assessment: Symptomatic

IndicationAppropriateness

Score (1–9)Evaluation of Chest Pain Syndrome or Anginal Equivalent

1. ● Low pre-test probability of CAD● ECG interpretable AND able to exercise

I (3)

2. ● Low pre-test probability of CAD● ECG uninterpretable OR unable to exercise

A (7)

3. ● Intermediate pre-test probability of CAD● ECG interpretable AND able to exercise

A (7)

4. ● Intermediate pre-test probability of CAD● ECG uninterpretable OR unable to exercise

A (9)

5. ● High pre-test probability of CAD● Regardless of ECG interpretability and ability to exercise

A (7)

6. ● Prior stress ECG test is uninterpretable or equivocal A (8)

Acute Chest Pain

7. ● Intermediate pre-test probability of CAD● ECG–no dynamic ST changes AND serial cardiac enzymes negative

A (8)

8. ● High pre-test probability of CAD● ECG–ST elevation

I (1)

New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome or Anginal Equivalent

9. ● Intermediate pre-test probability● Normal LV systolic function

A (8)

10. ● LV systolic function U (5)




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able 2. Detection of CAD and Risk Assessment: Asymptomatic (Without Chest Pain Syndrome or Anginal Equivalent)


Score (1–9)General Patient Populations

11. ● Low CHD risk (Framingham risk criteria) I (1)

12. ● Moderate CHD risk (Framingham)● ECG Interpretable

I (3)*

13. ● High CHD risk (Framingham) U (6)

The ranking of this indication as inappropriate is different from that given to similar but not identical indications in previously published appropriateness criteria. The ratings were done in accordance
ith established ACCF methodology. Furthermore, the Technical Panel for each modality operated independently without allowance and with discouragement for intermodality comparisons. Discrepantcores may be related to rating variability, differing Technical Panel composition, maturation of the appropriatness criteria process, or perceived differences in appropriateness.
able 3. Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations Withefined Comorbidities


Score (1–9)New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction

14. ● Moderate CHD risk (Framingham)● No prior CAD evaluation● Normal LV systolic function

A (7)

15 ● Moderate CHD risk (Framingham)● No prior CAD evaluation● Abnormal LV systolic dysfunction

U (5)

Valvular Heart Disease Requiring Valve Surgery

16. ● Moderate CHD risk (Framingham) I (3)

New-Onset Atrial Fibrillation

17. ● Low CHD risk (Framingham)● Part of the evaluation

I (2)*

18. ● Moderate to high CHD risk (Framingham)● Part of the evaluation

A (7)

Nonsustained Ventricular Tachycardia

19. ● Moderate to high CHD risk (Framingham)● Stress echo using exercise stress only

A (7)

ith established ACCF methodology. Furthermore, the Technical Panel for each modality operated independently without allowance and with discouragement for intermodality comparisons. Discrepantcores may be related to rating variability, differing Technical Panel composition, maturation of the appropriatness criteria process, or perceived differences in appropriateness.
able 4. Risk Assessment With Prior Test Results


Score (1–9)Asymptomatic OR Stable Symptoms, Normal Prior Stress Imaging Study

20. ● High CHD risk● Repeat stress echo study annually

I (2)

21. ● High CHD risk● Repeat stress echo study after 2 years or greater

U (5)

Known CAD: Asymptomatic OR Stable Symptoms, Abnormal Catheterization OR Abnormal Prior Stress Imaging Study

22. ● Assessment of severity of ischemia (CAD)● Less than 1 year to evaluate medically managed patients

I (2)

23. ● Assessment of severity of ischemia (CAD)● Greater than or equal to 2 years to evaluate medically managed patients

U (5)

Worsening Symptoms: Abnormal Catheterization OR Abnormal Prior Stress Imaging Study

24. ● Re-evaluation of medically managed patients A (8)

Asymptomatic Prior Coronary Calcium Agatston Score

25. ● Agatston score greater than or equal to 400 A (7)

26. ● Agatston score less than 100 I (1)

Chest Pain Syndrome or Anginal Equivalent

27. ● Coronary artery stenosis of unclear significance (cardiac catheterization or CT angiography) A (8)

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able 5. Risk Assessment: Preoperative Evaluation for Noncardiac Surgery†


Score (1–9)Low-Risk Surgery

28. ● Preoperative evaluation for noncardiac surgery risk assessment● Minor or intermediate clinical risk predictors

I (1)

Intermediate-Risk Surgery

29. ● Poor exercise tolerance (less than or equal to 4 METs)● Minor or no clinical risk predictors

I (2)

30. ● Poor exercise tolerance (less than or equal to 4 METs)● Intermediate clinical risk predictors

A (7)

High-Risk Nonemergent Surgery

31. ● Poor exercise tolerance (less than 4 METs) A (8)

32. ● Asymptomatic up to 1 year after normal catheterization, noninvasive test, or previousrevascularization

I (1)

See discussion and appendix for changes in the revised 2007 ACC/AHA Perioperative Guidelines relevant to these indications (10).

able 6. Risk Assessment: Following Acute Coronary Syndrome


Score (1–9)UA/NSTEMI—No Recurrent Symptoms or Signs of Heart Failure

33. ● Not planning to undergo early catheterization A (8)

Acute Coronary Syndrome—Asymptomatic Post-Revascularization (PCI or CABG)

34. ● Routine evaluation prior to hospital discharge I (1)

able 7. Risk Assessment: Post-Revascularization (PCI or CABG)


Score (1–9)Symptomatic

35. ● Evaluation of chest pain syndrome● Not in the early post-procedure period

A (8)

Asymptomatic

36. ● Less than 5 years after CABG I (2)*

37. ● Asymptomatic (e.g., silent ischemia) prior to previous revascularization● Greater than or equal to 5 years after CABG

U (6)

38. ● Symptomatic prior to previous revascularization● Greater than or equal to 5 years after CABG

U (5)

39. ● Asymptomatic (e.g., silent ischemia) prior to previous revascularization● Less than 2 years after PCI

I (3)*

40. ● Symptomatic prior to previous revascularization● Less than 2 years after PCI

I (2)

41. ● Asymptomatic (e.g., silent ischemia) prior to previous revascularization● Greater than or equal to 2 years after PCI

U (5)

ith established ACCF methodology. Furthermore, the Technical Panel for each modality operated independently without allowance and with discouragement for intermodality comparisons. Discrepantcores may be related to rating variability, differing Technical Panel composition, maturation of the appropriateness criteria process, or perceived differences in appropriateness.
able 8. Assessment of Viability/Ischemia


Score (1–9)Ischemic Cardiomyopathy, Assessment of Viability/Ischemia

42. ● Known CAD on catheterization● Patient eligible for revascularization

A (8)



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tress Echocardiography Appropriateness Criteria (by Appropriateness Category)

able 9. Stress Study for Hemodynamics (Includes Doppler During Stress)


Score (1–9)Valvular Stenosis

43. ● Evaluation of equivocal aortic stenosis● Evidence of low cardiac output● Use of dobutamine

A (8)

44. ● Asymptomatic individuals● Mild to moderate mitral stenosis

U (5)

45. ● Symptomatic individuals● Mild mitral stenosis

A (7)

46. ● Severe aortic or mitral stenosis I (2)

47. ● Asymptomatic severe AI or MR● LV size and function not meeting surgical criteria

A (7)

48. ● Severe AI or MR● Symptomatic or with severe LV enlargement or LV systolic dysfunction

I (2)

Pulmonary Hypertension

49. ● Suspected pulmonary hypertension● Normal or indeterminate resting echo study

U (5)

able 10. Contrast Use


Score (1–9)Use of Contrast With Stress Echo

50. ● Routine use of contrast● All segments visualized on noncontrast images

I (1)

51. ● Selective use of contrast● 2 or more contiguous segments are NOT seen on noncontrast images

A (8)

able 11. Appropriate Indications (Median Score 7 to 9)


Score (1–9)Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome or Anginal Equivalent

2. ● Low pre-test probability of CAD● ECG uninterpretable OR unable to exercise

A (7)

3. ● Intermediate pre-test probability of CAD● ECG interpretable AND able to exercise

A (7)

4. ● Intermediate pre-test probability of CAD● ECG uninterpretable OR unable to exercise

A (9)

5. ● High pre-test probability of CAD● Regardless of ECG interpretability and ability to exercise

A (7)

6. ● Prior stress ECG test is uninterpretable or equivocal A (8)

Detection of CAD: Symptomatic—Acute Chest Pain

7. ● Intermediate pre-test probability of CAD● ECG—no dynamic ST changes AND serial cardiac enzymes negative

A (8)

Detection of CAD: Symptomatic—New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome or Anginal Equivalent

9. ● Intermediate pre-test probability● Normal LV systolic function

A (8)

Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction

14. ● Moderate CHD risk (Framingham)● No prior CAD evaluation● Normal LV systolic function

A (7)



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able 11. Continued


Score (1–9)Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—

New-Onset Atrial Fibrillation

18. ● Moderate to high CHD risk (Framingham)● Part of the evaluation

A (7)

Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—Nonsustained Ventricular Tachycardia

19. ● Moderate to high CHD risk (Framingham)● Stress echo using exercise stress only

A (7)

Risk Assessment with Prior Test Results—Worsening Symptoms: Abnormal Catheterization OR Abnormal Prior Stress Imaging Study

24. ● Re-evaluation of medically managed patients A (8)

Risk Assessment With Prior Test Results—Asymptomatic, Prior Coronary Calcium Agatston Score

25. ● Agatston score greater than or equal to 400 A (7)

Risk Assessment With Prior Test Results—Chest Pain Syndrome or Anginal Equivalent

27. ● Coronary artery stenosis of unclear significance (cardiac catheterization or CT angiography) A (8)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—Intermediate-Risk Surgery

30. ● Poor exercise tolerance (less than or equal to 4 METs)● Intermediate clinical risk predictors

A (7)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—High-Risk Nonemergent Surgery

31. ● Poor exercise tolerance (less than 4 METs) A (8)

Risk Assessment: Following Acute Coronary Syndrome–UA/NSTEMI—No Recurrent Symptoms or Signs of Heart Failure

33. ● Not planning to undergo early catheterization A (8)

Risk Assessment: Post-Revascularization (PCI or CABG)—Symptomatic

35. ● Evaluation of chest pain syndrome● Not in the early post-procedure period

A (8)

Ischemic Cardiomyopathy Assessment of Viability/Ischemia—Ischemic Cardiomyopathy, Assessment of Viability/Ischemia

42. ● Known CAD on catheterization● Patient eligible for revascularization

A (8)

Stress Study for Hemodynamics (Includes Doppler During Stress)—Valvular Stenosis

43. ● Evaluation of equivocal aortic stenosis● Evidence of low cardiac output● Use of dobutamine

A (8)

45. ● Symptomatic individuals● Mild mitral stenosis

A (7)

47. ● Asymptomatic severe AI or MR● LV size and function not meeting surgical criteria

A (7)

Contrast Use—Use of Contrast With Stress Echo

51. ● Selective use of contrast● 2 or more contiguous segments are NOT seen on noncontrast images

A (8)



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able 12. Uncertain Indications (Median Score 4 to 6)


Score (1–9)Detection of CAD: Symptomatic—New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome or Anginal Equivalent

10. ● Intermediate pre-test probability● Abnormal LV systolic function

U (5)

Detection of CAD and Risk Assessment: Asymptomatic (Without Chest Pain Syndrome or Anginal Equivalent) General Patient Populations

13. ● High CHD risk (Framingham) U (6)

Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction

15. ● Moderate CHD risk (Framingham)● No prior CAD evaluation● Abnormal LV systolic dysfunction

U (5)

Risk Assessment With Prior Test Results—Asymptomatic OR Stable Symptoms, Normal Prior Stress Imaging Study

21. ● High CHD risk● Repeat stress echo study after 2 years or greater

U (5)

Risk Assessment With Prior Test Results—Known CAD: Asymptomatic OR Stable Symptoms, Abnormal Catheterization ORAbnormal Prior Stress Imaging Study

23. ● Assessment of severity of ischemia (CAD)● Greater than or equal to 2 years to evaluate medically managed patients

U (5)

Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic

37. ● Asymptomatic (e.g., silent ischemia) prior to previous revascularization● Greater than or equal to 5 years after CABG

U (6)

38. ● Symptomatic prior to previous revascularization● Greater than or equal to 5 years after CABG

U (5)

41. ● Asymptomatic (e.g., silent ischemia) prior to previous revascularization● Greater than or equal to 2 years after PCI

U (5)


44. ● Asymptomatic individuals● Mild to moderate mitral stenosis

U (5)

Stress Study for Hemodynamics (Includes Doppler During Stress)—Pulmonary Hypertension

49. ● Suspected pulmonary hypertension● Normal or indeterminate resting echo study

U (5)



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able 13. Inappropriate Indications (Median Score 1 to 3)


Score (1–9)Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome or Anginal Equivalent

1. ● Low pre-test probability of CAD● ECG interpretable AND able to exercise

I (3)

Detection of CAD: Symptomatic—Acute Chest Pain

8. ● High pre-test probability of CAD● ECG ST-elevation

I (1)

Detection of CAD and Risk Assessment: Asymptomatic (Without Chest Pain Syndrome or Anginal Equivalent)—General Patient Populations

11. ● Low CHD risk (Framingham risk criteria) I (1)

12. ● Moderate CHD risk (Framingham)● ECG interpretable

I (3)*

Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—Valvular Heart Disease Requiring Valve Surgery

16. ● Moderate CHD risk (Framingham) I (3)

Detection of CAD/Risk Assessment: Without Chest Pain Syndrome or Anginal Equivalent in Patient Populations With Defined Comorbidities—New-Onset Atrial Fibrillation

17. ● Low CHD risk (Framingham)● Part of the evaluation

I (2)*

Risk Assessment With Prior Test Results—Asymptomatic OR Stable Symptoms, Normal Prior Stress Imaging Study

20. ● High CHD risk● Repeat stress echo study annually

I (2)

Risk Assessment With Prior Test Results—Known CAD: Asymptomatic OR Stable Symptoms, Abnormal Catheterization ORAbnormal Prior Stress Imaging Study

22. ● Assessment of severity of ischemia (CAD)● Less than 1 year to evaluate medically managed patients

I (2)

Risk Assessment With Prior Test Results—Asymptomatic, Prior Coronary Calcium Agatston Score

26. ● Agatston score less than 100 I (1)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—Low-Risk Surgery

28. ● Preoperative evaluation for noncardiac surgery risk assessment● Minor or intermediate clinical risk predictors

I (1)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—Intermediate-Risk Surgery

29. ● Poor exercise tolerance (less than or equal to 4 METs)● Minor or no clinical risk predictors

I (2)

Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—High-Risk Nonemergent Surgery

32. ● Asymptomatic up to 1 year after normal catheterization, noninvasive test, or previousrevascularization

I (1)

Risk Assessment: Following Acute Coronary Syndrome—Asymptomatic Post-Revascularization (PCI or CABG)

34. ● Routine evaluation prior to hospital discharge I (1)

Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic

36. ● Less than 5 years after CABG I (2)*

39. ● Asymptomatic (e.g., silent ischemia) prior to previous revascularization● Less than 2 years after PCI

I (3)*

40. ● Symptomatic prior to previous revascularization● Less than 2 years after PCI

I (2)


46. ● Severe aortic or mitral stenosis I (2)

48. ● Severe AI or MR● Symptomatic or with severe LV enlargement or LV systolic dysfunction

I (2)

Contrast Use–Use of Contrast With Stress Echo

50. ● Routine use of contrast● All segments visualized on noncontrast images

I (1)

ith established ACCF methodology. Furthermore, the Technical Panel for each modality operated independently without allowance and with discouragement for intermodality comparisons. Discrepantcores may be related to rating variability, differing Technical Panel composition, maturation of the appropriateness criteria process, or perceived differences in appropriateness.


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eneral Discussion

he appropriateness criteria in this report provide anstimate of the reasonableness of the use of stress echocar-iography for the particular clinical scenarios presented inach of the 51 indications considered. They are expected toe useful for clinicians, health care facilities, and third-partyayers engaged in the delivery of cardiovascular imaging.xperience with already published appropriateness criteria

1,2) has shown their value across a broad range of situa-ions, guiding care of individual patients, educating caregiv-rs, and informing policy decisions regarding reimburse-ent for cardiovascular imaging.Appropriateness criteria represent the first component of

he chain of quality recommended for cardiovascular imag-ng (11). After ensuring proper test selection, the achieve-

ent of quality in imaging includes adherence to bestractices in image acquisition, image interpretation, andesults communication, as well as incorporation of findingsnto clinical care. All components are important for optimalatient care, although not all are addressed in this report.he development of appropriateness criteria and their

anking by the Technical Panel assumes that other qualitytandards are adequately met. It also is assumed that whenonsidering the appropriateness of ordering a repeat ornnual test that the prior image and report can be obtainednd are of sufficient quality as outlined above.

Although the appropriateness ratings reflect a generalxpert consensus of when stress echocardiography may oray not be useful for specific patient populations, physicians

nd other stakeholders should understand the role of clinicaludgment in determining whether to order a test for anndividual patient. For example, the rating of an indications inappropriate should not preclude a provider from per-orming stress echocardiographic procedures when there areatient- and condition-specific data to support that deci-ion. Indeed this may be the correct clinical pathway ifupported by mitigating characteristics of the patient. Like-ise, uncertain indications often require individual physi-

ian judgment and understanding of the patient to betteretermine the usefulness of a test for a particular scenario.s such, the ranking of an indication as uncertain (4–6)

hould not be viewed as limiting the use of stress echocar-iography for such patients. Finally, there may be clinicalituations in which the use of stress echocardiography for anndication considered to be appropriate does not alwaysepresent reasonable practice, such as a patient in whomnother diagnostic imaging test might be scheduled or haslready been performed.

The indications contained in this report are purposefullyroad to capture the range of situations in which cliniciansnd value in stress echocardiography information. However,s with the appropriateness criteria for other imaging modal-ties, they are not exhaustive because of the complexity and
umber of the potential clinical situations. For example, t

either the use of stress echocardiography prior to organransplantation nor all forms of perioperative echocardiographyere included as separate indications but are assumed to be

overed by the more general perioperative guidelines (10).Stress echocardiography tests, like many imaging tests,ay provide additional useful information beyond the

rimary purpose outlined by the indication. The appropri-teness criteria for stress echocardiography were not devel-ped to quantify the incremental information obtained byerforming the test for reasons beyond those stated in anndividual indication. For example, the additional informa-ion available with a stress echocardiogram, including thessessment of resting ejection fraction or the identificationf concomitant valve disease, was not considered whenetermining the appropriateness rankings. Thus, membersf the Technical Panel were asked specifically not toonsider implicit or additional information outside thecope of an individual indication in their rankings. As such,he entire list of indications from this document and thoseublished separately for transthoracic and transesophagealchocardiography (12) should be reviewed to assess aroader range of potential reasons for ordering a stresschocardiogram for an individual patient.

In addition, panelists were asked specifically not toonsider comparisons to other imaging procedures or otherppropriateness criteria documents while completing theirankings. While stress CT and MR are newer modalitieshich have not been extensively studied, stress echocardi-graphy and stress SPECT MPI have similar bodies ofvidence to support their use. The overwhelming majorityf final ratings of stress echocardiography and stressPECT MPI were concordant for similar clinical indica-ions. However, a small number of the final scores andating categories reported in this document differ from thosereviously published for stress SPECT MPI. Readershould note, however, that the categorical summaries tendo accentuate differences that sometimes are slight. Forxample, small fluctuations in a median rating (e.g., 4 vs. 3)ill cause an indication to switch appropriateness categories

e.g., from uncertain to inappropriate).There are several potential reasons for these discordant

ccurrences. The most likely reason for this is a simpleariation in rating by the different panel members, whetherue to composition, different levels of clinical experience, orifferent interpretations of data. The RAND process hasocumented that the interpretation of the literature byifferent sets of experts can yield slightly different finalatings (4). For example, one panel may contain a slightlyigher percentage of “modality experts” than another panel.he Appropriateness Criteria Task Force has subsequently

xamined this influence of specialty and made every effort torovide a balance of expertise. Another source of potentialariation is timing. As appropriateness criteria gain morexposure, Technical Panel members have greater familiarityith the indications and implementation requirements than

he panels of prior modules. Inconsistency in wording of by on March 3, 2008 cc.org


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ndications for the stress echocardiography and stress nu-lear panels may have also contributed to differences in somecenarios. For example, stress echocardiography indicationsombined CAD detection and risk assessment into singlendications, whereas the criteria for stress SPECT separatedhese indications.

The indications were developed and rated prior to theelease of the ACC/AHA 2007 Perioperative Guidelines10). As such, in addition to the Online Appendix (http://ontent.onlinejacc.org), the reader should refer to the 2007ersion of the guidelines for further discussion of the use ofoninvasive testing prior to surgery.There are many potential applications for appropriateness

riteria. Clinicians could use the ratings as a decisionupport or educational tool when ordering a test or provid-ng a referral to another qualified physician. The criteria also

ay be used to facilitate discussion with referring cliniciansho have patterns of ordering tests for inappropriate indi-

ations. Facilities and payers may choose to use the criteriaither prospectively in the design of protocols, automatedrder entry, and pre-authorization procedures, or retrospec-ively for quality reports. It is hoped that payers will use thisocument as the basis to inform rational strategies to ensurehat their members receive the highest-quality, cost-ffective cardiovascular care.

As outlined in the original methodology by the ACCF3), it is expected that services performed for appropriatendications will receive reimbursement. In contrast, serviceserformed for inappropriate indications will likely requiredditional documentation to justify payment because ofnique circumstances or the clinical profile of the patient.ayers should note that the Technical Panel and clinicalommunity do not consider uncertain indications as thosehat should not be performed or reimbursed. Rather, thencertain indications are those where the opinions of theanel vary and the data may be conflicting. In many of thesereas, additional research is clearly desirable. Indicationsith high clinical volume that are rated as uncertain identify

reas for increased focus and research.When used to assess performance, appropriateness crite-

ia should be applied in conjunction with systems thatupport quality improvement. Ordering forms containingssential information for determining appropriateness alongith periodic feedback reports to providers may help edu-

ate providers on their ordering patterns. Prospective pre-uthorization procedures, if put in place, are most effectivence a retrospective review has identified a pattern ofotential inappropriate use. Because the criteria are based onurrent scientific evidence and the deliberations of theechnical Panel, they should be used prospectively toenerate future discussions about reimbursement, buthould not be applied retrospectively to cases completedrior to issuance of this report.The primary objective of this report is to provide guid-

nce regarding the perceived suitability of stress echocardi-
graphy for diverse clinical scenarios. As with previous *

ppropriateness criteria documents, consensus among theaters was desirable, but any attempt to achieve completegreement within this diverse panel would have been arti-cial and not necessarily of clinical value. Two rounds ofatings with lively discussion between the ratings did lead toome consensus among panelists. However, further at-empts to drive consensus would have diluted true differ-nces in opinion among panelists and, therefore, was notndertaken.Future research analyzing patient outcomes utilizing

ndications rated appropriate would help ensure the equita-le and efficient allocation of resources for diagnostictudies. Review of medically necessary care may also im-rove the understanding of regional variations in imagingtilization. Further exploration of the indications rated asuncertain” will help generate the data required to furtherefine the appropriateness of stress echocardiography. Fi-ally, it will be necessary to periodically assess and updatehe indications and criteria as technology evolves and newata and field experience become available.

ppendix A: Stress Echocardiographyefinitions

etermining Pre-Test Probability of CAD

ngina: as defined by the ACC/AHA Guidelines onxercise Testing (9)

Typical Angina (Definite) (13):

. Substernal chest pain or discomfort that is

. provoked by exertion or emotional stress and

. relieved by rest and/or nitroglycerin.

Atypical Angina (Probable): Chest pain or discomfortthat lacks one of the characteristics of definite or typicalangina (13).

onanginal Chest Pain: Chest pain or discomfort thateets one or none of the typical angina characteristics (13).hest Pain Syndrome or Anginal Equivalent: Any con-

tellation of symptoms that the physician feels may repre-ent a complaint consistent with obstructive CAD. Exam-les of such symptoms include, but are not exclusive to,

able A1. Pre-Test Likelihood of CAD in Symptomatic Patientsccording to Age and Gender* (Combined Diamond/Forresternd CASS Data) (17,18)

Age(Years)

NonanginalChest Pain Atypical Angina Typical Angina

Men Women Men Women Men Women

0–39 4 2 34 12 76 26

0–49 13 3 51 22 87 55

0–59 20 7 65 31 93 73

0–69 27 14 72 51 94 86

Each value represents the percentage with significant CAD on catheterization.





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hest pain, chest tightness, burning, dyspnea, shoulder pain,alpitations, syncope, breathlessness, and jaw pain.re-Test Probability of CAD: Once the physician deter-ines the presence of symptoms that may represent ob-

tructive CAD (chest pain syndrome or anginal equivalentresent), then the pre-test probability of CAD should beetermined. There are a number of risk algorithms (14,15)vailable that can be used to calculate this probability.linicians should become familiar with those that pertain to

he populations they encounter most often. In scoring thendications, the following probabilities as calculated fromny of the various available algorithms should be applied.

Low pre-test probability: Less than 10% pre-test proba-bility of CADIntermediate pre-test probability: Between 10% and 90%pre-test probability of CAD

able A2. Comparing Pre-Test Likelihoods of CAD in Low-Riskymptomatic Patients With High-Risk Symptomaticatients—Duke Database (15)

Age(Years)

NonanginalChest Pain Atypical Angina Typical Angina

Men Women Men Women Men Women

5 3–35 1–19 8–59 2–39 30–88 10–78

5 9–47 2–22 21–70 5–43 51–92 20–79

5 23–59 4–25 45–79 10–47 80–95 38–82

5 49–69 9–29 71–86 20–51 93–97 56–84

ach value represents the percent with significant CAD. The first is the percentage for a low-risk,id-decade patient without diabetes, smoking, or hyperlipidemia. The second is that of the samege patient with diabetes, smoking, and hyperlipidemia. Both high- and low-risk patients haveormal resting ECGs. If ST-T-wave changes or Q waves had been present, the likelihood of CADould be higher in each entry of the table.

able A3. Men: 10-Year CHD Risk According to Framingham R

reen indicates below average risk; violet, average risk; yellow, moderately above average risk;ge for a nonsmoker, nondiabetic, with blood pressure less than 120/80 mm Hg, total cholester
nd greater than or equal to 55 mg/dl in women. †Number of points estimated from Table 4 of Grundynrecognized myocardial infarction, unstable angina, and CHD deaths. §Hard CHD includes all of the t

High pre-test probability: Greater than 90% pre-testprobability

The method recommended by the ACC/AHA Guide-ines for Chronic Stable Angina (16) is provided below as 1xample of a method used to calculate pre-test probabilitynd is a modification of a previously published literatureeview (17). Please refer to definitions of angina and Table1. Please note that the following table only predictsre-test probability in patients without other complicatingistory or ECG findings. History and electrocardiographicvidence of prior infarction dramatically affect pre-testrobability. Detailed nomograms are available that incorpo-ate the effects of a history of prior infarction, electrocar-iographic Q waves, electrocardiographic ST- and T-wavehanges, diabetes, smoking, and hypercholesterolemia (9)Table A2 presents 1 example).

etermining Pre-Test Risk Assessment forisk Stratification

isk Assessment

he rating sheets on risk assessment include indications inatients with suspected CAD.It is assumed that clinicians will use echocardiography

tudies in addition to standard methods of risk assessments presented in the AHA/ACC Scientific Statement: As-essment of Cardiovascular Risk by Use of Multiple-Risk-actor Assessment Equations (19). See the scientific state-ent to determine Framingham Risk Score (Tables A3 and4) to calculate CHD risk percentage. As noted in the

cientific statement, these scores should be modified on theasis of additional relevant factors shown to affect risk such

core

d, high risk. �Low-risk level is defined in the Framingham Report (21) as the risk of CHD at any0 to 199 mg/dl, LDL-C 100 to 129 mg/dl, and HDL-C greater than or equal to 45 mg/dl in men

isk S

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et al. (19). ‡Total Coronary Heart Disease (Total CHD) includes angina pectoris, recognized andotal CHD events except for angina pectoris. Adapted from (19).



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s obesity, physical inactivity, psychosocial factors, familyistory of premature CHD, ethnic characteristics (especiallyouth Asians in the United States), and hypertriglyceride-ia.

HD Risk‡

Based on the AHA/ACC Scientific Statement on Cardio-ascular Risk Assessment [19])

CHD Risk–LowDefined by the age-specific risk level that is below

average. In general, low risk will correlate with a 10-yearabsolute CHD risk less than 10%.CHD Risk–Moderate

Defined by the age-specific risk level that is average orabove average. In general, moderate risk will correlatewith a 10-year absolute CHD risk between 10% to 20%.CHD Risk–High

Defined as a 10-year absolute CHD risk of greaterthan 20% or the presence of diabetes mellitus.†

Grundy et al. (19) cite Framingham when assigning patients with diabetes mellitus

able A4. Women: 10-Year CHD Risk According to Framingham

reen indicates below average risk; violet, average risk; yellow, moderately above average risk;ge for a nonsmoker, nondiabetic, with blood pressure less than 120/80 mm Hg, total cholesternd greater than or equal to 55 mg/dl in women. †Number of points estimated from Table 4 ofnrecognized myocardial infarction, unstable angina, and CHD deaths. §Hard CHD includes all

o a category of high short-term risk because these patients typically have multiple riskactors and have poor prognoses if they develop CHD.

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valuating Perioperative Risk foroncardiac Surgery§

ethod for Determining Perioperative Risk

Based on the recommendations from the ACC/AHAerioperative Cardiovascular Evaluation for Noncardiacurgery [20])Review Figure A1, “Stepwise Approach to Preoperativeardiac Assessment.” Based on the algorithm, once it isetermined that the patient does not require urgent surgery,nd that there has not been revascularization within the lastyears, the clinician should determine the patient’s periop-

rative risk predictors (see definitions in the following text).f major risk predictors are present, Figure A1 suggestsonsideration of coronary angiography and postponing oranceling noncardiac surgery. Once perioperative risk pre-ictors are assessed based on the algorithm, then the surgicalisk and patient’s functional status should be used tostablish the need for noninvasive testing.

Definitions and algorithms cited were current at the time of the technical panel and

k Score

d, high risk. �Low-risk level is defined in the Framingham Report (21) as the risk of CHD at any0 to 199 mg/dl, LDL-C 100 to 129 mg/dl, and HDL-C greater than or equal to 45 mg/dl in ment al. (19). ‡Total Coronary Heart Disease (Total CHD) includes angina pectoris, recognized andotal CHD events except for angina pectoris. Adapted from (19).

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re those reviewed by the technical panel at time of rating. See 2007 ACC/AHAerioperative Guidelines for updated content (10).



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igure A1. Stepwise Approach to Preoperative Cardiac Assessment

teps are discussed in the text. Definitions and algorithms cited were current at the time of the technical panel and are those reviewed by the technical panel at time of rat-
ng. See 2007 ACC/AHA Perioperative Guidelines for updated content (10). *Subsequent care may include cancellation or delay of surgery, coronary revascularization fol-owed by noncardiac surgery, or intensified care. CHF � congestive heart failure; ECG � electrocardiogram; MET � metabolic equivalent; MI � myocardial infarction.


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erioperative Risk Predictors�

Major risk predictors

Unstable coronary syndromes, decompensated HF, sig-ificant arrhythmias, and severe valve disease.

Intermediate risk predictors

Mild angina, prior MI, compensated or prior HF, dia-etes, or renal insufficiency.

Minor risk predictors

Advanced age, abnormal ECG, rhythm other than sinus,ow functional capacity, history of cerebrovascular accident,nd uncontrolled hypertension.

urgical Risk Categories�

High-Risk Surgery–cardiac death or MI greater than 5%Emergent major operations (particularly in the el-

derly), aortic and peripheral vascular surgery, prolongedsurgical procedures associated with large fluid shiftsand/or blood loss.Intermediate-Risk Surgery–cardiac death or MI equal to1% to 5%

Carotid endarterectomy, head and neck surgery, sur-gery of the chest or abdomen, orthopedic surgery, pros-tate surgery.Low-Risk Surgery–cardiac death or MI less than 1%

Endoscopic procedures, superficial procedures, cata-ract surgery, breast surgery.

CG–Uninterpretable

efers to ECGs with resting ST-segment depressiongreater than or equal to 0.10 mV), complete left bundle-ranch block, pre-excitation (Wolf-Parkinson-White syn-rome), or paced rhythm.

ppendix B: Methods

anel Selection

takeholders were given the opportunity to participate inhe appropriateness criteria process by submitting nomineesrom their organizations through a Call for Nominationseleased in the summer of 2006. From this list of nominees,he Task Force selected panel members to ensure anppropriate balance with respect to expertise in the specificodality, referring physicians, academic versus private prac-

ice, health services research, and specialty training.

evelopment of Indications

he process for creating a robust set of indications involvedonsulting current literature and previously published guide-

tAs defined by the ACC/AHA Guideline Update for Perioperative Cardiovascularvaluation of Non-Cardiac Surgery (20).


ines and clinical policy statements. The indications capturehe majority of scenarios faced by cardiologists or referringhysicians, but are not meant to be inclusive of all potentialndications for which a stress echocardiography imagingtudy may be performed. Review was done by the Taskorce, including additional comments from external review-rs. As a result of the meeting of the Technical Panel prioro the second round of rating, a number of the indicationsere clarified and modified. A final set of indications

omprised the list of possible clinical scenarios that wereated for appropriateness by the panelists and compiled forhis report.

ating Process

he Technical Panel was instructed to follow the processutlined in the document, “ACCF Proposed Method forvaluating the Appropriateness of Cardiovascular Imaging”

3). The appropriateness method combines expert clinicaludgment with the scientific literature in evaluating theenefits and risks of medical procedures. Each panel mem-er has equal weight in producing the final result for the setf indications they are asked to rate and the method doesot force consensus.The rating process includes a modified Delphi process

nvolving 2 rounds of ratings and an intervening face-to-ace meeting. At the face-to-face meeting, each panelisteceived a personalized rating form that indicated his or herating for each indication and the distribution of de-dentified ratings of other members of the panel. In addi-ion, the moderator received a summary rating form withimilar information (including panelist identification), alongith other statistics that measured the level of agreement

mong panel members. A measure of the level of disagree-ent was applied to each score after both the first and

econd round scoring was completed. This project employedhe BIOMED Concerted Action on Appropriateness def-nition for a panel size of 14 to 16. As defined in theAND/UCLA manual (4) upon which the ACCF ratingsethod is based, the BIOMED rule for agreement (�) is

hat no more than 4 panelists rate the indication outside the-point region containing the median; for disagreement�), at least 5 panelists rate in each extreme rating regioni.e., 1 to 3 and 7 to 9). Measures of agreement and theispersion of ratings (mean absolute deviation from theedian) may highlight areas where definitions are not clear

r ratings are inconsistent, where panelist perceptions of theaverage” patient may differ, or where various specialtyroups or individual panelists may have differences oflinical opinion. In cases of obvious disagreement or outliercores, the indication was highlighted in a summary tablend identification of the outlier raters brought to thettention of the moderator. This information was used by
he moderator to guide the panel’s discussion.


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elationships With Industry

he ACCF and its partnering organizations rigorouslyvoid any actual, perceived, or potential conflicts of interesthat may arise as a result of an outside relationship orersonal interest of a member of the Technical Panel.pecifically, all panelists are asked to provide disclosuretatements of all relationships that may be perceived as realr potential conflicts of interest. These statements wereeviewed by the ACCF Appropriateness Criteria Taskorce, discussed with all members of the Technical Panel at

he face-to-face meeting, and updated and reviewed asecessary. A table of disclosures of the Technical Panel andask Force Members can be found in the Appendix D.

iterature Review

he Technical Panel members were asked to refer to theelevant guidelines for a summary of the relevant literature,uideline recommendation tables, and reference lists pro-ided for each indication table when completing theiratings (Online Appendix at http://content.onlinejacc.org).astly, they were provided Web links to the previouslyublished materials pertaining to the appropriateness crite-ia work (1–3).

ppendix C: ACCF Appropriateness Criteriaask Force and Technical Panels

tress Echocardiography Writing Group

amela S. Douglas, MD, MACC, FAHA, FASE–LeadAuthor, Appropriateness Criteria for Stress Echocar-diography–Past President, ACC; Past President, ASE;Ursula Geller Professor of Research in CardiovascularDiseases, Duke University Medical Center, Durham,NC

ijoy Khandheria, MD, FASE, FACC–Professor of Med-icine and Chair, Division of Cardiovascular Disease,Mayo Clinic, Scottsdale, AZ

aymond F. Stainback, MD, FACC, FASE–AssistantProfessor of Medicine (Clinical), Baylor College ofMedicine; Medical Director, Noninvasive Cardiac Im-aging and Adult Echocardiography Laboratories, St.Luke’s Episcopal Hospital, Texas Heart Institute; Part-ner, Hall-Garcia Cardiology Associates, Houston, TX

eil J. Weissman, MD, FACC, FASE–Professor of Med-icine, Georgetown University Medical Center, Wash-ington, DC; Director of Cardiac Ultrasound, Cardio-vascular Research Institute, Washington HospitalCenter, Washington, DC

tress Echocardiography Technical Panel

ric D. Peterson, MD, MPH, FACC, FAHA–Moderatorof the Technical Panel–Professor of Medicine andDirector, Cardiovascular Research, Duke Clinical Re-search Institute, Duke University Medical Center,
Durham, NC

obert C. Hendel, MD, FACC, FAHA–MethodologyLiaison for the Technical Panel–Midwest Heart Spe-cialists, Fox River Grove, IL

aymond F. Stainback, MD, FACC, FASE–WritingGroup Liaison for the Technical Panel–Assistant Pro-fessor of Medicine (Clinical), Baylor College of Medi-cine; Medical Director, Noninvasive Cardiac Imagingand Adult Echocardiography Laboratories, St. Luke’sEpiscopal Hospital, Texas Heart Institute; Partner,Hall-Garcia Cardiology Associates, Houston, TX

ichael Blaivas, MD, RDMS, FACEP–Associate Profes-sor of Emergency Medicine; Chief, Emergency Ultra-sound; and Director, Emergency Ultrasound FellowshipProgram, Medical College of Georgia, Augusta, GA

oger D. Des Prez, MD, FACC–Oklahoma Heart Insti-tute, Tulsa, OK

inda D. Gillam, MD, FACC, FAHA, FASE–AssistantProfessor of Medicine and Medical Director, CardiacValve Program, Columbia University, New York, NY

erry Golash, MD–Medical Director, Aetna Health, Inc.,New York, NY

oren F. Hiratzka, MD, FACC, FAHA, FACS–MedicalDirector, Cardiac Surgery, TriHealth, Inc. (BethesdaNorth and Good Samaritan Hospitals), Cincinnati, OH

illiam G. Kussmaul, MD, FACC–Associate Professor ofMedicine, Drexel University College of Medicine; Car-diology Consultants of Philadelphia, Philadelphia, PA

rthur J. Labovitz, MD, FACC, FAHA, FASE, FCCP–Professor of Internal Medicine, Director, Division ofCardiology, Director, Fellowship Program, and Direc-tor, Echocardiography Lab, Saint Louis UniversitySchool of Medicine, St. Louis, MO

oAnn Lindenfeld, MD, FACC–Professor of Medicine andDirector, Heart Transplantation Program, University ofColorado at Denver and Health Sciences Center, Den-ver, CO

rederick A. Masoudi, MD, MSPH, FACC–AssociateProfessor of Medicine, Denver Health Medical Centerand University of Colorado at Denver and HealthSciences Center, Denver, CO

aul H. Mayo, MD, FCCP–Professor of Clinical Medi-cine, Albert Einstein College of Medicine, Bronx, NY;Director, MICU, Beth Israel Medical Center, NewYork, NY

odd D. Miller, MD, FACC, FAHA–Professor of Med-icine and Co-Director, Nuclear Cardiology Laboratory,Mayo Clinic, Rochester, MN

avid Porembka, DO, FCCM–Professor of Anesthesiol-ogy, Surgery, and Internal Medicine, Adjunct Professorof United States Air Force Aerospace Medicine, Cin-cinnati, OH

ohn A. Spertus, MD, MPH, FACC–Professor, Universityof Missouri–Kansas City School of Medicine, Directorof Cardiovascular Education and Outcomes Research,Mid America Heart Institute of St. Luke’s Hospital,
Kansas City, MO



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. Samuel Wann, MD, MACC–Chairman, Department ofCardiovascular Medicine, Wisconsin Heart Hospital,Wauwatosa, WI

usan E. Wiegers, MD, FACC, FASE–Associate Professorof Medicine, Director, Clinical Echocardiography andCo-Director, Cardiovascular Fellowship, University ofPennsylvania School of Medicine, Philadelphia, PA

CCF Appropriateness Criteria Task Force

alph G. Brindis, MD, MPH, FACC–Chair, Task Force–Regional Senior Advisor for Cardiovascular Disease,Northern California Kaiser Permanente; Clinical Pro-fessor of Medicine, University of California at SanFrancisco; Chief Medical Officer and Chairman,NCDR Management Board, American College of Car-diology, Washington, DC

amela S. Douglas, MD, MACC, FAHA, FASE–Past
President, ACC; Past President, ASE; Ursula Geller

Professor of Research in Cardiovascular Diseases, DukeUniversity Medical Center, Durham, NC

obert C. Hendel, MD, FACC, FAHA–Midwest HeartSpecialists, Fox River Grove, IL

anesh R. Patel, MD–Assistant Professor of Medicine,Division of Cardiology, Duke University Medical Cen-ter, Durham, NC

ric D. Peterson, MD, MPH, FACC, FAHA–Professor ofMedicine and Director, Cardiovascular Research, DukeClinical Research Institute, Duke University MedicalCenter, Durham, NC

ichael J. Wolk, MD, MACC–Past President, ACC;Clinical Professor of Medicine, Weill-Cornell MedicalSchool, New York, NY

oseph M. Allen, MA–Director, TRIP (Translating Re-search Into Practice), American College of Cardiology,
Washington, DC
PPENDIX D. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR STRESS ECHOCARDIOGRAPHYPPROPRIATENESS CRITERIA WRITING GROUP, TECHNICAL PANEL, TASK FORCE, AND INDICATIONEVIEWERS—RELATIONSHIPS WITH INDUSTRY (IN ALPHABETICAL ORDER)

Committee Member Research Grant

Speakers Bureau/Honoraries/

Expert Witness Stock Ownership Board of Directors

Consultant/Scientific Advisory Board/

Steering Committee

Stress Echocardiography Appropriateness Criteria Writing Group

r. Pamela S. Douglas None None None None ● GE Healthcare

r. Bijoy Khandheria None None None None None

r. Raymond F.Stainback

None None None None None

r. Neil J. Weissman ● Arena Pharmaceuticals● Bristol-Myers Squibb Imaging● Acusphere● Medtronic● Carbamedics● Edwards● St. Jude Medical

None None None ● Pfizer● Wyeth Pharmaceuticals

Stress Echocardiography Appropriateness Criteria Technical Panel

r. Michael Blaivas None None None None None

r. Roger D. Des Prez None None None None None

r. Linda D. Gillam ● Acusphere● Bristol-Myers Squibb

● Bristol-Myers Squibb None None None

r. Terry Golash None None ● Aetna None None

r. Robert C. Hendel ● Astellas Healthcare● GE Healthcare● Cornatus Genetics

● Bristol-Myers Squibb None None ● GE Healthcare

r. Loren F. Hiratzka None None None None None

r. William G.Kussmaul


r. Arthur J. Labovitz ● Boehringer Ingelheim● Encysive

● Baxter Healthcare None None None



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Steering Committee

r. JoAnn Lindenfeld ● Wyeth Pharmaceuticals● NovoCardia● Zealand● SomoLogic

None None None None

r. Frederick A.Masoudi

None ● Takeda, NorthAmerica

None None ● Takeda, North America● Amgen● United Healthcare

r. Paul H. Mayo None None None None None

r. Todd D. Miller ● Bristol-Myers Squibb● Radiant Medical● TherOx● TargeGen● KAI Pharmaceuticals● King Pharmaceuticals

None None None None

r. Eric D. Peterson ● Millennium Pharmaceuticals● Schering-Plough● Bristol-Myers Squibb/Sanofi

None None None None

r. David Porembka None None None None None

r. John A. Spertus ● Amgen None ● Amgen● OutcomesInstruments

● HealthOutcomesSciences

None ● Amgen● United Healthcare

r. Raymond F.Stainback


r. L. Samuel Wann None None None None None

r. Susan E. Wiegers None None None None None

Stress Echocardiography Appropriateness Criteria Task Force

r. Joseph M. Allen None None None None None

r. Ralph G. Brindis None None None None None

r. Pamela S. Douglas None None None None ● GE Healthcare

r. Robert C. Hendel ● Astellas Healthcare● GE Healthcare● Cornatus Genetics

● Bristol-Myers Squibb ● GE Healthcare

r. Manesh R. Patel None None None None ● Genzyme● Amgen

r. Eric D. Peterson ● Millennium Pharmaceuticals● Schering-Plough● Bristol-Myers Squibb/Sanofi

None None None None

r. Michael J. Wolk None None None None None

Stress Echocardiography Appropriateness Criteria Indication Reviewers

r. William Armstrong None None None None ● Point Biomedical● St. Jude Medical

r. Christopher M.Kramer

● Siemens Medical Solutions● Novartis Healthcare● Astellas Healthcare● Merck

● GE Healthcare None None None



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Steering Committee

r. Robert McNamara None None None None None

r. Catherine M. Otto None None None None None

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merican College of Cardiology Foundationohn C. Lewin, MD, Chief Executive Officeroseph M. Allen, MA, Director, TRIP (Translating Re-earch Into Practice)aren Cowdery Caruth, MBA, Senior Specialist, Appro-riateness Criteriarin A. Barrett, Senior Specialist, Clinical Policy anduidelines

EFERENCES

1. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropri-ateness criteria for single-photon emission computed tomographymyocardial perfusion imaging (SPECT MPI): a report of the Amer-ican College of Cardiology Foundation Strategic Direction Commit-tee Appropriateness Criteria Working Group and the AmericanSociety of Nuclear Cardiology. J Am Coll Cardiol 2005;46:1587–605.

2. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria forcardiac computed tomography and cardiac magnetic resonance imag-ing. J Am Coll Cardiol 2006;48:1475–97.

3. Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method forevaluating the appropriateness of cardiovascular imaging. J Am CollCardiol 2005;46:1606–13.

4. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLAAppropriateness Method User’s Manual. Arlington, VA: RAND,2001.

5. Bierig SM, Ehler D, Knoll ML, Waggoner AD. American Society ofEchocardiography minimum standards for the cardiac sonographer: aposition paper. J Am Soc Echocardiogr 2006;19:471–4.

6. Intersocietal Commission for the Accreditation of EchocardiographyLaboratories. Standards for organizations and for testing. Available at:http://www.intersocietal.org/icael/apply/standards.htm. AccessedMay 1, 2007.

7. Beller GA, Bonow RO, Fuster V. ACC revised recommendations fortraining in adult cardiovascular medicine. Core Cardiology TrainingII. (COCATS 2). (Revision of the 1995 COCATS training state-ment). J Am Coll Cardiol 2002;39:1242–6.

8. Quiñones GA, Douglas PS, Foster E, et al. ACC/AHA clinicalcompetence statement on echocardiography: a report of the AmericanCollege of Cardiology/American Heart Association/American Collegeof Physicians–American Society of Internal Medicine Task Force onClinical Competence. Developed in collaboration with the AmericanSociety of Echocardiography, the Society of Cardiovascular Anesthe-siologists, and the Society of Pediatric Echocardiography. J Am CollCardiol 2003;41:687–708.

9. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guidelineupdate for exercise testing: summary article: a report of the American

Ki


College of Cardiology/American Heart Association Task Force onPractice Guidelines (Committee to Update the 1997 Exercise TestingGuidelines). J Am Coll Cardiol 2002;40:1531–40.

0. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007guidelines on perioperative cardiovascular evaluation and care fornoncardiac surgery. J Am Coll Cardiol 2007;50:e159–241.

1. Douglas P, Iskandrian AE, Krumholz HM, et al. Achieving quality incardiovascular imaging: proceedings from the American College ofCardiology-Duke University Medical Center Think Tank on Qualityin Cardiovascular Imaging. J Am Coll Cardiol 2006;48:2141–51.

2. Douglas PS, Khandheria B, Stainback RF, Weissman NJ. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness cri-teria for transthoracic and transesophageal echocardiography. J AmColl Cardiol 2007;50:187–204.

3. Diamond GA. A clinically relevant classification of chest discomfort.J Am Coll Cardiol 1983;1:574–5.

4. Morise AP, Haddad WJ, Beckner D. Development and validation ofa clinical score to estimate the probability of coronary artery disease inmen and women presenting with suspected coronary disease. Am JMed 1997;102:350–6.

5. Pryor DB, Shaw L, McCants CB, et al. Value of the history andphysical in identifying patients at increased risk for coronary arterydisease. Ann Intern Med 1993;118:81–90.

6. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guidelineupdate for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(Writing Committee on the Management of Patients With ChronicStable Angina). J Am Coll Cardiol 2003;41:159–68.

7. Diamond GA, Forrester JS. Analysis of probability as an aid in theclinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–8.

8. Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalenceof high-risk coronary artery disease in patient subsets (CASS). Circu-lation 1981;64:360–7.

9. Grundy SM, Pasternak R, Greenland P, et al. AHA/ACC scientificstatement: assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: a statement for healthcare professionals fromthe American Heart Association and the American College of Cardiol-ogy. J Am Coll Cardiol 1999;34:1348–59.

0. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline updatefor perioperative cardiovascular evaluation for noncardiac surgery—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(Committee to Update the 1996 Guidelines on Perioperative Cardio-vascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol2002;39:542–53.

1. Murabito JM, D’Agostino RB, Silbershatz H, Wilson PWF. A riskprofile from the Framingham Heart Study. Circulation 1997;96:44–9.

ey Words: stress echocardiography y appropriateness criteria y cardiacmaging y coronary artery disease y diagnostic testing.


http://www.intersocietal.org/icael/apply/standards.htm


doi:10.1016/j.jacc.2007.12.005 published online Mar 3, 2008; J. Am. Coll. Cardiol.

Peterson, Michael J. Wolk, and Joseph M. Allen Ralph G. Brindis, Pamela S. Douglas, Robert C. Hendel, Manesh R. Patel, Eric D.

Mayo, David Porembka, John A. Spertus, L. Samuel Wann, Susan E. Wiegers,Kussmaul, Arthur J. Labovitz, JoAnn Lindenfeld, Frederick A. Masoudi, Paul H.

D. Des Prez, Linda D. Gillam, Terry Golash, Loren F. Hiratzka, William G.Eric D. Peterson, Robert C. Hendel, Raymond F. Stainback, Michael Blaivas, Roger

Pamela S. Douglas, Bijoy Khandheria, Raymond F. Stainback, Neil J. Weissman, Medicine

Endorsed by the Heart Rhythm Society and the Society of Critical CareComputed Tomography, and Society for Cardiovascular Magnetic Resonance for Cardiovascular Angiography and Interventions, Society of Cardiovascular American Heart Association, American Society of Nuclear Cardiology, Society

Society of Echocardiography, American College of Emergency Physicians, Cardiology Foundation Appropriateness Criteria Task Force, American

Criteria for Stress Echocardiography: A Report of the American College of ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness

This information is current as of March 3, 2008

& ServicesUpdated Information

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appropriateness criteria for stress echocardiography … for stress echo.pdferic d. peterson, md,...

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