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Tables
- TABLE 1
Clinical Scenarios for the Use of Stress–Rest Perfusion PET to Assess the Presence of Flow-Limiting Obstructive CAD as a Potential Substrate for Chest Pain (or Equivalent) Symptoms, or for Risk Stratification and Prognostic Value, in Symptomatic Patients with Suspected or Known CAD
Scenario no. Description Appropriateness Score Symptomatic patients with low pretest probability of CAD: interpretable ECG AND able to exercise 1 Symptomatic patients with a low pretest probability for CAD, who have an interpretable ECG and are able to undergo adequate exercise stress Rarely Appropriate 2 Symptomatic patients with low pretest probability of CAD: uninterpretable ECG OR unable to exercise 2 Symptomatic patients with a low pretest probability of CAD, who have an uninterpretable ECG or are unable to exercise Rarely Appropriate 3 3 Symptomatic patients with a low pretest probability for CAD, who have an uninterpretable ECG Rarely Appropriate 3 4 Symptomatic patients with a low pretest probability for CAD, who are unable to undergo adequate exercise stress Rarely Appropriate 3 Symptomatic patients with intermediate pretest probability of CAD: interpretable ECG AND able to exercise 5 Symptomatic patients with an intermediate pretest probability for CAD, who have an interpretable ECG and are able to undergo adequate exercise stress Appropriate 7 Symptomatic patients with intermediate pretest probability of CAD: uninterpretable ECG OR unable to exercise 6 Symptomatic patients with an intermediate pretest probability for CAD, who have an uninterpretable ECG Appropriate 9 7 Symptomatic patients with an intermediate pretest probability for CAD, who are unable to undergo adequate exercise stress Appropriate 9 Symptomatic patients with high pretest probability of CAD: interpretable ECG AND able to exercise 8 Symptomatic patients with a high pretest probability for CAD, who have an interpretable ECG and are able to undergo adequate exercise stress Appropriate 8 Symptomatic patients with high pretest probability of CAD: uninterpretable ECG OR unable to exercise 9 Symptomatic patients with a high pretest probability for CAD, who have an uninterpretable ECG Appropriate 9 10 Symptomatic patients with a high pretest probability for CAD, who are unable to undergo adequate exercise stress Appropriate 9 Patients who present to the ED (or inpatients) with ACS features 11 Patients who present to the ED (or inpatients) with symptoms suspicious for CAD with or without known CAD, who have features consistent with non-STEMI or ACS (increase in Tn levels or dynamic ECG changes) Rarely Appropriate 1 12 Patients who present to the ED (or inpatients) with symptoms suspicious for CAD with or without known CAD, who have features consistent with unstable angina or ACS (but no increase in Tn levels and no dynamic ECG changes) Appropriate 7 Patients who present to the ED (or inpatients) with chest pain or equivalent symptoms with or without known CAD, who have equivocal Tn levels or a temporal Tn pattern not consistent with ACS 13 Patients who present to the ED (or inpatients) with chest pain or equivalent symptoms with or without known CAD, who have equivocal Tn levels or a temporal Tn pattern not consistent with ACS Appropriate 8 Patients who present to the ED (or inpatients) with symptoms of chest pain that may be due to ACS, normal Tn levels, and no dynamic ECG changes 14 Patients who present to the ED (or inpatients) with symptoms of chest pain that may be due to ACS, with normal Tn levels and no dynamic ECG changes Appropriate 8 Patients who present to ED (or inpatients) with symptoms of chest pain that are unlikely to be due to ACS, normal Tn levels, and no dynamic ECG changes 15 Patients who present to the ED (or inpatients) with symptoms of chest pain that are unlikely to be due to ACS, with normal Tn levels and no dynamic ECG changes Appropriate 7 - TABLE 2
Clinical Scenarios for the Use of PET MPI in Asymptomatic Patients (Without Symptoms or Ischemic Equivalent)
Scenario no. Description Appropriateness Score Asymptomatic patients by pretest CAD risk 16 Asymptomatic patients with a low pretest global CAD risk (<7.5%) Rarely Appropriate 1 17 Asymptomatic patients with an intermediate pretest global CAD risk (7.5%–20%), who have an interpretable resting ECG and are able to exercise Rarely Appropriate 2 18 Asymptomatic patients with an intermediate pretest global CAD risk (7.5%–20%), who have an uninterpretable resting ECG or are unable to exercise May be Appropriate 5 19 Asymptomatic patients with a high pretest probability of CAD (>20%) May be Appropriate 5 20 Asymptomatic patient with an intermediate pretest CAD risk (7.5%–20%), who have a calcium score of 400–1,000 May be Appropriate 6 21 Asymptomatic patients with a high pretest CAD risk (>20%), who have a calcium score of 400–1,000 Appropriate 8 22 Asymptomatic patients who have a calcium score of >1,000 Appropriate 8 23 Asymptomatic patients with peripheral vascular disease May be Appropriate 5 24 Asymptomatic patients with a family history of premature CAD Rarely Appropriate 3 25 Asymptomatic patients with familial hyperlipidemia May be Appropriate 5 Asymptomatic patients with equivocal or abnormal prior test results 26 Asymptomatic patients with equivocal or abnormal prior test results from CCTA or ICA Appropriate 8 27 Asymptomatic patients with recent (<90 d) equivocal or abnormal prior test results from stress testing (imaging or nonimaging) May be Appropriate 6 28 Asymptomatic patients with regional or global LV systolic dysfunction Appropriate 8 29 Asymptomatic patients with new LBBB Appropriate 8 30 Asymptomatic patients with AF May be Appropriate 5 31 Asymptomatic patients with abnormal resting ECG results that show abnormal or pathologic Q waves May be Appropriate 6 32 Asymptomatic patients with abnormal resting ECG results that show ST-T segment abnormalities May be Appropriate 5 33 Asymptomatic patients with known stable CAD without prior revascularization May be Appropriate 6 Asymptomatic patients with a history of revascularization (PCI or CABG) 34 Asymptomatic patients with a history of PCI of <2 y Rarely Appropriate 2 35 Asymptomatic patients with a history of PCI of >2 y May be Appropriate 6 36 Asymptomatic patients with a prior CABG of <5 y Rarely Appropriate 2 37 Asymptomatic patients with a prior CABG of >5 y May be Appropriate 6 Asymptomatic patients with prior heart transplantation 38 Evaluation for CAV in asymptomatic patients with prior heart transplantation Appropriate 8 Asymptomatic patients being considered for solid organ transplantation (kidney, lung, liver) 39 Evaluation for CAD in patients being considered for solid organ transplantation (e.g., kidney, lung, liver) Appropriate 8 Asymptomatic patients undergoing cancer treatment 40 Asymptomatic patients during or after chemotherapy or radiation therapy for cancer who have a reduced LVEF May be Appropriate 5 41 Asymptomatic patients during or after chemotherapy or radiation therapy for cancer Rarely Appropriate 1 Asymptomatic patients with a history of coronary vasculitis or high-risk coronary anomalies 42 Asymptomatic patients with a history of coronary vasculitis and evidence of structurally abnormal coronary arteries (e.g., aneurysms) Appropriate 7 43 Asymptomatic patients with a history of high-risk coronary anomalies May be Appropriate 5 - TABLE 3
Clinical Scenarios for the Use of Rest or Stress Perfusion PET in Patients with Diagnosed Heart Failure (Resting LV Function Previously Assessed but No Prior CAD Evaluation)
Scenario no. Description Appropriateness Score Patients with diagnosed heart failure with reduced ejection fraction 44 Patients with diagnosed heart failure with reduced ejection fraction, no established history of CAD, and a low clinical risk of CAD Appropriate 7 45 Patients with diagnosed heart failure with reduced ejection fraction, no established history of CAD, and an intermediate clinical risk of CAD Appropriate 9 46 Patients with diagnosed heart failure with reduced ejection fraction, no established history of CAD, and a high clinical risk of CAD Appropriate 8 Patients with diagnosed HFpEF 47 Patients with diagnosed HFpEF, no established history of CAD, and a low clinical risk of CAD May be Appropriate 5 48 Patients with diagnosed HFpEF, no established history of CAD, and an intermediate clinical risk of CAD Appropriate 9 49 Patients with diagnosed HFpEF, no established history of CAD, and a high clinical risk of CAD Appropriate 9 Patients with diagnosed heart failure undergoing assessment of viability and hibernation 50 Patients with diagnosed heart failure who are undergoing assessment of viability and hibernation with 18F-FDG PET: rest perfusion PET Appropriate 9 51 Patients with diagnosed heart failure who are undergoing assessment of viability and hibernation: rest and stress perfusion PET Appropriate 9 - TABLE 4
Clinical Scenarios for the Use of Rest or Stress Perfusion PET in the Evaluation of Patients with Known or Suspected Cardiac Sarcoidosis
Scenario no. Description Appropriateness Score 52 Patients undergoing assessment of myocardial inflammation with 18F-FDG PET: rest perfusion PET Appropriate 9 53 Evaluation of patients with suspected cardiac sarcoidosis who have not been previously evaluated for CAD in whom myocardial inflammation imaging with 18F-FDG PET is planned: stress and rest perfusion PET May be Appropriate 5 54 Evaluation of patients with suspected cardiac sarcoidosis who have been previously evaluated for CAD in whom myocardial inflammation imaging with 18F-FDG PET is planned: stress and rest perfusion PET Rarely Appropriate 1 55 Patients undergoing reevaluation for response to therapy or recurrent inflammation with 18F-FDG PET: rest perfusion PET Appropriate 9 - TABLE 5
Clinical Scenarios for the Use of Stress Perfusion PET in the Evaluation of Arrhythmias Without Ischemic Equivalent (No Prior Cardiac Evaluation)
Scenario no. Description Appropriateness Score Clinically stable patients with sustained VT 56 Clinically stable patients with an episode of sustained VT who have a low global clinical risk of CAD May be Appropriate 6 57 Clinically stable patients with an episode of sustained VT who have an intermediate clinical risk of CAD Appropriate 9 58 Clinically stable patients with an episode of sustained VT who have a high clinical risk of CAD Appropriate 8 59 Clinically unstable patients with an episode of sustained VT Rarely Appropriate 1 Patients with a recent episode of VF 60 Clinically stable patients with a recent episode of VF who have a low clinical risk of CAD Rarely Appropriate 1 61 Clinically unstable patients with a recent episode of VF Rarely Appropriate 1 Patients with exercise-induced VT or nonsustained VT 62 Patients with nonsustained VT who have a low clinical risk of CAD May be Appropriate 4 63 Patients with exercise-induced VT who have a low clinical risk of CAD May be Appropriate 5 64 Patients with nonsustained VT who have an intermediate clinical risk of CAD Appropriate 7 65 Patients with exercise-induced VT who have an intermediate clinical risk of CAD Appropriate 8 66 Patients with nonsustained VT who have a high clinical risk of CAD Appropriate 8 67 Patients with exercise-induced VT who have a high clinical risk of CAD May be Appropriate 4 Patients with frequent PVCs 68 Patients with frequent PVCs who have a low clinical risk of CAD Appropriate 7 69 Patients with frequent PVCs who have an intermediate clinical risk of CAD Appropriate 8 70 Patients with frequent PVCs who have a high clinical risk of CAD Rarely Appropriate 2 Patients with infrequent PVCs 71 Patients with infrequent PVCs who have a low clinical risk of CAD Rarely Appropriate 1 72 Patients with infrequent PVCs who have an intermediate clinical risk of CAD May be Appropriate 5 73 Patients with infrequent PVCs who have a high clinical risk of CAD May be Appropriate 5 Patients with new-onset AF 74 Patients with new-onset AF who have a low global clinical risk of CAD Rarely Appropriate 2 75 Patients with new-onset AF who have an intermediate global clinical risk of CAD May be Appropriate 5 76 Patients with new-onset AF who have a high global clinical risk of CAD May be Appropriate 6 Evaluation of patients before the initiation of antiarrhythmic medications 77 Patients with a low global CAD risk before initiation of antiarrhythmic medications May be Appropriate 5 78 Patients with an intermediate global CAD risk before initiation of antiarrhythmic medications May be Appropriate 6 79 Patients with a high global CAD risk before initiation of antiarrhythmic medications Appropriate 7 - TABLE 6
Clinical Scenarios for the Use of Stress Perfusion PET in Patients With Syncope Without an Ischemic Equivalent
Scenario no. Description Appropriateness Score 80 Patients with syncope and a low global clinical risk of CAD Rarely Appropriate 2 81 Patients with syncope and an intermediate global clinical risk of CAD May be Appropriate 5 82 Patients with syncope and a high global clinical risk of CAD Appropriate 7 - TABLE 7
Clinical Scenarios for the Use of PET MPI in the Assessment of CMD in Symptomatic Patients
Scenario no. Description Appropriateness Score Symptomatic patients with known obstructive or nonobstructive HCM 83 Symptomatic patients with positive results of an exercise ECG stress test Appropriate 8 84 Symptomatic patients with negative results of an exercise ECG stress test Appropriate 8 85 Symptomatic patients with positive or negative results of an exercise ECG stress test and exclusion of obstructive CAD by angiography Appropriate 8 86 Symptomatic patients with positive or negative results of an exercise ECG stress test and normal SPECT perfusion findings Appropriate 7 87 Asymptomatic patients with positive or negative results of an exercise ECG stress test Rarely Appropriate 3 Symptomatic patients with known LV hypertrophy related to arterial hypertension, diabetes mellitus, or obesity Symptomatic patients with arterial hypertension 88 Symptomatic patients with positive results of an exercise ECG stress test Appropriate 9 89 Symptomatic patients with negative results of an exercise ECG stress test Appropriate 9 90 Symptomatic patients with positive or negative results of an exercise ECG stress test and without evidence of CAD by angiography Appropriate 9 91 Asymptomatic patients with positive results of an exercise ECG stress test May be Appropriate 4 92 Asymptomatic patients with negative results of an exercise ECG stress test Rarely Appropriate 1 93 Symptomatic patients with positive or negative results of an exercise ECG stress test and exclusion of coronary atherosclerosis by angiography Rarely Appropriate 2 94 Symptomatic patients with positive or negative results of an exercise ECG stress test who have atherosclerosis and nonobstructive CAD as shown by angiography Appropriate 8 Symptomatic patients with diabetes mellitus 95 Symptomatic patients with positive results of an exercise ECG stress test Appropriate 8 96 Symptomatic patients with negative results of an exercise ECG stress test Appropriate 8 97 Symptomatic patients with positive or negative results of an exercise ECG stress test who have atherosclerosis and nonobstructive CAD as shown by angiography Appropriate 8 98 Symptomatic patients with positive or negative results of an exercise ECG stress test and normal SPECT perfusion findings Appropriate 8 99 Asymptomatic patients with positive results of an exercise ECG stress test Appropriate 7 100 Asymptomatic patients with negative results of an exercise ECG stress test Rarely Appropriate 1 Symptomatic patients with obesity 101 Symptomatic patients with positive results of an exercise ECG stress test Appropriate 9 102 Symptomatic patients with negative results of an exercise ECG stress test Appropriate 9 103 Symptomatic patients with positive or negative results of an exercise ECG stress test who have atherosclerosis and nonobstructive CAD as shown by angiography Appropriate 8 104 Symptomatic patients with positive or negative results of an exercise ECG stress test who do not have atherosclerotic CAD as shown by angiography Rarely Appropriate 2 105 Symptomatic patients with positive or negative exercise ECG stress test and normal SPECT perfusion findings Appropriate 8 106 Asymptomatic patients with positive results of an exercise ECG stress test May be Appropriate 5 107 Asymptomatic patients with negative results of an exercise ECG stress test Rarely Appropriate 1 Symptomatic postmenopausal women 108 Symptomatic postmenopausal women with positive results of an exercise ECG stress test Appropriate 9 109 Symptomatic postmenopausal women with negative results of an exercise ECG stress test Appropriate 9 110 Symptomatic postmenopausal women with positive or negative results of an exercise ECG stress test and exclusion of coronary atherosclerosis by angiography Rarely Appropriate 1 111 Symptomatic postmenopausal women with positive or negative results of an exercise ECG stress test who have atherosclerosis and nonobstructive CAD as shown by angiography Appropriate 9 112 Symptomatic postmenopausal women with positive or negative results of an exercise ECG stress test and normal SPECT perfusion findings Appropriate 9 113 Asymptomatic postmenopausal women with positive results of an exercise ECG stress test May be Appropriate 5 114 Asymptomatic postmenopausal women with negative results of an exercise ECG stress test Rarely Appropriate 1 Symptomatic patients with syndrome X: no obstructive CAD but ongoing chest pain syndrome 115 Patients with ongoing chest pain syndrome and positive results of an exercise ECG stress test who have nonobstructive CAD as shown by coronary angiography Appropriate 9 116 Patients with ongoing chest pain syndrome and negative results of an exercise ECG stress test who have no evidence of obstructive CAD as shown by coronary angiography Appropriate 8 117 Patients with ongoing chest pain syndrome, positive results of an exercise ECG stress test, and normal SPECT perfusion findings Appropriate 9 118 Patients with ongoing chest pain syndrome, negative results of an exercise ECG stress test, and normal SPECT perfusion findings Appropriate 8 Scenario no. Description Appropriateness Score Patients with advanced obesity or with large breasts or dense breast tissue Patients with advanced obesity (BMI > 35m2/kg) 119 Symptomatic patients with advanced obesity (BMI > 35 m2/kg) Appropriate 9 120 Symptomatic patients with advanced obesity (BMI > 35 m2/kg) who have atherosclerosis or nonobstructive CAD as shown by coronary angiography (invasive or noninvasive) Appropriate 8 121 Symptomatic patients with advanced obesity (BMI > 35 m2/kg) and normal results of coronary angiography (invasive or noninvasive) Appropriate 7 122 Symptomatic patients with advanced obesity (BMI > 35 m2/kg) and equivocal findings on stress–rest myocardial perfusion SPECT Appropriate 9 123 Asymptomatic patients with advanced obesity (BMI > 35 m2/kg) who are at high cardiovascular risk when undergoing noncardiac surgery Appropriate 7 124 Asymptomatic patients with advanced obesity (BMI > 35 m2/kg) who are at intermediate cardiovascular risk when undergoing noncardiac surgery May be Appropriate 5 125 Asymptomatic patients with advanced obesity (BMI > 35 m2/kg) who are at low cardiovascular risk when undergoing noncardiac surgery Rarely Appropriate 2 Women with large breasts or dense breast tissue that causes attenuation artifacts 126 Symptomatic women with large breasts or dense breast tissue Appropriate 8 127 Symptomatic women with large breasts or dense breast tissue who have atherosclerosis or nonobstructive CAD as shown by angiography (invasive or noninvasive) Appropriate 8 128 Symptomatic women with large breasts or dense breast tissue and normal results of coronary angiography (invasive or noninvasive) Appropriate 7 129 Symptomatic women with large breasts or dense breast tissue and normal results of stress–rest myocardial perfusion SPECT Appropriate 7 130 Symptomatic women with large breasts or dense breast tissue and equivocal findings on stress–rest myocardial perfusion SPECT Appropriate 9 131 Asymptomatic women with large breasts or dense breast tissue at high risk when undergoing noncardiac surgery Appropriate 7 132 Asymptomatic women with large breasts or dense breast tissue at intermediate risk when undergoing noncardiac surgery May be Appropriate 5 133 Asymptomatic women with large breasts or dense breast tissue at low risk when undergoing noncardiac surgery Rarely Appropriate 2 Symptomatic young women and young men Symptomatic young women (age < 45 y) 134 Symptomatic young women (age < 45 y) with positive or negative results of an exercise ECG stress test or negative results of stress imaging testing with SPECT or echocardiography, but persistent chest pain syndrome Appropriate 8 135 Symptomatic young women (age < 45 y) with positive or negative results of an exercise ECG stress test, who have atherosclerosis or nonobstructive CAD as shown by angiography, but persistent chest pain syndrome Appropriate 8 136 Symptomatic young women (age < 45 y) with positive or negative results of an exercise ECG stress test and normal results of coronary angiography, but persistent chest pain syndrome Appropriate 7 137 Symptomatic young women with positive or negative results of an exercise ECG stress test and normal SPECT perfusion findings, but persistent chest pain syndrome Appropriate 7 Symptomatic young men (age < 40 y) 138 Symptomatic young men (age < 40 y) with negative results of stress–rest imaging testing with SPECT or echocardiography, but persistent chest pain syndrome Appropriate 8 139 Symptomatic young men (age < 40 y) with positive or negative results of an exercise ECG stress test, who have atherosclerosis, nonobstructive CAD, and persistent chest pain syndrome Appropriate 8 140 Symptomatic young men (age < 40 y) with positive or negative results of an exercise ECG stress test and normal results on a coronary angiogram, but persistent chest pain syndrome Appropriate 7 Children and adolescents with congenital heart disease 141 In children and adolescents with congenital heart disease that could compromise the blood flow supply to the heart, exercise echocardiography, because of the absence of any radiation exposure, should be given preference. If exercise echocardiography is not feasible, then exercise and rest perfusion SPECT is an option. If the patient cannot exercise or the congenital heart disease may compromise the blood flow supply independent of exercise stress, then stress-only or stress–rest perfusion PET is a viable option because of its low radiation exposure. Appropriate 8 Patients with familial hypercholesterolemia 142 Symptomatic individuals with familial hypercholesterolemia with negative stress–rest imaging findings, but persistent chest pain syndrome Appropriate 7 143 Symptomatic individuals with familial hypercholesterolemia with positive or negative results of an exercise ECG stress test, who have atherosclerosis and nonobstructive CAD, but persistent chest pain Appropriate 8 144 Symptomatic individuals with familial hypercholesterolemia with positive or negative results of an exercise ECG stress test and normal results on a coronary angiogram, but persistent chest pain Appropriate 7 145 Symptomatic individuals with familial hypercholesterolemia with positive or negative results of an exercise ECG stress test who have no coronary artery calcifications on noncontrast CCT Appropriate 7 146 Symptomatic individuals with familial hypercholesterolemia and positive or negative results of an exercise ECG stress test who have coronary artery calcifications on noncontrast CCT Appropriate 8 147 Asymptomatic individuals with familial hypercholesterolemia with positive or negative results of an exercise ECG stress test Rarely Appropriate 2 Symptomatic patients with CAD with known left main or multivessel disease 148 Symptomatic patients with known left main or multivessel disease as shown by ICA Appropriate 9 149 Symptomatic patients with CAD in the left main segment or in all 3 vessels as shown by noninvasive CTA Appropriate 9 150 Symptomatic patients with coronary artery calcifications in the left main segment or in all 3 vessels as shown by noncontrast CCT Appropriate 9 Asymptomatic patients with CAD with known left main or multivessel disease 151 Asymptomatic patients with known left main or multivessel disease as shown by coronary angiography May be Appropriate 6 152 Asymptomatic patients with pronounced coronary calcifications in the left main or in all 3 main vessels as shown by noncontrast CCT Appropriate 7 153 Asymptomatic patients with mild coronary calcifications in the left main or in all 3 main vessels as shown by noncontrast CCT Rarely Appropriate 3 Patients who have undergone CABG 154 Symptomatic patients after undergoing CABG: stress–rest perfusion PET if exercise SPECT cannot be performed Appropriate 8 155 Symptomatic patients after undergoing CABG: stress–rest perfusion PET if exercise SPECT is equivocal Appropriate 9 156 Asymptomatic patients within 5 y of undergoing CABG Rarely Appropriate 2 157 Asymptomatic patients ≥ 5 y after undergoing CABG May be Appropriate 6 Patients who have undergone PCI in multivessel disease 158 Symptomatic patients with known multivessel disease who have undergone PCI, in whom exercise SPECT cannot be performed Appropriate 8 159 Symptomatic patients with known multivessel disease who have undergone PCI and who have equivocal exercise SPECT results Appropriate 9 160 Asymptomatic patients within 2 y of undergoing PCI, in whom the diagnostic yield of stress–rest perfusion PET would be low or nonexistent Rarely Appropriate 2 161 Asymptomatic patients ≥ 2 y after undergoing PCI May be Appropriate 6 Use of rest or stress–rest perfusion in patients in conjunction with 18F-FDG PET to assess cardiac sarcoidosis 162 Patients with suspected cardiac sarcoidosis: rest perfusion PET as an integral part of the 18F-FDG PET protocol in the detection and characterization of cardiac sarcoidosis Appropriate 8 163 Patients with suspected cardiac sarcoidosis and concurrent chest pain symptoms or dyspnea, who are undergoing rest perfusion and the 18F-FDG PET protocol: addition of stress perfusion PET Appropriate 8 Use of rest or stress–rest perfusion in patients in conjunction with 18F-FDG PET to assess myocardial viability 164 Patients with assessment of myocardial viability in ischemic cardiomyopathy: rest or stress perfusion PET as an integral part of the 18F-FDG PET protocol in the detection and characterization of myocardial viability Appropriate 9 Symptomatic patients who are apparent nonresponders to pharmacologic vasodilation with a need to change to dobutamine stress testing 165 Symptomatic patients with an intermediate probability of CAD who are undergoing functional testing with myocardial perfusion SPECT or PET during pharmacologic stimulation and rest: repeat imaging test with PET but with dobutamine stimulation if there is no hemodynamic response (change in arterial blood pressure or no heart rate increase) during pharmacologic vasodilator stress Rarely Appropriate 3 Symptomatic patients with transplant vasculopathy 166 Symptomatic patients or patients with suspected cardiac graft rejection Appropriate 8 Symptomatic patients with vasculitis and arteritis (Kawasaki and Takayasu disease) 167 Symptomatic patients with suspected vasculitis and arteritis Appropriate 8 Scenario no. Description Appropriateness Score Abnormal results of a prior exercise ECG test 168 Abnormal results of a prior exercise ECG test < 90 d ago with no intervening revascularization and sequential testing Rarely Appropriate 1 169 Abnormal results of a prior exercise ECG test May be Appropriate 5 170 Abnormal results of a prior exercise ECG test with a low-risk DTS (>10) May be Appropriate 6 171 Abnormal results of a prior exercise ECG test with an intermediate-risk DTS (−10 to +4) Appropriate 8 172 Abnormal results of a prior exercise ECG test with a high-risk DTS (< −10) Appropriate 8 173 ETT achieving ≥10 METs with no ischemic ST depression May be Appropriate 4 Abnormal results of a prior stress imaging study 174 Abnormal results of a prior stress imaging study Rarely Appropriate 3 175 Equivocal or discordant results of a prior stress test with or without imaging Appropriate 8 176 CAD of uncertain clinical significance on prior CCTA or ICA Appropriate 8 177 Abnormal prior CCT calcium results (Agatston score < 100) in asymptomatic patients Rarely Appropriate 2 178 Abnormal prior CCT calcium results (Agatston score 100–400) in asymptomatic patients May be Appropriate 5 179 Abnormal prior CCT calcium results (Agatston score > 1,000) in asymptomatic patients Appropriate 8 Follow-up testing (>90 d): asymptomatic patients After abnormal results of a prior exercise ECG test 180 Last test < 2 y ago Rarely Appropriate 1 181 Last test ≥ 2 y ago Rarely Appropriate 1 After abnormal results of a prior stress imaging study (non-PET) 182 Last test < 2 y ago Rarely Appropriate 2 183 Last test ≥ 2 y ago Rarely Appropriate 1 Follow-up testing (>90 d): patients with stable symptoms After abnormal results of a cardiovascular imaging test 184 Last test < 2 y ago Rarely Appropriate 1 185 Last test ≥ 2 y ago May be Appropriate 4 After abnormal results of a prior stress imaging study (PET) 186 Abnormal results of prior PET MPI 3–6 mo ago Rarely Appropriate 1 187 Abnormal results of prior PET MPI > 6 mo ago Rarely Appropriate 2 After obstructive CAD as shown on prior coronary angiography (invasive or noninvasive) 188 Last test < 2 y ago May be Appropriate 6 189 Last test ≥ 2 y ago May be Appropriate 6 After normal results of a prior exercise ECG test 190 Low global CAD risk (<7.5%) Rarely Appropriate 1 191 Intermediate CAD risk (7.5%–20%) when tested < 2 y ago Rarely Appropriate 2 192 Intermediate CAD risk (7.5%–20%) when tested ≥ 2 y ago Rarely Appropriate 3 193 High global CAD risk (>20%) when tested < 2 y ago May be Appropriate 4 194 High global CAD risk (>20%) when tested ≥ 2 y ago May be Appropriate 5 - TABLE 10
Clinical Scenarios for the Use of PET MPI in Preoperative Evaluation for Noncardiac Surgery
Scenario no. Description Appropriateness Score Preoperative evaluation of patients for noncardiac surgery 195 Patients with moderate to good functional capacity (≥4 METs) or no clinical risk factors (history of ischemic heart disease, history of compensated or prior heart failure, history of cerebral vascular disease, diabetes mellitus, renal insufficiency) Rarely Appropriate 1 196 Asymptomatic patients < 1 y after normal functional stress testing results Rarely Appropriate 1 197 Asymptomatic patients < 2 y after normal coronary morphology results by either CT or invasive angiogram Rarely Appropriate 1 Patients with poor (<4 METs) or unknown functional capacity 198 Low-risk surgery and no clinical risk factors Rarely Appropriate 1 199 Low-risk surgery and ≥ 1 clinical risk factor Rarely Appropriate 2 200 Intermediate-risk surgery and no clinical risk factors May be Appropriate 4 201 Intermediate-risk surgery and ≥ 1 clinical risk factor May be Appropriate 5 202 Vascular surgery and no clinical risk factors Appropriate 7 203 Vascular surgery and ≥ 1 clinical risk factor Appropriate 8 204 Evaluation for CAD in patients being considered for kidney transplantation Appropriate 8 205 Evaluation for CAD in patients being considered for liver transplantation Appropriate 8 206 Evaluation for CAD in patients being considered for lung transplantation Appropriate 8 - TABLE 11
Clinical Scenarios for the Use of PET MPI to Determine Exercise Level Before Initiation of Exercise Prescription or Cardiac Rehabilitation
Scenario no. Description Appropriateness Score 207 Exercise prescription Rarely Appropriate 1 208 Determination of exercise level before initiation of exercise prescription Rarely Appropriate 1 209 Before the initiation of cardiac rehabilitation and able to exercise Rarely Appropriate 1 210 After revascularization (PCI or CABG) Rarely Appropriate 1 Workgroup member Reported relationships Thomas H. Schindler • Siemens, Validation of IQ – SPECT/CT for Cardiac Perfusion • GE Healthcare, Flupiridaz, PET Perfusion Study Timothy M. Bateman • License/Patent, ExSPECT • Imagen Pro/MD/3D/Q Rob Beanlands • Lantheus Medical Imaging, Consultant • Lantheus Medical Imaging, Research/Grants • Jubilant DRAX Image, Consultant • Jubilant DRAX Image, Research/Grants Daniel S. Berman • Bayer Pharmaceuticals, Grant, MRI • Cedars-Sinai Medical, Royalties, Software Panithaya Chareonthaitawee • None Lorraine De Blanche • None Marcelo Di Carli • Spectrum Dynamics, Clinical Trial, SPECT MPI Vasken Dilsizian • GE Healthcare, Research Grant, Cardiac Innervation Sharmila Dorbala • None Robert Gropler • Sanofi, Scientific Advisory Meeting, PET MPI • Biomedical Systems, Consultant, Read EKGs • Bayer, Research Grant, MR MPI Venkatesh Murthy • Ionetix, Scientific Advisor, Cyclotrons • Siemens, Research Grant, Cardiac SPECT • General Electric, Stock • Cardinal Health, Stock Terrence D. Ruddy • GE Healthcare, Clinical Trial Agreement, Myocardial Blood Flow • Advanced Accelerator Applications, Clinical Trial Agreement, Apoplosis Imaging Ronald G. Schwartz • Astellas, Speaker Leslee Shaw • None Prem Soman • Astellas, Grant funding • Alnylam, Advisory board Hein J. Verberne • None David Winchester • Roche Diagnostics, Grant, Biomarkers
Jump to section
- Article
- EXECUTIVE SUMMARY
- INTRODUCTION
- METHODOLOGY
- SECTION 1: SYMPTOMATIC PATIENTS WITH SUSPECTED OR KNOWN CAD
- SECTION 2: ASYMPTOMATIC PATIENTS (WITHOUT SYMPTOMS OR ISCHEMIC EQUIVALENT)
- SECTION 3: DIAGNOSED HEART FAILURE (RESTING LV FUNCTION PREVIOUSLY ASSESSED BUT NO PRIOR CAD EVALUATION)
- SECTION 4: EVALUATION OF PATIENTS WITH KNOWN OR SUSPECTED CARDIAC SARCOIDOSIS
- SECTION 5: EVALUATION OF ARRHYTHMIAS WITHOUT ISCHEMIC EQUIVALENT (NO PRIOR CARDIAC EVALUATION)
- SECTION 6: SYNCOPE WITHOUT ISCHEMIC EQUIVALENT
- SECTION 7: ASSESSMENT OF CMD IN SYMPTOMATIC PATIENTS
- SECTION 8: SPECIFIC POPULATIONS
- SECTION 9: PRIOR TESTING OR PROCEDURES
- SECTION 10: PREOPERATIVE EVALUATION FOR NONCARDIAC SURGERY
- SECTION 11: DETERMINATION OF EXERCISE LEVEL BEFORE INITIATION OF EXERCISE PRESCRIPTION OR CARDIAC REHABILITATION
- BENEFITS AND HARMS OF IMPLEMENTING THE AUC GUIDANCE
- IMPLEMENTATION OF THE AUC GUIDANCE
- APPENDIX A: WORKGROUP MEMBERS AND EXTERNAL REVIEWERS
- APPENDIX B: DEFINITION OF TERMS AND ACRONYMS
- APPENDIX C: DISCLOSURES AND CONFLICTS OF INTEREST (COIs)
- APPENDIX D: PUBLIC COMMENTARY
- Acknowledgments
- REFERENCES
- Figures & Data
- Info & Metrics
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