Revista: Criterios de la Multimodalidad para la enfermedad Coronaria Detección de riesgos by H David Cortes

Multimodality WritingGroup forChronic Coronary Disease

MultimodalityAppropriateUseCriteria fortheDetectionandRiskAssessment ofChronicCoronaryDisease

AReportoftheAmericanCollegeofCardiologySolutionSetOversightCommittee,AmericanHeart Association,AmericanSocietyofEchocardiography,AmericanSocietyofNuclearCardiology, AmericanSocietyofPreventiveCardiology,HeartFailureSocietyofAmerica,HeartRhythmSociety, SocietyforCardiovascularAngiographyandInterventions,SocietyofCardiovascularComputed Tomography,SocietyforCardiovascularMagneticResonance,andSocietyofThoracicSurgeons

DavidE.Winchester,MD,MS,FACC, Co-Chair*

DavidJ.Maron,MD,FACC, Co-Chair*

RonBlankstein,MD,FACCy

IanC.Chang,MD,FACCz

AjayJ.Kirtane,MD,MS,FACCx RaymondY.Kwong,MD,FACCk

PatriciaA.Pellikka,MD,FACC{

JordanM.Prutkin,MD,MHS,FACC#

RaymondRussell,MD,FACC**

AlexanderT.Sandhu,MD,MSz

Rating Panel

L.SamuelWann,MD,MACC, Moderator*

IanC.Chang,MD,FACC, WritingGroupRepresentativez AlexanderT.Sandhu,MD,MS, WritingGroup

Representativez

*AmericanCollegeofCardiologyRepresentative. ySocietyofCardiovascularComputedTomographyRepresentative. Representative. zFellow-in-TrainingRepresentative. xSocietyforCardiovascularAngiographyandInterventions Representative. kSocietyforCardiovascularMagneticResonanceRepresentative. {AmericanSocietyofEchocardiographyRepresentative. #HeartRhythmSocietyRepresentative. **AmericanSocietyofNuclearCardiologyRepresentative.

W.PatriciaBandettini,MDk

DennisA.Calnon,MD,FACC**

ManuelD.Cerqueira,MD,FACC*

LarryS.Dean,MD,FACC*

MilindY.Desai,MBBS,FACC*

ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyClinicalPolicyApprovalCommitteeinMarch2023. TheAmericanCollegeofCardiologyrequeststhatthisdocumentbecitedasfollows:WinchesterDE,MaronDJ,BlanksteinR,ChangIC,KirtaneAJ, KwongRY,PellikkaPA,PrutkinJM,RussellR,SandhuAT.ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS2023multimodalityappropriateusecriteriaforthedetectionandriskassessmentofchroniccoronarydisease:areportoftheAmericanCollegeofCardiologySolutionSet OversightCommittee,AmericanHeartAssociation,AmericanSocietyofEchocardiography,AmericanSocietyofNuclearCardiology,AmericanSocietyof PreventiveCardiology,HeartFailureSocietyofAmerica,HeartRhythmSociety,SocietyforCardiovascularAngiographyandInterventions,Societyof CardiovascularComputedTomography,SocietyforCardiovascularMagneticResonance,andSocietyofThoracicSurgeons. JAmCollCardiol 2023;81(25):2445-2467.

Copies:ThisdocumentisavailableonthewebsiteoftheAmericanCollegeofCardiology(www.acc.org).Forcopiesofthisdocument,pleasecontact ElsevierInc.ReprintDepartmentviafax(212-633-3820)ore-mail(reprints@elsevier.com).

Permissions:Multiplecopies,modiﬁcation,alteration,enhancement,and/ordistributionofthisdocumentarenotpermittedwithouttheexpress permissionoftheAmericanCollegeofCardiology.RequestsmaybecompletedonlineviatheElseviersite(https://www.elsevier.com/about/ ourbusiness/policies/copyright/permissions).

APPROPRIATEUSECRITERIA ACC/AHA/ASE/ASNC/ASPC/HFSA/ HRS/SCAI/SCCT/SCMR/STS2023

ISSN0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2023.03.410

JOURNALOFTHEAMERICANCOLLEGEOFCARDIOLOGY VOL.81,NO.25,2023 ª 2023BYTHEAMERICANCOLLEGEOFCARDIOLOGYFOUNDATION

PUBLISHEDBYELSEVIER

Solution Set

Oversight Committee

HowardJ.Eisen,MD,FACC*

StephenE.Fremes,MD,FACC*

MarioF.L.Gaudino,MDyy

LindaD.Gillam,MD,MACC{

NicoleL.Lohr,MD,PHD,FACCzz

JosephE.Marine,MD,MBA,FACC#

KhurramNasir,MBBS,FACCxx

LesleeJ.Shaw,PHD,FACCy

NicoleM.Bhave,MD,FACC, Chair

NitiR.Aggarwal,MD,FACC

KatieBates,ARNP,DNP

BiykemBozkurt,MD,PHD,FACC

JohnP.Erwin III,MD,FACC

ChayakritKrittanawong,MDkk

DharamJ.Kumbhani,MD,SM,FACC

GurusherS.Panjrath,MBBS,FACC

JacquelineE.Tamis-Holland,MD,FACCx JohnB.Wong,MD*

yySocietyofThoracicSurgeonsRepresentative. zzAmericanHeartAssociationRepresentative. xxAmericanSocietyofPreventiveCardiologyRepresentative.

JavierA.Sala-Mercado,MD,PHDkk

BarbaraWiggins,PHARMD,FACC

DavidE.Winchester,MD,MS,FACC

MeganCoylewright,MD,MPH,FACC, ExOfﬁcio

kkFormermemberoftheSolutionSetOversightCommitteeduring developmentofthedocument.

TABLEOFCONTENTS ABSTRACT 2446 PREFACE 2447 1.INTRODUCTION 2448 2.METHODS 2448 2.1.ClinicalScenarioConstruction 2449 2.2.RatingProcessandScoring 2449 3.ASSUMPTIONS 2450 Figure1FlowchartofAppropriatenessTables 2451 TableAAdvantagesandLimitationsofImaging Modalities 2452 4.DEFINITIONS 2453 TableBExamplesofInconclusiveStress Imaging 2454 TableCRisk-EnhancingFactors 2455 5.ABBREVIATIONS 2455 6.RESULTSOFRATINGS 2455 7.MULTIMODALITYFORTHEDETECTIONANDRISK ASSESSMENTOFISCHEMICHEARTDISEASEAUC (BYCLINICALSCENARIO) 2456 Section1 2456 Table1.1SymptomaticPatientsWithNoKnown CCDandNoPriorTesting 2456 Table1.2SymptomaticPatientsWithoutKnown CCDandWithPriorTesting 2456 Table1.3SymptomaticPatientsWithPriorMIor Revascularization 2457 Section2 2457 Table2.1AsymptomaticPatientsWithout KnownASCVD 2457 Table2.2AsymptomaticPatientsWithPrior RevascularizationorMI 2457 Table2.3AsymptomaticPatientsUndergoing AssessmentofanExerciseProgramorCardiac Rehabilitation 2458 Table2.4OtherCardiovascularConditionsin PatientsWithoutSymptomsofIschemia 2458 8.DISCUSSION 2459 9.CONCLUSIONS 2461 REFERENCES 2462 APPENDIX AuthorRelationshipswithIndustry(RWI)and OtherEntities(Relevant) 2463 ABSTRACT TheAmericanCollegeofCardiology(ACC)Foundation, alongwithkeyspecialtyandsu bspecialtysocieties,conductedanappropriateusereviewofstresstestingand Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2446

anatomicdiagnosticproceduresforriskassessmentand evaluationofknownorsuspectedchroniccoronarydisease(CCD),formerlyreferre dtoasstableischemicheart disease(SIHD).Thisdocumentre ﬂ ectsanupdatingofthe priorAppropriateUseCriteri a(AUC)publishedforradionuclideimaging,stressechocardiography(echo),calcium scoring,coronarycomputedtomographyangiography (CCTA),stresscardiacmagneticresonance(CMR),and invasivecoronaryangiographyforSIHD.Thisisinkeepingwiththecommitmenttoreviseandre ﬁ netheAUCon afrequentbasis.Aswiththepriorversionofthisdocument,ratingoftestmodalitiesisprovidedside-by-sidefor agivenclinicalscenario.Theseratingsareexplicitlynot consideredcompetitiverankingsduetothelimited availabilityofcomparativeevidence,patientvariability, andtherangeofcapabilitiesavailableinanygivenlocal setting. 1-4

ThisversionoftheAUCforCCDisafocusedupdateof thepriorversionoftheAUCforSIHD. 4 Keychanges beyondtheupdatedratingsbasedonnewevidence includethefollowing:

1.Clinicalscenariosrelatedtopreoperativetestingwere removedandwillbeincorporatedintoanotherAUC documentunderdevelopment.

2.Someclinicalscenariosandtableswereremovedinan efforttosimplifytheselectionofclinicalscenarios. Additionally,the ﬂ owchartoftableshasbeenreorganized,andallclinicalscenariotablescannowbe reachedbyansweringalimitednumberofclinical questionsaboutthepatient,startingwiththepatient ’ s symptomstatus.

3.Severalclinicalscenarioshavebeenrevisedtoincorporatechangesinotherdocumentssuchaspretest probabilityassessment,atheroscleroticcardiovascular disease(ASCVD)riskassessment,syncope,andothers. ASCVDriskfactorsthatarenotaccountedforin contemporaryriskcalculatorshavebeenaddedas modi ﬁ erstocertainclinicalscenarios.

The64clinicalscenariosratedinthisdocumentare limitedtothedetectionandriskassessmentofCCDand weredrawnfromcommonapplicationsoranticipated uses,aswellasfromcurrentcl inicalpractice guidelines. 5 Theseclinicalscenariosdonotspeci ﬁ callyaddresspatientshavingacutechestpainepisodes.Theymay,however,beapplicableintheinpatientsettingifthepatientis nothavinganacutecoronarysyndromeandwarrants evaluationforCCD.

Usingstandardizedmethodology,clinicalscenarios weredevelopedtodescribecommonpatientencountersin clinicalpracticefocusedoncommonapplicationsand anticipatedusesoftestingforCCD.Whereappropriate,the scenariosweredevelopedonthebasisofthemostcurrent ACC/AmericanHeartAssociati onguidelines.Aseparate,

independentratingpanelscor edtheclinicalscenariosin thisdocumentonascaleof1to9,followingamodi ﬁ ed Delphiprocessconsistentw iththerecentlyupdatedAUC developmentmethodology.Scoresof7to9indicatethata modalityisconsideredappropriatefortheclinicalscenario presented,midrangescores of4to6indicatethatamodalitymaybeappropriatefortheclinicalscenario,and scoresof1to3indicatethatamodalityisrarelyappropriate.

PREFACE

TheACChasalonghistoryofdevelopingdocuments(eg, decisionpathways,healthpolicystatements,AUC)to providememberswithguidanceonbothclinicaland nonclinicaltopicsrelevanttocardiovascularcare.Inmost circumstances,thesedocumentshavebeencreatedto complementclinicalpracticeguidelinesandtoinform cliniciansaboutareaswhereevidenceisnewandevolving orwheresuf ﬁ cientdataismorelimited.Despitethis, numerousgapspersist,highlightingtheneedformore streamlinedandef ﬁ cientprocessestoimplementbest practicesinpatientcare.

CentraltotheACC ’ sstrategicplanisthegenerationof actionableknowledge aconceptthatplacesemphasison makingclinicalinformatio neasiertoconsume,share, integrate,andupdate.Tothisend,theACChasshifted fromdevelopingisolateddocumentstocreatingintegrated “ solutionsets. ” Thesearegroupsofcloselyrelatedactivities,policy,mobileapplications,decision-supporttools, andotherresourcesnecessarytotransformcareand/or improvehearthealth.Solutionsetsaddresskeyquestions facingcareteamsandattempttoprovidepracticalguidancetobeappliedatthepointofcare.Theyuseboth establishedandemergingmethodstodisseminateinformationforcardiovascularconditionsandtheirrelated management.Thesuccessofsolutionsetsrests fi rmlyon theirabilitytohaveameasurableimpactonthedeliveryof care.Becausesolutionsetsre fl ectcurrentevidenceand ongoinggapsincare,theassociatedtoolswillbere fi ned overtimetomatchchangingevidenceandmemberneeds.

AUCrepresentakeycomponentofsolutionsets.They consistofcommonclinicalscenariosassociatedwithgiven diseasestatesandratingsthatde ﬁ newhenitisreasonable toperformtestingand,importantly,whenitisnot.AUC methodologyreliesoncontentdevelopmentworkgroups, whichcreatepatientscenarios,andindependentrating panels,whichuseamodi ﬁ edDelphiprocesstoratethe relevantoptionsfortestingandinterventionasAppropriate,MayBeAppropriate,orRarelyAppropriate.AUC shouldnotreplaceclinicianjudgmentandpracticeexperience,butshouldfunction astoolstoimprovepatient careandhealthoutcomesinacost-effectivemanner.

NicoleBhave,MD,FACC Chair,ACCSolutionSetOversightCommittee

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2447

1.INTRODUCTION

SincetheintroductionofAUCin2005,theACChasproducedanumberofdocumentsthatsynthesizeevidence forspeci fi ccardiovascularproceduresintoappropriate usestandards.TheAUCweredevelopedtosupportutilizationofhigh-qualitypatternsofprocedureuse(ie, appropriateuse)whileinformingeffortstoreduce resourceusewhenbene fi tstopatientsareunlikely. 1-3 The rangeoftoolsusedtoevaluatecardiovasculardiseasehas expandedoverthepastdecade,especiallyinthe fi eldof noninvasiveimaging.Thepurposeofthisdocumentisto delineatetheappropriateuseofvariousinvasiveand noninvasivetestingmodalitiesforthediagnosisand/or evaluationofCCDacrosscommonpatientpresentations (clinicalscenarios),includingthefollowing:

1.Patientswithsymptomsofischemia:withoutprior testing( Table1.1 ),withpriortestingbutwithout myocardialinfarction(MI)orrevascularization ( Table1.2 ),andwithpriorMIorrevascularization ( Table1.3 )

2.Patientswithoutsymptomsofischemia:testingforrisk ofASCVDevents( Table2.1 ),andwithpriorMIorprior revascularization( Table2.2 )

3.Patientsseekingtoinitiat eaphysicalexerciseorcardiacrehabilitationprogram( Table2.3 )

4.Patientswithothercardiovascularconditionssuchas heartfailure,arrhythmias,orsyncope( Table2.4 )

2.METHODS

WritingGroup

AttheoutsetoftheAUCdevelopmentprocess,the SolutionSetOversightCommittee(SSOC)appoints1to2 expertstoserveaschair,cochairs,orchair/vice-chairof thewritinggroup.TheSSOC,incollaborationwiththe chair(s),thenappointsadditionalmemberstoserveon themultidisciplinarywritinggroup,whichusuallyranges insizefrom5to9members.

Thegoalofthewritinggroupistodeveloppatient scenariosthatarelikelytobeencounteredinclinical practiceandtocategorizethosescenariosbasedon symptoms,anatomy,and/ordiseasestate.Patientpresentationvarieswidely,andnotallclinicalfactorswillbe fullycapturedinthescenarios.Wherepossible,the writinggroupmapsthescenariostorelevantguidelines, clinicaltrials,andotherdatasources.

Recommendationsforwritinggroupmembersmaybe solicitedfromACCMemberCouncilsaswellasrelevant professionalsocieties.InaccordancewiththeACC ’ sDiversityandInclusionprinciples,everyeffortismadeto ensurethatthewritinggroupmembersvaryinage,sex,

andethnicity/race.Inaddition,oneormoreearly-career physicians,fellows-in-training,orcardiovascularteam membersareincluded.Other importantconsiderations forthegroup ’ smakeupincludespecialty,appropriate organizational/contentexpertise,practicesetting,and geographiclocation.SSOCcon sidersrelevantrelationshipsinconsiderationofACC ’ sRWIPolicyintheformationofallwritinggroups.

Reviewers

SSOCidenti fi esagroupofreviewerstoprovidefeedbacktothewritinggrouppriortosendingthescenariosto theratingpanel.Similartoboththewritinggroupand ratingpanel,reviewersareso licitedfromvariedsources bothinternaltotheCollegeaswellasotherrelevantsocietiesandorganizations.Speci fi cally,reviewersprovide feedbackonwhetherthescenariosarecomprehensive andrepresenttypicalpatients,andwhetherthedocumentprovidesaccuratede fi nitionsandassumptions,as wellasacceptableevidencemapping.

RatingPanel

Theratingpanelisresponsibleforratingeachclinical scenario.Tomaximizetheinputfromabroadarrayof stakeholders,theratingpaneliscomposedofexpertsin cardiovascularmedicine,generalinternalmedicine/hospitalpractice,andoutcomesresearch.TheSSOCisalso responsibleforappointingmemberstotheratingpanel. Themembershipusuallyincludes15to17individuals, includingpracticingclinici answithexpertiseintheclinicaltopicbeingevaluated, practicingclinicianswith expertiseinacloselyrelated discipline,andoftenaprimarycarephysician,anexpert instatisticalanalysis,and anexpertinclinicaltrialdesign.Anindividualfromthe publicsectorand/orapayerrepresentativemayalsobe included.

Thepanelincludescliniciansotherthancardiologists toreducethepotentialforbiasamongclinicianswith expertiseinindividualtesti ngmodalitiesortreatment methods.TheSSOChasastron ginterestinmaintaining balancebetweenspecialistswhousethetechnologyor treatmentmethodsaddressedinthespeci ﬁ csetofAUC, andotherprofessionalswhorepresentreferringclinicians,includinggeneralcard iologists,outcomespecialists,and/orprimarycarephysicians.Specialistswhose keyareaofpracticeisthemainAUCtopicunderconsiderationrepresent <50%ofthepanel.

Similartothewritinggroup,recommendationsfor ratingpanelmembersaresolicitedfromvariedsources. EveryeffortismadetoadheretotheACC ’ sDiversityand Inclusionprinciples,andrelevantRWIistakeninto consideration.Additionally,SSOCstrivestoincludeone ormoreearlycareerphysicians ,fellows-in-training,or cardiovascularteammembersaspartofthepanel.All ratingpanelshaveanoddnumberofindividualsto

JACCVOL.81,NO.25,2023

JUNE27,2023:2445 – 2467 2448

Winchester etal

AUCforMMIofChronicCoronaryDisease

ensurethatthe ﬁ nalmedianscorere ﬂ ectsawhole number.

ThemethodsfordevelopmentofAUChaveevolved overtimeandwererecentlyupdated. 1-3

Thisdocumentsummarizesthediagnosticandprognosticcapabilitiesofamultitudeofcardiovasculartests toinformchoicesfortestingincommonclinicalscenariosfortheevaluationandmanagementofCCD.Both symptomaticandasymptomaticclinicalscenariosare considered,aswellaspresentationsforpatientswith andwithoutapriorhistoryofCCD.Thisdocumentintendstoprovidetestingrecommendationsbasedonthe decisionsthatwouldbeapplicabletoprovidingrealworldpatientcareandshouldstandasareferencefor cardiovascularspecialistsandreferringphysicians.The documentisintendednottodetermineasinglebesttest foreachclinicalscenario,butrathertoproviderecommendationsforarangeoftestingoptionsthatmayor maynotbereasonableforaspeci fi cclinicalscenario.It iscriticaltounderstandthattheAUCshouldbeusedto assessanoverallpatternofc linicalcareratherthanbeingthe fi nalarbitratorofspeci fi cindividualcasesand shouldnotbeusedasthesoledeterminationofpayment bypayors.TheACCanditscollaboratorsbelievethatan ongoingreviewofone ’ spracticeusingthesecriteriawill helpguidemoreeffectivetestingand,ultimately,better patientoutcomes.

2.1.ClinicalScenarioConstruction

Theclinicalscenarioshavebeendevelopedbyadiverse writinggroupcomposedofindividualswhoareexperts inbothgeneralcardiologyandalsononinvasiveor invasivecardiacdiagnostictesting.Thewritinggroup soughttocreatesetsofclinicalscenariosthatcoverthe majorityofsituationsforw hichknownorsuspectedCCD patientsarereferredforcard iovasculartesting.Whereverpossibleduringthew ritingprocess,thegroup membersmappedthescenariostorelevantclinical guidelinesandkeypublicationsorreferences(see SupplementalAppendix1 ).Thisincludeddiagnosisorientedguidelinesandmodality-speci ﬁ cguidelines. Majorconsiderationwasgiventotryingcoverasmany clinicalscenariosaspossibl e,inbalancewithusability andeaseofnavigationofthedocument.Thewriting grouprecognizesthatpatientpresentationsvarywidely, andnotallclinicalfactorsarefullycapturedbythese clinicalscenarios.

2.2.RatingProcessandScoring

Afterthescenarioswerecreated,theywerereviewedand critiquedbytheSSOCandbyexternalreviewers, includinggeneralcardiologists,preventivecardiologists,

imagingexperts,electrophysiologists,cardiacsurgeons, andphysiciansininternalmedicineandhospitalmedicine.Afterrevisionbythewritinggroupbasedonfeedbackfromthereviewers,thescenariosweresenttoan independentratingpanel. 1-3

Tomaximizetheinputfromabroadarrayofstakeholders,theratingpanelwascomprisedofexpertsin cardiovascularmedicine,gen eralmedicalpractice(internalmedicine/hospitalmedicine),andoutcomesresearch. Noncardiologistswereincludedintheprocesstoreduce thepotentialforbiasamongphysicianswithexpertisein individualtestingmodalities.Theratingpanelwasprovidedwithrelevantevidenceandguidelinestoinform theirratings.Formalleadershiproleswereestablishedfor facilitatingpanelinteractio natthesubsequentface-tofacemeeting.Althoughpanelmemberswerenotprovidedexplicitsafetyandcostinformationtohelpdeterminetheirappropriateuseratings,theywereaskedto implicitlyconsidersafetyandcostasadditionalfactorsin theirevaluationofappropriateuse.Inratingthesescenarios,theAUCRatingPanelwasaskedtoassesswhether theuseofthetestforeachscenariowasAppropriate(A), MayBeAppropriate(M),orRarelyAppropriate(R)(see de ﬁ nitionsinthefollowingtext).Whenscoringeach scenario,theraterswerein structedtoassumethateach modalityislocallyavailable,performedonappropriate equipment,andinterpretedbyindividualswithrelevant trainingandexpertise.

The fi rststepintheprocesswasformembersofthe ratingpaneltoevaluateandsc oretheclinicalscenarios independently(referredtoasthe fi rst-roundrating). Then,thepanelheldavirt ual,onlinemeetingwhere panelmembersweregiventheirscoresandablinded summaryoftheirpeers ’ scores.Thepaneldiscussedthe scenariosandthescores,andthenpanelmemberswere askedagaintoindependentlyprovidescoresforeach clinicalscenario(s econd-roundrating).Afterthesecondroundrating,theresultsweresentbacktothewriting groupforreview.Atthispoint,thewritinggrouphada fi nalchancetoclarifyclinicalscenariosand,ifnecessary, returntotheratingpanelforrescoring.Amoredetailed descriptionofthemethodsisprovidedinaprevious publication, “ ACCFProposedMethodforEvaluatingthe AppropriatenessofCardiovascularImaging, ” whichwas updatedin2018. 2 Basedonthesemultipleroundsofreview,scoring,andrevision,eachscenariowasclassi fi ed asAppropriate,MayBeAppropriate,orRarelyAppropriate.Althoughratingsfortheclinicalscenariosare categorizedinto3groupsbasedonappropriateness,the appropriatenessoftestingismostaccuratelyviewedasa continuum,dependingonthevariationsofbene fi tsand risksinindividualpatients.

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2449

Appropriate,medianscore7to9 :Anappropriateoptionformanagementofpatientsinthispopulation becausebene ﬁ tsgenerallyoutweighrisks;aneffective optionforindividualcareplans,althoughnotalways necessary,dependingonphysicianjudgmentand patient-speci ﬁ cpreferences(ie,procedureisgenerally acceptableandgenerallyreasonablefortheclinical scenario).

MayBeAppropriate,medianscore4to6 :Attimes,an appropriateoptionformanagementofpatientsinthis populationduetovariableevidenceoragreement regardingthebene ﬁ t-riskratio,potentialbene ﬁ tbasedon practiceexperienceintheabsenceofevidence,and/or variabilityinthepopulation;effectivenessforindividual caremustbedeterminedbyapatient ’ sphysicianin consultationwiththepatientonthebasisofadditional clinicalvariablesandjudgmentalongwithpatientpreferences(ie,proceduremaybeacceptableandmaybe reasonablefortheclinicalscenario).

RarelyAppropriate,medianscore1to3 :Rarelyan appropriateoptionformanagementofpatientsinthis populationduetothelackofaclearbene ﬁ t/riskadvantage;rarelyaneffectiveoptionforindividualcareplans; exceptionsshouldhavedocumentationoftheclinical reasonsforproceedingwiththiscareoption(ie,procedureisnotgenerallyacceptableandisnotgenerally reasonablefortheclinicalscenario).

Thelevelofagreementamongpanelistsasde fi nedby RANDwasanalyzedonthebasisoftheRAND/UCLA modi fi edDelphiPanelmethodruleforapanelof14to17 members. 1 , 6 Ratingswereconsideredtobeinagreement whenfewerthan5panelists ’ ratingsfelloutsideofthe 3-pointregioncontainingthe medianscore.Disagreement wasde fi nedaswhen5ormorepanelists ’ ratingsfellin boththeAppropriateandtheRarelyAppropriatecategories.Anyclinicalscenariohavingdisagreementwas categorizedasMayBeAppropriateregardlessofthe fi nal medianscore.

3.ASSUMPTIONS

Tolimitinconsistenciesininterpretation,thefollowing assumptionsandconsiderationsshouldbeappliedwhen interpretingtheratings.

1.Eachtestisperformed,interpreted,andreportedin compliancewithpublishedcriteriaforqualitycardiac diagnostictesting,asprovidedbynationallaboratory accreditationstandardsandsocietalqualityguideline documents,includingthefollowing.

n ExerciseECG 7

n Coronaryartery calciumscans 8-10

n Stressechocardiogram 11-13

n Radionuclidemyocardialperfusionimaging(MPI)14-17

n CMR 18-22

n CCTA 23-26

n Invasivecoronaryangiography 27-29

n Radiation 30-32

2.UseoftheseAUCassumesthateachmodalityislocally available,performedonappropriateequipment,and interpretedbyindividualswithacceptabletraining andexpertise.

3.Thediagnosticandprognosticvalueofaprevioustest generallydecreasesovertime.

4.Theclinicalstatusofthepatientshouldbeassumedto bevalidasstatedintheclinicalscenario(eg,athoroughhistoryhasbeenobtainedandaphysicalexaminationhasbeenconductedsuchthatan asymptomaticpatientistrulyasymptomaticforthe scenarioinquestion).

5.TheclinicalscenariosinthisAUCdocumentarenot intendedforpatientswithacuteconditions(suchas acutecoronarysyndromeoracutedecompensated heartfailure),althoughtheymaybeapplicableto evaluatinghospitalizedpatientsundergoinganevaluationforCCD.

6.Allpatientsarereceivingoptimalstandardcare, includingguideline-basedriskfactormodi ﬁ cationfor primaryorsecondarypreventionofischemicheart diseaseunlessspeci ﬁ callynoted.

7.Intheeventofanequivocalorinconclusivenoninvasivetest(stresselectro cardiogram[ECG],stress imaging,orCCTA),wherefurthertestingisclinically warranted,adifferenttestmodalityshouldbe performed.

8.Intheeventofequivocalorinconclusiveresultsona coronaryangiogram,physio logicaltesting(eg,using fractional ﬂ owreserve[FFR]ornonhyperemicindexes,noninvasivestresstesting,orintravascular ultrasoundforleftmaincoronaryarteryassessment) maybeperformedasneeded.

9.Avarietyofadditionaltechnologiesareavailableto augmentthediagnosticandprognosticinformation yieldedbynoninvasiveimagingtechniques(eg, computedFFRforCCTA,myocardialperfusionfor stressecho,noveldetectorarrangementsforsinglephotonemissioncomputedtomography[SPECT], myocardialblood ﬂ owreserveforCMRandposition emissiontomography[PET],etc);however,these technologiesarenotalwaysroutinelyavailable.Detailsaboutwhenthesetechnologiesareappropriateis beyondthescopeofthisdocument,andindividual ratingsdonotassumethatthesetechnologieswere necessarilyusedorperformed.

10.Beforeperforminganoninvasivestressimaging study,relevantdiagnosticinformationshouldbe reviewedforalternative explanationsofthesymptomsbeingevaluated. 30 Forexample,beforestress echo,thebaselinerestingimagingperformedshould

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2450

This flowchartguidesusersofthedocumenttowardthetablewithclinicalscenariosmostapplicableforthepatientinwhomimagingofchroniccoronarydisease(CCD) isbeingconsidered.The flowchartprioritizesthepresenceorabsenceofsymptomsofCCDbeforefurthercategorizationisoffered.Forthosepatientswhomaybe classifiedintomorethan1oftheclinicalindicationtablesand/oralgorithms,this flowchartplacesclinicalconditionsintoahierarchytoaidinassessingappropriateness. ASCVD ¼ atheroscleroticcardiovasculardisease;CV ¼ cardiovascular;ex ¼ excluding;MI ¼ myocardialinfarction;Rehab ¼ rehabilitation;Revasc ¼ revascularization; Rx prescription;w/o without.

includeascreeningassessmentofcardiacstructure andfunction,includingglobalandsegmentalventricularfunction,chambersizes,wallthickness,and cardiacvalves,unlessassessmentofthesehasalready beenperformed.ForCMRandCCTA,scoutimages shouldbereviewedforanyrelevantchestpathology.

11.Ifthepatient ’ scharacteristicsarecapturedunder morethan1clinicalscena rio,thepresenceofsymptomsshouldgenerallybetheprimarycriterionfor navigatingthe ﬂ owchartin Figure1 andtestselection fromthetables.

12.Clinicalscenariosthatdescriberoutineorsurveillance imagingimplythatthetestisbeingconsideredsolely becauseaperiodoftimehaselapsed,notbecauseof anychangeinclinicalcircumstancesoranyneedto considerachangeintherapy( Table2.2 ).

13.Whenconsideringtestin gthatincludesanexercise component,itshouldbeassumedthatthepatienthas nolimitationsthatwouldprecludeexercisingtoa symptomaticendpoint,achievingatleast80%oftheir age-andsex-predictedworkloador $85%oftheiragepredictedmaximalheartr ate.Similarly,unless otherwisestated,itshouldbeassumedthattheECGis interpretable.

14.Selectionforandmonitoringofcontrastagentuseis assumedtobeinaccordancewithpublished standards. 21 , 26

15.Theclinicalscenariosare,attimes,purposefully broadtocoveranarrayofcardiovascularsignsand symptomsandtoaccountfortheorderingphysician ’ s bestjudgmentastotheriskofischemicheartdisease. Cleardocumentationofthereasonfororderingthe testorprocedureshouldbeincludedinthemedical record.Additionally,therearelikelyclinicalscenarios thatarenotcoveredinthisdocument.

16.Insomeclinicalscenarios,itmaybereasonableto eitherperformornotperformatest.Tore ﬂ ectthis, acolumnlabeled “ defertesting ” isprovidedto indicatethattestingmay bedeferredatthistime, untilachangeinthepatient ’ sstatuswarrants reappraisal.

17.Individualtestmodalitieshaveuniquelimitationsas wellasadvantagesthatprovideinformationsupplementarytothedetectionofcoronaryarterydisease andmyocardialischemia.Insomecases,theselimitationsandadvantageswouldmakeaspeci ﬁ ctest modalitysuperiortoothersforanindividualpatient. Examplesarelistedin TableA

FIGURE1 FlowchartofAppropriatenessTables

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2451

TABLEA AdvantagesandLimitationsofImagingModalities

TestModality

Advantages

EchocardiographyCanevaluatevalvedisease,diastolicparameters,pulmonaryhypertension,myocardialdiseases,pericardialdisease.Canbe performedwithpharmacologicalorexercisestress.

SPECTCanbeperformedwithpharmacologicalvasodilationorpharmacological/exercisestress.

PETCanquantifypeakmyocardialblood ﬂowandmyocardialblood ﬂowreserve,whichimprovediagnosisandprognosticationand mayallowfordetectionofmicrovasculardisease.

CMRCanassesswallmotion,ischemia,andinfarctioninonestudy.Canquantifymyocardialblood ﬂowtoimprovetestaccuracyand assessmyocardialandpericardialdiseases.Canperformviabilitytesting.

CACCandetectthepresenceandamountofcalciﬁedcoronaryplaque;robustprognosticvalue;doesnotrequireacontrastagent. CCTACandetectbothnonobstructiveandobstructiveplaque.Canidentifynoncardiaccausesforsomesymptoms.CTstressperfusion andCTFFRcanassessforischemia.

InvasiveangiographyCandetectbothnonobstructiveandobstructiveplaque.CanperformphysiologicaltestingusingFFRornonhyperemicindices, intravascularimaging(eg,IVUS/OCT),additionaltestingforcoronaryspasmandmicrovasculardisease,andadjunctive hemodynamicassessments(eg,rightandleftheartcatheterization).

TestModality Limitations

Echocardiography*

Limitedacousticwindows(COPD,obesity,breastimplants).

SPECT* Attenuation,motion,andsofttissueartifactsmayunderestimateextentofdisease.Exposuretoradiation.

PET*

Notwidelyavailablewithexercise.Exposuretoradiation.

CMR* Claustrophobia,artifacts,andsafetyprecautionswithmetallicmedicaldevices.

CCTAReducedqualitymaybepresentinpatientswithmorbidobesity,highorirregularheartrates,orseverecoronarycalciﬁcation. Exposuretoradiation.

InvasiveangiographyProceduralcomplications.Exposuretoradiation.

*Vasodilatortestingiscontraindicatedifcaffeinewasusedwithinthelast12hours;stresstestingiscontraindicatedwhenthereishigh-riskunstableanginaoracuteMI(<2days). CCTA ¼ coronarycomputedtomographyangiography;CMR ¼ cardiacmagneticresonance;COPD ¼ chronicobstructivepulmonarydisease;CT ¼ computedtomography;FFR ¼ fractional ﬂowreserve;IVUS ¼ intravascularultrasound;OCT ¼ opticalcoherencetomography;PET ¼ positronemissiontomography;SPECT ¼ single-photonemissioncomputed tomography.

18.Testingmodalitiesareratedfortheirlevelofappropriatenessspeci ﬁ ctoclinicalscenariosratherthana rankordercomparisonagainstothertestingmodalities.Thegoalofthisdocumentistoidentifyanyand allteststhatareconsideredreasonableforagiven clinicalscenario.Assuch,morethan1testtypeor evenalltestsmaybeconsidered “ Appropriate, ”“ May BeAppropriate, ” or “ RarelyAppropriate. ”

19.Ifmorethan1modalityfallsintothesameappropriate usecategory,itisassumedthatclinicianjudgment; testadvantagesanddisadvantages( TableA );and availablelocalexpertise,facilities,andequipment willbeconsideredtodeterminetheoptimaltestforan individualpatient.

20.Clinicalscenarioratings containedhereinsupersede theratingsofsimilarclini calscenarioscontainedin previousAUCdocuments.

21.Eachtestmodalityconsideredinthisdocumenthas inherentrisksthatmayincludebutarenotlimitedto radiationexposure,sensitivitytoiodinatedor gadolinium-basedcontrastagents,otherbodily injury,andinterpretatione rror.Foranygivenpatient,

itisassumedthattheorderingandperformingclinicianshaveaccountedfortheseindividualrisksin theirchoiceoftest.

22.Clinicalscenarios,suchasbutnotlimitedto, advancedmalignancy,fra ilty,unwillingnessto considertesting,technica lreasonsrenderingtesting infeasible,orcomorbiditieslikelytomarkedlyincreaseproceduralriskarebeyondthescopeofthis documentbutshouldbetakenintoconsiderationin testselection.Thesemayrelatetoclinicalappropriatenessforrevascularization.

23.Unlessexplicitlystated,itshouldbeassumedthat patientspresentingwithaspeci ﬁ cclinicalscenarioare potentialcandidatesforallofthetesttypesanddo nothaveanycontraindications.

RadiationSafety

24.UsersoftheAUCareawarethatthegenerallyapplied assumptionamongexpertsinradiationbiologyand epidemiologyisalinearno-thresholdrelationship betweenradiationexposureandsubsequentriskof cancerandthatradiationexposureforanygiventest willbeaslowasreasonablyachievable(ALARA).Tests thatimpartionizingradi ationwillbeperformedby laboratoriesthathaveadoptedcontemporarydosereductiontechniques. 31-34

Multimodality-Speci ﬁ cAssumptions/Considerations ComparativeRating

Risk/Bene ﬁ t

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2452

25.Testingwithoutradiationorano-testingstrategy shouldbeconsideredforlow-riskpremenopausal women. 35

Cost/Value

26.Inselectingatest,clinicalbene fi tsareconsidered fi rst.Costandvaluemayalsobeconsidered,although estimatingtheseforanindividualpatientmaybe dif fi cultdueto:

a.Differencesinreimbursementdependingonregion,setting,andpayer

b.Differencesincostbetweencardiovasculartesting options

c.Differencesinchargesversusreimbursement

d.Downstreamorserialtesting

e.Costtoreduceanadverseeventortoaddqualityadjustedlifeexpectancy

f.Detectionofnoncardiacconditions,bothpositive (occultmalignancy)andpotentiallynegative (incidental ﬁ ndings)

EvidenceReview

27.Clinicalscenarioswere ratedbasedonthebestavailabledataandweremappedtorelevantclinicalpracticeguidelines.

28.Newertechnologiesshouldnotbeconsideredmoreor lessappropriatecomparedwitholdertechnologies.

4.DEFINITIONS

Appropriatetest: Atestinwhichtheexpectedclinical bene fi texceedstherisksoftheprocedurebyasuf fi ciently widemargin,suchthattheprocedureisgenerally consideredacceptableorreasonablecare.Fordiagnostic imagingprocedures,bene fi tsincludeincrementalinformationthat,whencombinedwithclinicaljudgment, augmentsef fi cientpatientcare.Thesebene fi tsare weighedagainstthepotentialnegativeconsequences (risksincludethepotentialhazardofmisseddiagnoses, radiation,contrastagents ,and/orunnecessarydownstreamprocedures).

ASCVD: ClinicalASCVDisde ﬁ nedbyahistoryofacute coronarysyndrome;stableangina;coronaryorother arterialrevascularization;orstroke,transientischemic attack,orperipheralarterialdiseasepresumedtobeof atheroscleroticorigin.

ASCVDriskestimation :Fordecision-makingabout appropriatenessoftesting,someclinicalscenariosare basedonASCVDrisk.Severaldi fferentriskcalculatorsare availableforclinicianstousewithindividualpatientsto

estimatethelong-termlikelihoodofASCVDevents.Cliniciansaresuggestedtouseacalculatorthathasbeen validatedinthepopulationofpatientstheyareevaluating.ForNorthAmericanpopulations,theACCASCVD RiskEstimatorisrecommended.

Clinicalscenario :Aspeci ﬁ csetofpatientcharacteristicsthatde ﬁ neauniquesituationforwhichcardiovasculartestingmaybeconsidered.

CCD :Diseasesoftheheartrelatedtocurrentorprior myocardialischemiainastablephase,includinghistory ofacutecoronarysyndrome,obstructiveatherosclerosis withorwithoutcoronaryrevascularization,ischemiawith noobstructivecoronaryathero sclerosis,orischemicheart failure.PatientswithCCDmaybeasymptomaticormay haveactivesymptoms,includinganginapectoris,dyspnea,and/orfatigue.Thesesymptomsmayormaynotbe relatedtoexertion.

Deﬁnitionsfor Table1.1

Likelyanginalsymptoms: Chest/epigastric/shoulder/ arm/jawpain,chestpressure/discomfort,whenoccurring withexertionoremotionalstressandrelievedbyrest, nitroglycerin,orboth.

Less-likelyanginalsymptoms :Symptomsincluding dyspneaorfatiguewhennotexertionalandnotrelieved byrest/nitroglycerin;alsoinc ludesgeneralizedfatigueor chestdiscomfortoccurringinatimecoursenotsuggestive ofangina(eg,resolvesspontaneouslywithinsecondsor lastsforanextendedperiodandisunrelatedtoexertion).

Noncardiacexplanation: Analternativediagnosis,such asgastroesophagealre ﬂ ux,chesttrauma,anemia,chronic obstructivepulmonarydiseas e,orpleurisy,ispresentand isthemostlikelyexplanationforthepatient ’ ssymptoms.

Deﬁnitionsfor Table1.2

Coronaryarterycalciumdataandreportingsystem(CACDRS): Astandardizedreportingsystemtoreportthedegreeandextentofcoronaryarterycalci fi cationforeither quanti fi edmeasurements(eg,Agatstonscore)orvisual estimatesofcoronarycalci fi cation.

Coronaryarterydisease-reportinganddatasystem (CAD-RADS): Astandardizedreportingsystemtoprovide greaterconsistencyofreportingthedegreeofcoronary stenosismeasuredonaCCTA.

AbnormalECG :AnECGwith ﬁ ndingsconcerningfor ischemiaorpriorinfarctionsuchasrestingST-segment depressionorT-waveinversions,Qwaves,orleft bundlebranchblock.

Normalexercisetreadmilltest :Adequateexertional effortwithnoevidenceofischemiaandnoreproduction ofsymptoms.

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2453

TABLEB ExamplesofInconclusiveStressImaging TestModalityInconclusiveResult

SPECT/PETMotionartifact,attenuationdefects, arrhythmia,apicalthinningartifact StressechocardiogramPoorwindows,poorendocardialvisualization, failuretoachieveadequateheartrate StressCMRArtifacts,arrhythmia

CMR ¼ cardiacmagneticresonance;PET ¼ positronemissiontomography;SPECT ¼ single-photonemissioncomputedtomography.

Inconclusiveexercisetreadmilltest :Anexercisestress testthatdoesnotprovideasuf fi cientlevelofcon fi dence forclinicalcare,suchas <85%maximumpredictedheart rateachieved,STsegmentsthatareuninterpretabledue tobaselineabnormalities,orST-segmentchangesthat resolverapidlyorarenonspeci fi c.

Inconclusivestressimaging: ASPECT,PET,echo,or CMRimagingstressstudythatdoesnotprovideadequate orreliableinformationtoallowadiagnosisortherapeutic strategiestobeestablishedtoasuf ﬁ cientlyhighlevelof clinicalcon ﬁ dence( TableB ).

Normalstressimaging :Noevidenceofischemiaor infarction.

Mildischemia :Ischemiaispresentbutaffects <10%of themyocardiumonstressnuclearimaging, <4of32 subsegments(epicardialandendocardialsubsegmentsof 16segments)onstressCMR,or <3of16segmentson stressechoorstressCMR.

Moderatetosevereischemia :Moderatetosevere ischemiahasbeende ﬁ nedasanestimateof $5%annual riskofcardiacdeathornonfatalMI.Thislevelofrisk correlatesasfollows:forstressnuclearimaging, $10% ischemicmyocardium;forstressecho, $3of16newly dysfunctionalsegmentsduringstress;andforstress CMR, $4of32subsegmentswithischemicperfusiondefectsduringvasodilationstressor >3of16segmentswith neworworseneddysfunctionduringexercisestagesor progressiveinotropicstress.

Categoriesofinvasivecoro naryangiographyresults:

n Mildornone:maximalcoronarydiameterstenosisis 0%to39%

n Intermediate:maximalcoronarydiameterstenosisis 40%to69%

n Obstructive:maximalcoronarydiameterstenosis is $70%ORleftmaincoronaryarterystenosis $50%)

Invasivephysiologicaltesting :Theresultsofcoronary physiologicaltestingaregenerallyreportedascontinuous

variables(rangingfrom0-1).Althoughclinicalstudiesof thesetestshavebeenperformedusingdichotomouscutpoints,theresultsofthesetestsshouldnotbeconsidered onlydichotomously.Lowervaluescorrelatewithmore severeischemiaandworseclinicaloutcomes,andthere maybevaluesaboveacutpointthatdonotruleout myocardialischemia.Thisde ﬁ nitiondoesnotassumethat acomprehensiveassessmentformicrovasculardysfunctionwasperformed.

Deﬁnitionsfor Table1.3

Incompleterevascularization :Coronaryrevascularizationbypercutaneouscoronary intervention(PCI)orcoronaryarterybypassgraftwithsuspectedorknown residualobstructiveepicard ialcoronaryarterystenosis thatmayormaynotbeamenabletorevascularization,or unrevascularizedcoronary arteriesfollowinganacute coronarysyndrome.Examplesincludeanincomplete surgicalorpercutaneousrevascularization(unrevascularizedterritoriesduetopoortargets,chronicocclusion, ordiffusedisease),priorMIwithoutculpritarteryrevascularization,orpriorMIwi thresidualobstructive coronaryarterydisease(CAD)inanon – infarct-related artery.

Similartopriorischemicepisode :Patientswhoare presentingwithsymptomsthataresimilarincharacterto thosewhichoccurredatthetimeofaprioracutecoronary syndromeorstableanginaevent.

Likelyanginalsymptoms :Chest/epigastric/shoulder/ arm/jawpain,chestpressur e/discomfort,whenoccurring withexertionoremotionalstressandrelievedbyrest, nitroglycerin,orboth.

Less-likelyanginalsymptoms :Symptomsincluding dyspneaorfatiguewhennotexertionalorrelievedby rest/nitroglycerin;alsoincludesgeneralizedfatigueor chestdiscomfortoccurringinatimecoursenotsuggestive ofangina(eg,resolvesspontaneouslywithinsecondsor lastsforanextendedperiodandisunrelatedtoexertion).

Deﬁnitionsfor Table2.1

ASCVDrisk :Seede ﬁ nitionsprovidedin Table1.2

Nontraditionalriskfactors :Inadditiontotraditional riskfactors,therearesevera lconditionsthatareassociatedwithprematureatherosclerosisorrapidprogressionofatherosclerosis.Insomecases,theseriskfactors mayalsobeassociatedwithgreatermorbidityand/or mortalityinthesettingofanacutecoronarysyndrome. Assuch,thepresenceofsuchconditionsmayin ﬂ uencea clinician ’ sdecisiontoevaluateapatientforthepresence

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2454

TABLEC Risk-EnhancingFactors

FamilyhistoryofprematureASCVD(men,age <55y;women,age <65y)

Primaryhypercholesterolemia(LDL-C,160-189mg/dL[4.1-4.8mmol/L]);non–HDL-C190-219mg/dL[4.9-5.6mmol/L])

Metabolicsyndrome(increasedwaistcircumference,elevatedtriglycerides[>175 mg/dL],elevatedbloodpressure,elevatedglucose,andlowHDL-C[<40 mg/dLinmen; <50mg/dLinwomen]arefactors;tallyof3makesthe diagnosis)

Chronickidneydisease(eGFR15-59mL/min/1.73m2 withorwithoutalbuminuria; nottreatedwithdialysisorkidneytransplantation)

Chronicinﬂammatoryconditionssuchaspsoriasis,RA,lupus,orHIV/AIDS

Historyofprematuremenopause(beforeage40y)andhistoryofpregnancyassociatedconditionsthatincreaselaterASCVDrisksuchaspreeclampsia, gestationaldiabetes

Noncoronaryvasculardisease(eg,ABI <0.9)

High-riskraces/ethnicities(eg,SouthAsianancestry)

Elevatedhigh-sensitivityC-reactiveprotein($2.0mg/L)

ElevatedLp(a): $50mg/dLor $125nmol/L

ElevatedapoB $130mg/dL

Persistentlyelevated,primaryhypertriglyceridemia($175mg/dL)

Coronarycalciﬁcationsonpriorimaging(chestx-ray,chestCT)

Priorchestradiation

Chemotherapywithvasotoxicitypotential

ABI ankle-brachialindex;apoB apolipoproteinB;ASCVD atheroscleroticcardiovasculardisease;CT ¼ computedtomography;eGFR ¼ estimatedglomerular ﬁltrationrate;HDL-C ¼ high-densitylipoproteincholesterol;LDL-C ¼ low-densitylipoproteincholesterol;Lp(a) lipoproteina;RA rheumatoidarthritis.

ofcoronaryatherosclerosi sorSIHD.Examplesareprovidedin TableC

Deﬁnitionsfor Table2.2

Incompleterevascularization: CoronaryrevascularizationbyPCIorcoronaryarterybypassgraftwithsuspected orknownresidualobstructiveepicardialcoronaryartery stenosisthatmayormaynotbeamenabletorevascularization,orunrevascularizedcoronaryarteriesfollowing anacutecoronarysyndrome.Examplesincludean incompletesurgicalorpercu taneousrevascularization (unrevascularizedterritori esduetopoortargets,chronic occlusion,ordiffusedisease),priorMIwithoutculprit arteryrevascularization,orpriorMIwithresidual obstructiveCADinanon – infarct-relatedartery.

Priorhigh-riskPCI: Revascularizationposingahigherthan-normalriskforrestenosisorclosure(eg,PCIofa diffuselydiseasedsaphenousveingraft,treatmentof recurrentin-stentrestenosis )orahigherriskforadverse sequelaeshouldrestenosisoccur(eg,leftmaincoronary arteryPCIorsingleremainingvessel/conduit).

Deﬁnitionsfor Table2.4

Frequentprematureventricularcontractions(PVCs): Morethan30PVCsperhour. 36-38

InfrequentPVCs :ThirtyorfewerPVCsperhour. Sustainedventriculartachycardia(VT) :Cardiac arrhythmiaofconsecutivecomplexesoriginatinginthe ventriclesatarate >100beats/min(cyclelength: <600 milliseconds)lasting >30secondsorrequiringterminationduetohemodynamiccompromisein <30seconds.

NonsustainedVT :Cardiacarrhythmiaof $3consecutivecomplexesoriginatingintheventriclesatarate >100 beats/min(cyclelength: <600milliseconds)thatselfterminatesin <30secondsandwithouthemodynamic compromise.

Heartfailure :StagesB,C,andDheartfailure,as de ﬁ nedbytheACCF/AHAGuidelinefortheManagement ofHeartFailure. 39

Syncope: Asymptomthatpresentswithanabrupt, transient,completelossofconsciousness,associated withinabilitytomaintainposturaltone,withrapidand spontaneousrecovery.Thepresumedmechanismiscerebralhypoperfusion.Thereshouldnotbeclinicalfeaturesofothernonsyncopalcausesoflossof consciousness,suchasseizure,antecedenthead trauma,orapparentlossofconsciousness(ie,pseudosyncope). 40-42

5.ABBREVIATIONS

AUC ¼ AppropriateUseCriteria

CAD ¼ coronaryarterydisease

CMR ¼ cardiacmagneticresonance

CCTA ¼ coronarycomputedtomo graphyangiography

ECG ¼ electrocardiogram

Echo ¼ echocardiogram

MPI ¼ myocardialperfusionimaging

PCI ¼ percutaneouscoronaryintervention

PVC ¼ prematureventricularcontraction

SIHD ¼ stableischemicheartdisease

VT ¼ ventriculartachycardia

6.RESULTSOFRATINGS

The fi nalratingsforMultimodalityAUContheDetection andRiskAssessmentofCCDarelistedbyclinicalscenario in Tables1.1,1.2,1.3,2.1,2.2,2.3,and2.4 .The fi nalscore re fl ectsthemedianscoreofthe15ratingpanelmembers andhasbeenlabeledaccordingtothecategoriesof Appropriate(median7to9),MayBeAppropriate(median 4to6),andRarelyAppropriate(median1to3) ( SupplementalAppendix1 ).Thediscussionsectionhighlightsfurthergeneraltrendsinthescoringrelatedto speci fi cpatientpopulations.

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2455

7.MULTIMODALITYFORTHEDETECTIONAND RISKASSESSMENTOFISCHEMICHEARTDISEASE AUC(BYCLINICALSCENARIO)

TABLE1.1 SymptomaticPatientsWithNoKnownCCDandNoPriorTesting

1. n Less-likelyanginalsymptomswithanoncardiac explanation

2. n Less-likelyanginalsymptoms, age <50yand0or1CVriskfactor

3. n Less-likelyanginalsymptoms, age50yoraboveand/or $2CVriskfactors

4. n Likelyanginalsymptoms, age <50yand0or1CVriskfactor

5. n Likelyanginalsymptoms, age50yoraboveand/or $2CVriskfactors

CVriskfactors:diabetesmellitus,smoking,familyhistoryofprematureCAD,hypertension,dyslipidemia. A ¼ Appropriate;CAC ¼ coronaryarterycalcium;CAD ¼ coronaryarterydisease;cath ¼ cardiaccatheterization;CCD ¼ chroniccoronarydisease;CCTA ¼ coronarycomputed tomographyangiography;CMR ¼ cardiacmagneticresonance;CV ¼ cardiovascular;ECG ¼ electrocardiogram;echo ¼ echocardiography;M ¼ MayBeAppropriate;MPI ¼ myocardial perfusionimaging;R ¼ RarelyAppropriate.

TABLE1.2 SymptomaticPatientsWithoutKnownCCDandWithPriorTesting *

n CACscore ¼ 0(CAC-DRS0)M(5)M(6)M(6)M(6)M(5)R(1)M(5)

19. n CACscore1-99(CAC-DRS1)M(6)M(5)M(6)M(5)M(5)R(3)M(5)

20. n CACscore100-299(CAC-DRS2)A(7)A(7)A(7)A(7)A(7)M(5)M(4)

21. n CACscore $300(CAC-DRS3)A(7)A(7)A(7)A(7)M(6)M(6)R(3)

22. n InvasivecoronaryangiographywithmildornoCAD and/ornormalinvasivephysiologicaltesting ‡

23. n Invasivecoronaryangiographywithintermediate severityand/orinvasiveph ysiologicaltestingnotdone ‡

24. n InvasivecoronaryangiographywithobstructiveCAD and/orabnormalinvasivep hysiologicaltesting ‡

Ifgrayedout,ratingnotapplicable

*Referstosequentialtestingbeingdoneaspartofacontinuedpatientevaluationorapplicationofrecenttestingresultsinthereevaluationofapatient †StressimagingcouldbeSPECT,PET,echo,orCMR.

‡Referstodiagnosticangiography,notpercutaneouscoronaryintervention

A ¼ Appropriate;ASCVD ¼ atheroscleroticcardiovasculardisease;CAC ¼ coronaryarterycalciumscore;CAC-DRS ¼ CoronaryArteryCalciumDataandReportingSystem; CAD ¼ coronaryarterydisease;CAD-RADS ¼ CoronaryArteryDisease-ReportingandDataSystem;cath ¼ cardiaccatheterization;CCD ¼ chroniccoronarydisease;CCTA ¼ coronary computedtomographyangiography;CMR ¼ cardiacmagneticresonance;CTCA ¼ computedtomographycoronaryangiography;ECG ¼ electrocardiogram;echo ¼ echocardiography; ET exercisestresstest;M MayBeAppropriate;MPI myocardialperfusionimaging;PET positronemissiontomography;R RarelyAppropriate;SPECT single-photon emissiontomography.

ClinicalScenarioText ECG Treadmill Stress NuclearMPI Stress Echo Stress CMRCACCCTACathNoTest

R(3)R(2)R(2)R(2)R(3)R(1)R(1)A(8)

M(4)R(3)R(3)R(3)M(4)R(3)R(1)A(7)

M(6)M(6)M(6)M(5)M(6)M(5)R(2)M(4)

A(7)A(7)A(7)A(7)M(6)A(7)R(3)R(3)

A(7)A(8)A(8)A(7)M(5)A(7)A(7)R(1)

ClinicalScenarioText ECG Treadmill Stress NuclearMPI Stress Echo Stress CMRCACCCTACathNoTest 6.

7. n NormalETM(6)M(6)M(6)M(5)M(6)R(3)M(5) 8. n InconclusiveETA(8)A(8)A(7)M(5)A(8)M(5)R(3) 9. n AbnormalETA(8)A(8)A(7)M(4)A(8)A(8)M(5) 10. n Normalstressimaging † R(1)R(2)R(2)R(2)M(4)A(7)M(5)M(6) 11. n Mildischemiaonstressimaging † R(1)R(3)R(3)R(3)R(3)A(7)M(6)M(5) 12. n Inconclusivestressimaging † R(1)M(5)M(5)M(5)M(4)A(8)M(6)R(3) 13. n Moderatetosevereischemiaonstressimaging † R(1)R(1)R(1)R(1)R(2)A(7)A(9)M(4) 14. n CCTAwithnoCADorupto49% stenosis(CAD-RADS0-2) M(4)M(5)M(5)M(5)R(1)R(2)M(6) 15. n CCTAwithmoderatestenosis50%-69%(CAD-RADS3)M(6)A(7)A(7)A(7)R(1)A(7)M(5) 16.

17.

18.

n AbnormalECGM(4)A(8)A(8)A(8)M(5)A(8)M(5)M(4)

n CCTAwithseverestenosis $70%(CAD-RADS4-5)M(5)M(6)M(6)M(6)R(1)A(8)M(5)

n CCTAinconclusive(CAD-RADSN)A(7)A(8)A(8)A(8)R(1)A(7)R(3)

R(2)M(3)R(2)M(4)R(1)R(1)A(7)

M(5)A(7)A(8)A(7)R(1)R(1)M(4)

R(2)M(4)M(4)M(4)R(1)R(1)M(4)

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2456

n PriorMI,norevascularization,nonanginalsymptomsM(5)M(6)M(6)M(6)R(1)M(6)M(5)M(5)

n AssessmentofmyocardialviabilityR(1)A(8)A(7)A(8)R(1)R(1)R(1) 33. n Priortocardiacrehabilitation,coronarydisease (noneworworseningsymptoms) A(7)M(5)M(5)M(4)R(1)R(2)R(1)M(4)

Ifgrayedout,ratingnotapplicable.

A ¼ Appropriate;CABG ¼ coronaryarterybypassgraft;CAC ¼ coronaryarterycalciumscore;cath ¼ cardiaccatheterization;CCTA ¼ coronarycomputedtomographyangiography; CMR cardiacmagneticresonance;ECG electrocardiogram;echo echocardiography;M MayBeAppropriate;MPI myocardialperfusionimaging;MI myocardialinfarction; PCI ¼ percutaneouscoronaryintervention;R ¼ RarelyAppropriate.

TABLE2.1 AsymptomaticPatientsWithoutKnownASCVD

n IntermediateASCVDrisk7.5%to20% withorwithoutrisk-enhancingfactors †

38. n HighASCVDrisk >20%M(5)M(4)M(4)M(4)M(6)M(4)R(2)M(5)

*RiskcalculatedusingtheASCVDriskestimator.

†See TableC,Risk-EnhancingFactors.

A ¼ Appropriate;ASCVD ¼ atheroscleroticcardiovasculardisease;CAC ¼ coronaryarterycalciumscore;cath ¼ cardiaccatheterization;CCTA ¼ coronarycomputedtomography angiography;CMR cardiacmagneticresonance;ECG electrocardiogram;echo echocardiography;M MayBeAppropriate;MPI myocardialperfusionimaging;R Rarely Appropriate.

TABLE2.2 AsymptomaticPatientsWithPriorRevascularizationorMI

n IncompleterevascularizationM(5)M(6)M(6)M(6)R(1)M(4)R(2)M(5) 40. n Priorhigh-riskPCIM(4)M(6)M(5)M(5)R(1)M(4)R(3)M(5)

41. n <5yafterCABGR(2)R(2)R(2)R(2)R(1)R(3)R(1)A(7)

42. n >5yafterCABGM(4)M(4)M(4)M(4)R(1)M(4)R(2)A(7)

43. n <2yafterPCIR(2)R(2)R(2)R(2)R(1)R(2)R(1)A(7)

44. n >2yafterPCIM(5)M(5)M(5)M(5)R(1)M(4)R(1)A(7)

45. n Patientsathighriskfororwith ahistoryofsilentischemia *

M(4)A(7)A(7)A(7)R(1)M(5)R(3)M(5)

46. n AssessmentofmyocardialviabilityR(1)A(7)M(6)A(7)R(1)R(1)R(1)

47. n IsolatedevaluationofbypassgraftpatencyR(3)M(5)M(5)M(5)R(1)A(7)R(3)M(6)

Ifgrayedout,ratingnotapplicable.

*DiabetesmellituswithacceleratedprogressionofCAD,chronickidneydisease,peripheralarterydisease,priorbrachytherapy,in-stentrestenosis,saphenousveingraftintervention.43

A ¼ Appropriate;CABG ¼ coronaryarterybypassgraft;CAC ¼ coronaryarterycalciumscore;cath ¼ cardiaccatheterization;CCTA ¼ coronarycomputedtomographyangiography; CMR ¼ cardiacmagneticresonance;ECG ¼ electrocardiogram;echo ¼ echocardiography;M ¼ MayBeAppropriate;MI ¼ myocardialinfarction;MPI ¼ myocardialperfusionimaging; PCI percutaneouscoronaryintervention;R RarelyAppropriate.

ClinicalScenarioText ECG Treadmill Stress NuclearMPI Stress EchoStressCMRCACCCTACathNoTest 25. n IncompleterevascularizationM(4)A(8)A(8)A(7)R(1)R(3)M(6)M(4) 26. n PriorPCI,symptomssimilartopriorischemic episodeand/oranginalsymptoms M(5)A(8)A(8)A(8)R(1)M(5)A(7)M(5) 27. n PriorPCI,nonanginalsymptomsM(5)M(6)M(6)M(6)R(1)M(5)R(3)M(6) 28. n PriorCABG,symptomssimilartopriorischemic episodeand/oranginalsymptoms M(4)A(8)A(8)A(8)R(1)M(6)A(7)M(5) 29. n PriorCABG,nonanginalsymptomsM(5)M(6)M(6)M(6)R(1)M(6)R(3)M(5) 30. n PriorMI,norevascularization,symptomssimilarto priorischemicepisodeand/oranginal M(5)A(8)A(8)A(8)R(1)A(7)A(7)R(3) 31.

32.

TABLE1.3 SymptomaticPatientsWithPriorMIorRevascularization

ClinicalScenarioText ECG Treadmill Stress NuclearMPI Stress Echo Stress CMRCACCCTACathNoTest 34. n LowASCVDrisk <5% * R(2)R(1)R(1)R(1)M(4)R(1)R(1)A(8) 35. n BorderlineASCVDrisk5%to7.5%M(4)R(2)R(2)R(2)A(7)R(2)R(1)A(7) 36. n BorderlineASCVDrisk5%to7.5%with risk-enhancingfactors † M(4)R(3)R(3)R(3)A(7)R(3)R(1)A(7) 37.

M(5)R(3)R(3)R(3)A(8)R(3)R(1)M(5)

ClinicalScenarioText ECG Treadmill Stress Nuclear MPI Stress Echo Stress CMRCACCCTACath No Test 39.

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2457

exerciseprogram,withoutknown CCD

50. n PriortocardiacrehabilitationA(7)M(4)M(4)M(4)R(1)R(2)R(1)M(5) A Appropriate;CAC coronaryarterycalciumscore;cath cardiaccatheterization;CCD chroniccoronarydisease;CCTA coronarycomputedtomographyangiography;CMR cardiacmagneticresonance;ECG ¼ electrocardiogram;echo ¼ echocardiography;HFpEF¼ heartfailurewithpreservedejectionfraction;HFrEF ¼ heartfailurewithreducedejection fraction;M ¼ MayBeAppropriate;MI ¼ myocardialinfarction;MPI ¼ myocardialperfusionimaging;R ¼ RarelyAppropriate.

TABLE2.4 OtherCardiovascularConditionsinPatientsWithoutSymptomsofIschemia

Newly-DiagnosedHeartFailure(RestingLVFunctionPreviouslyAssessedbutNoPriorCADEvaluation)

51. n

55. n FrequentPVCsornonsustainedVTA(7)A(7)A(7)A(7)R(3)M(6)M(5)M(4)

n ParoxysmalsupraventriculartachycardiaM(5)R(2)R(3)R(3)R(1)R(2)R(1)M(5) 57. n New-onsetatrial ﬁ brillation/ ﬂ utterM(5)R(3)R(3)R(3)R(2)R(3)R(1)M(5)

n Priortoinitiationofantiarrhythmic therapyinpatientswithhighglobalCADrisk

59. n Exercise-inducedVTA(7)A(7)A(8)A(7)R(2)A(7)A(7)R(1)

63. n InitialevaluationsuggestsotheretiologyM(4)R(3)M(4)R(3)R(2)R(2)R(1)M(6)

Cardio-oncology

64. n Priorchestradiation,nosymptoms, >5yagoM(4)M(4)M(6)M(5)M(6)M(6)R(2)M(5)

Ifgrayedout,ratingnotapplicable

A ¼ Appropriate;CAC ¼ coronaryarterycalciumscore;CAD ¼ coronaryarterydisease;cath ¼ cardiaccatheterization;CCTA ¼ coronarycomputedtomographyangiography;CMR ¼ cardiacmagneticresonance;CV ¼ cardiovascular;ECG ¼ electrocardiogram;echo ¼ echocardiography;HFpEF¼ heartfailurewithpreservedejectionfraction;HFrEF ¼ heartfailure withreducedejectionfraction;M MayBeAppropriate;MPI myocardialperfusionimaging;PVC prematureventricularcontraction;R RarelyAppropriate;VT ventricular tachycardia.

TABLE2.3

fanExerciseProgramorCardiacRehabilitation ClinicalScenarioText Exercise ECG Stress NuclearMPI Stress Echo Stress CMRCACCCTACath No Test 48.

Priortoinitiationofanunsupervised

M(6)R(3)R(3)R(3)R(3)R(1)R(1)A(7) 49.

A(7)M(5)M(5)M(4)R(1)R(2)R(1)M(4)

AsymptomaticPatientsUndergoingAssessmento

n Priortoinitiationofanunsupervised exerciseprogram,withknownCCD

ECG Treadmill Stress Nuclear MPI Stress Echo Stress CMRCACCCTACathNoTest

ClinicalScenarioText

NewlydiagnosedHFpEFM(4)A(7)A(8)A(7)R(3)A(7)M(6)R(3) 52. n NewlydiagnosedHFrEFM(4)A(7)A(8)A(8)R(2)A(7)A(8)R(1) 53. n ScreeningfortransplantvasculopathyR(3)A(7)A(7)A(7)R(1)A(7)A(8) EvaluationofArrhythmiasWithoutIschemicEquivalent(NoPriorCardiacEvaluation)

54. n InfrequentPVCsM(4)R(2)R(2)R(2)R(2)R(1)R(1)A(8)

58.

60. n SustainedVTA(7)A(7)A(7)A(7)R(2)A(7)A(7)R(1) 61. n Ventricular ﬁ brillationM(4)A(7)A(7)A(7)R(1)A(7)A(8)R(1) SyncopeWithoutIschemicEquivalent 62. n InitialevaluationsuggestsCVabnormalitiesA(7)A(7)A(7)A(7)R(3)M(6)M(5)R(3)

56.

M(6)A(7)A(7)A(7)R(3)A(7)R(3)R(3)

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2458

ThefoundationforthisAUCdocumentisthe2013AUCfor MultimodalityImaginginSIHD,oneofthe fi rstdocumentstoshiftawayfromatest-modality – speci fi cfocus towardaclinicalfocus. 4 Inthisrevision,thewritinggroup soughttoproduceabalanceddocumentthatofferedease ofuseandacomprehensivelistofclinicalscenarios.The writinggroupestablishedaformalde fi nitionofCCD, whichhadnotbeendoneinpriorACCdocuments,to delineatethescopeofthedocument.Substantialchanges weremadetotheorganizational fl owchart,andsome tablesweresimpli fi edorremoved.Inafewinstances,the writinggroupfeltthatexpansionofscenarioswaswarrantedtocaptureclinicallyrelevantsituationsthatwere notacknowledgedinthepriorversion.BecausetheACC hasastandaloneAUCdocumentbeingdevelopedonthe managementofheartdiseaseintheperioperative/periproceduralsetting,thoseclinicalscenarioswereremoved fromthisdocument.Aswiththepriorversion,this documentrefersonlytopatien tswithstableconditions, andaseparateAUCaddressingacutechestpainsyndromesisbeingconsideredbytheACC.

Becauseofthesechanges,thisdocumentconsistsof 20%fewerclinicalscenarioscomparedwiththeprior iteration. 4 Althoughratingsinthisdocumentsupersede thoseinthe2013document,itshouldbenotedthatthe ACChassponsoredotherAUCdocumentsthatmayhave someoverlapwithscenariosinthisdocument.For example,the2017AUCforvalvularheartdiseaseprovide recommendationsonischemiatestingmodalitiesinpatientswithsyncopeandpalpitations. 44 TheAmerican CollegeofRadiologymaintainsmanyappropriateness documentsthathaveacategorizationstructurethatdiffersfromtheACC ’ s. 45 Thisrepresentsanareaofongoing uncertaintyforcliniciansandforhealthpolicybecause similarscenariosindocu mentsdevelopedthrough differentmethodsmayhavediscordantappropriateness ratings. 46

Asidefromchangesinclinicalscenarios,oneofthe mostsubstantialchangesinthisversionoftheAUCisthe inclusionofa “ notesting ” columnalongsidethenoninvasiveandinvasivetestingcolumns.Intermsofprecedentforthischange,the2018AUCforperipheralartery interventionincluded “ continueorintensifymedical therapy ” asanoptionalongsideinvasivemanagement options. 47 Thewritinggroupforthe2013AUCofmultimodalityimagingforSIHDacknowledgedinthediscussionthata “ notestatall ” ratingmayalsobeconsidered anoptionforsomeclinicalscenarios. 4 Thewritinggroup forthisdocumentfeltitwastimetoadopta “ notest ” columntoformallyacknowledgethattestingmaybe safelydeferredinsomesituations.Ratingofthe “ notest ”

optionwasomittedforselectedscenarioswherethe writinggroupdidnotthin kitapplicable.Clinicians shouldremainawarethattheappropriatenessoftesting deferral,aswiththeappropriatenessofothertesting modalities,maychangewhenthereisachangeinthe patient ’ sclinicalscenario.Ifsuchachangeoccurs,the appropriatenessofdeferringtestingandotheroptions shouldbeevaluatedunderthenewlyapplicableclinical scenario.

Theinclusionofthe “ notest ” columnintroducessome novelconsiderationsandpote ntialimplications.First, therearegenerallylessdataexaminingtheclinicalimpact onoutcomesandsafetyofnotperformingtesting comparedwithperformingtesting.Clinicalscenariosof patientsforwhomtestingwasconsideredandnotpursuedisdif ﬁ culttocaptureinmedicalrecords.Thismakes evaluationofdeferredtestingchallengingtoaudit.Second,thepresenceofa “ notest ” optionprovidesanopportunitytoengageinshareddecision-makingwith patients,allowingpersonalvaluesandpreferencesto weighonthechoicetoperformatest.Third,thewriting groupstronglyadvisesagainstuseofthisdocumentand itsratingsformakingblanketinsurancecoverageor reimbursementdecisions.Ifbothtestingand “ notest ” are ratedappropriateinagivenc linicalscenario,clinical decision-makingshouldbei nformedbytheindividual patient ’ ssituation.

InthisversionoftheAUC,thesummary fl owchart ( Figure1 )hasbeenrearrangedwithareducedhierarchyto trytomorecloselyfollowthe fl owofclinicaldecisionmaking.Thiswasintendedtomakenavigationtothe desiredclinicalscenarioeasi er.Thepriorversionofthe AUCforthedetectionandriskassessmentofSIHDnoted intheassumptions, “ Ifthepatient ’ scharacteristicsare capturedundermorethan1indication,thepatientshould becategorizedaccordingto thehierarchyprovidedin Figure1 ” 4 Inthecurrentversion,clinicianswillhaveto relyonclinicaljudgmentinsituationswhereapatient fi ts intomorethan1clinicalscenario.Bystartingthehierarchywithayes/noquestionaboutsymptoms,thedocumentpotentiallyfavorsthoseclinicalscenariosthatare moreoftenratedasappropriate(insymptomaticpatients) comparedwithotherscenariosinwhichapatientis asymptomatic.Thewritinggroupsuggeststhatwhena patient fi tsmorethan1scenario,thescenariobest matchingthepredominantclinicalquestionshouldbe applied.

Throughoutthewritingproc ess,thewritinggrouphad severaldiscussionsaboutwhethertodividecertain testingmodalitiesintosubtypes.Forexample,CTcould befurtheridenti ﬁ edascoronaryCTangiographyaloneor withCT-basedFFR,ornuclearMPIasPETorSPECT.Ultimately,thiswasnotdoneforseveralreasons.First,

8.DISCUSSION

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2459

althoughtherearepotentialclinicalreasonstoperform1 typeoftestoveranother,thosereasonsmaynotalways becapturedwithintheclinicalscenarios.Forexample,if PETprovidessuperiorimagequalitytoSPECTinpatients withobesity,buttheclinicalscenariosdonotspeci fi cally addresstestinginobesevsnormal-weightpatients,then theappropriatenessratingsarenotlikelytobedifferent andwouldaddunnecessarycomplexitytothetables. Second,fortheclinicalscenariosthatwereincluded,the writinggroupdidnotthinkthatidentifyingthespeci fi c subtypeswithinagivenimagingmodalitywouldresultin anysubstantialdifferenceintheratings(eg,forapatient withrecurrentanginalsymptomsafterPCI,bothSPECT andPETcouldbeappropriate).Third,theadditionof morecolumnscouldincreasethecomplexityandreduce theusabilityofthetables.Fourth,essentiallyallmodalitieshavesubtypes,andthewritinggroupdidnotbelieve itwouldbeappropriateorbene fi cialtoinclude1test modalitysubtypepreferentiallywithoutincludingall subtypesasseparatecolumns.Thepotentiallyrelevant differencesforindividualimagingmodalitiesare acknowledgedin TableA andshouldbeincorporatedwith clinicalfeatures,clinicaljudgment,andlocalavailability andexpertisewhenselectingatestingstrategy.

Asaresultoftheefforttosimplifyapplicationofthe AUCinthisversionofthedocument,thetermsforclassifyinganginawerechanged.Thepriorversionofthis documentusedtheterms typicalangina,atypicalangina, and nonanginalsymptoms ,whereasthisversionofthe AUCusestheterms likelyanginal and less-likelyanginal symptoms.Although atypicalangina hasaspeci fi cde finitionbasedoncriteriafromDiamondandForrester ’ s symptomclassi fi cation,thistermisknowntobeapplied incorrectlyinclinicalpractice.Forexample,forpatients withsymptomsthatmaybeischemic,consciousorunconsciousbiasonthepartoftheclinicianmayresultin thesymptomsbeinglabeledatypicaltojustifynotperformingatest.However,forpatientswithsymptoms unlikelytohaveanischemicorigin,thetermatypical anginacanbeusedtojustifytesting.In Table1.1 ,wehave includedaclinicalscenariowhereaclear,noncardiac etiologyispresenttodemonstrateforcliniciansthat testingshouldtypicallynotbeperformed “ justtobe sure. ” Duetotheseparateprocessesandthemethodology speci fi ctoguidelineandAUCdevelopment,theterms usedinthisdocumentdonotmirrorthe “ cardiac ” and “ possiblycardiac ” termsusedinthe2021chestpain guideline.ForusersofthisAUC,thewritinggroupconsiderstheterms “ likelyanginal ” and “ cardiac ” tobe equivalent,aswellas “ lesslikelyanginal ” and “ possibly cardiac. ”

Inclinicalscenariosforsymptomaticpatientswithno priortesting,therecommendationtocalculatethepretest likelihoodofobstructivecoronarydiseasehasbeen

removed( Table1.1 ).Theprimaryreasonforthischangeis thatthepretestlikelihoodstrategy,asdescribedinthe priorversionoftheAUC,doesnotperformwellatidentifyingpatientswhocouldsafelydefertestingorthoseat highpretestlikelihoodofobstructiveCAD.Contemporary cohortdatahasdemonstratedhowchangesintheepidemiologyofCADwarrantreth inkingthesetraditional strategies. 48 , 49 Thewritinggroupelectedtousethe simpli fi edsymptompro fi lesdescribedearlier,recognizingthatformanypatientswithsymptoms,testingfor CCDisappropriate.Byadoptingthisstrategy,thisversion oftheAUCforimaginginCCDisthe fi rsttoincorporate patientriskfactors,notjustageandsex,asrelevant considerationswhendecidingonatestforCCD.

Theapproachtosymptomaticpatientswithprior testinghasbeenredesignedinthisAUCdocument ( Table1.2 ).BasedontheavailableliteratureonhowAUC forCCDwerebeingusedinclinicalpractice,Tables2.0to 2.3inthe2013AUCwererarelyused.Bycollapsingthese scenariosintoasingletable,the fl owchartwassubstantiallysimpli fi ed.The2013documentusedacutoffof90 daystode fi nesequentialtestsperformedaspartofa continuedevaluationforagivenclinicalpresentationvs anoldertestwithlessclinicalrelevance.Althoughthisis animportantclinicaldistinction,thewritinggroup believedthatthe90-daytimecutoffwasarbitraryand electedtoprovide1tabletocoverallrecommendations forsequentialtesting.

Clinicalscenariosrelatedtotheassessmentofpatients withpriorrevascularizationhavealsobeenrevised,now basedonsymptomstatus( Table1.3 ).Speci ﬁ cally,patients withpriorrevascularizationarenowcategorizedbasedon whethertheirsymptomsareanginalorsimilarinquality topriorCCDepisodes.Thiswasdonewiththeintentof acknowledgingthatpatientswithpriorrevascularization mayexperienceawidearrayofsymptoms,someofwhich aremorelikelytobeischemic,andsomeofwhichare clearlynoncardiacinorigi n.Intheformer,invasive testingmaybewarranted,butinthelatter,ischemia testingcanoftenbedeferred. Acknowledgingtheresults ofrecentstudies,suchastheISCHEMIA(International StudyofComparativeHealthEffectivenessWithMedical andInvasiveApproach)trial,e ithertestingordeferralof testingmaybesuitableforsymptomaticpatientswith priorrevascularizationbasedontheirpreferencesand individualclinic alsituations. 50 , 51

Theclinicalscenariosforasymptomaticpatients withoutknownASCVD( Table2.1 )aresigni fi cantlymodifi edfromthepriordocument.InsteadofusingglobalCAD riskandECGinterpretabilityortheabilitytoexercise, thesescenariosintendedforASCVDscreeninghavebeen modi fi edbasedonthecategoriesof10-yearASCVDrisk andthepresenceofrisk-enhancingfactors.Priorchest radiation,coronaryarterycalci fi cationsonchestimaging,

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2460

andpriorchemotherapywithvasotoxicitypotentialare includedasadditionalconsiderations.Thereasonfor thesechangeswastobetteralignrecommendationsfor CCDtestingwiththepatientgroupsdescribedinthe clinicalguidelinesonprev entionandthemanagementof bloodcholesterol. 9 , 10

Theremainderofthetables, Tables2.2,2.3,and2.4 , includeafewadditionalclinicalscenariosclosingpotentialgapsinthepriorAUCandacknowledgingongoing changesinclinicalpractice.In Table2.2 ,scenarioshave beenaddedforassessinggraftpatencybeforeredosternotomy,forviabilityassessment,andformanagementof patientwithoratriskforsilentischemia. Table2.3 now providesrecommendationsforunsupervisedexercise prescriptionsinpatientswithandwithoutknownheart disease.Last, Table2.4 addsguidanceonscreeningfor transplantvasculopathy,testinginnewparoxysmalsustainedVTandatrial ﬂ utter,andanewheadingforcardiooncologyandassessmentofpatientswithahistoryof chestradiation.Thistableincludesscenariosforsyncope thathavechangedtoalignthisAUCdocumentwiththe 2017ACC/AHA/HRSsyncopegu ideline,whichprovides recommendationsforcardiovasculartestingbasedon history,physicalexamination,andECG. 42

Becauseofthesechangestotheclinicalscenarios,itis dif ﬁ culttocomparetheratingsforindividualscenarios andtestswiththoseinpriordocuments( Table1.1 ).Substantialchangestoscenariosfortheassessmentofpatientswithpriortestingandp riorMI/revascularization makecomparisonstothepriordocumentimmaterial ( Tables1.2and1.3 ).Althoughpatientswithoutsymptoms in Table2.1 arecategorizedinadifferentfashionthanin the2013document,theratingpanelfeltthatmosttesting isnotlikelywarrantedforthesepatients.Oneexceptionis CACscoring,whichhasgreat ersupportacrossthespectrumofrisk.Ratingsin Tables2.2and2.3 arelargelyunchanged.In Table2.4 ofthisdocument,manyofthe scenarioratingsareidentica ltothosefrom2013.Testing inthesettingofnew-onsetatrial ﬁ brillationisgenerally consideredrarelyappropriateinthisdocument,whereas sometestoptionswerepreviouslyratedasmaybe appropriate.

FutureDirections

TheACCiswellinto2decadesofpublishingAUCtohelp guidecliniciansonappropriatenessoftestsandproceduresforpatients.Weanticipatethatthesedocumentswill continuetoplayanimportantroleinday-to-daypractice andmaysoonhavealargerroleinmeasuringqualityata healthsystemlevelandthroughsocietalclinicalregistries.Currentdecision-supportsystemsareoftendif ﬁ cult

tonavigate,andwearehopefulthatelectronichealth recordvendorswillcontinuetoworkonstrategiesto implementAUCinawaythatautomaticallygathersrelevantdataformakingappropriatenessdeterminations.At present,administrativedatalacktheclinicalgranularity necessarytocapturetherelev antdetailsofclinicalscenariostoapplyappropriatenesscriteria.Inthefuture, patient-reportedsymptompro ﬁ lesmayhelpenhancethe patientvoiceandfurtherautomatetheprocess.

Limitations

AswithallpreviousversionsoftheAUC,therearelimitationstotheexerciseoftryingtosimplifymyriadpatient presentationstoabrieflistofclinicalscenarios.Some patientswillinevitablynot ﬁ ttheprecisede ﬁ nitions provided.Thetimescalefordraftingandrevisingsuch documentsmeanstherecommendationswillinherently lagbehindpublishedevidence.Forexample,workon developingtheclinicalscenariosandratingthetestoptionsprecededthepublicationofrecentchestpain guidelinesaswellasthependingchroniccoronarydiseasemanagementguide linesbymultipleyears. 52 Althoughthewritinggroupworkedinternallywiththe ACCtoeliminateanydisagreementswiththesedocuments,theycouldnotbeinherentlypartofthedevelopmentoftheseAUC.TheACCisd evelopingnewstrategies to “ chunk ” guidelinesandotherdocumentssothatthey willbeeasiertoupdateonashortertimetable.

9.CONCLUSIONS

The2023AUCformultimodalityimaginginCCDhasbeen substantiallyrevisedinanefforttomakeapplication easierandmorecloselyalignedtohowclinicaldecisions aremadeinpractice.Specia lattentionhasbeenpaidto aligningthisdocumentwithclinicalpracticeguidelines andcontemporaryscienti ﬁ cstudies.Severalinnovations havebeenintroduced,mostnotablyacolumnofratings for “ notest, ” reinforcingtheconceptthatnoteverypatientencounterwarrantsc ardiovasculartesting.

ACCPRESIDENTANDSTAFF

B.HadleyWilson,MD,FACC,President

CathyC.Gates,ChiefExecutiveOf ﬁ cer

JosephM.Allen,MA,TeamLead,ClinicalStandardsand SolutionSets

AmyDearborn,TeamLead,ClinicalPolicyContent Development

Mar ί aVelásquez,ProjectMa nager,AppropriateUse Criteria

GraceRonan,TeamLead,ClinicalPolicyPublications

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2461

REFERENCES

1. HendelRC,LindsayBD,AllenJM,etal.ACCappropriateusecriteriamethodology:2018update:areport oftheAmericanCollegeofCardiologyAppropriateUse CriteriaTaskForce. JAmCollCardiol.2018;18:935–948

2. PatelMR,SpertusJA,BrindisRG,etal.ACCFproposedmethodforevaluatingtheappropriatenessof cardiovascularimaging. JAmCollCardiol.2005;46: 1606–1613

3. HendelRC,PatelMR,AllenJM,etal.Appropriate useofcardiovasculartechnology:2013ACCFappropriateusecriteriamethodologyupdate:areportofthe AmericanCollegeofCardiologyFoundationAppropriateUseCriteriaTaskForce. JAmCollCardiol 2013;61:1305–1317

4. WolkMJ,BaileySR,DohertyJU,etal.ACCF/ AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS2013 multimodalityappropriateusecriteriaforthedetection andriskassessmentofstableischemicheartdisease:a reportoftheAmericanCollegeofCardiologyFoundationAppropriateUseCriteriaTaskForce,American HeartAssociation,AmericanSocietyofEchocardiography,AmericanSocietyofNuclearCardiology,Heart FailureSocietyofAmerica,HeartRhythmSociety,SocietyforCardiovascularAngiographyandInterventions, SocietyofCardiovascularComputedTomography,SocietyforCardiovascularMagneticResonance,andSocietyofThoracicSurgeons. JAmCollCardiol.2014;63: 380

406

5. FihnSD,GardinJM,AbramsJ,etal.2012ACCF/ AHA/ACP/AATS/PCNA/SCAI/STSguidelineforthe diagnosisandmanagementofpatientswithstable ischemicheartdisease:areportoftheAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines,andthe AmericanCollegeofPhysicians,AmericanAssociation forThoracicSurgery,PreventiveCardiovascularNurses Association,SocietyforCardiovascularAngiography andInterventions,andSocietyofThoracicSurgeons. JAmCollCardiol.2012;60:e44–e164

6. FitchK,BernsteinSJ,AguilarMD,etal. TheRAND/ UCLAAppropriatenessMethodUser’sManual.RAND Corporation;2001

7. FletcherGF,AdesPA,KligﬁeldP,etal.Exercise standardsfortestingandtraining. Circulation 2013;128:873–934

8. HechtH,BlahaMJ,BermanDS,etal.Clinicalindicationsforcoronaryarterycalciumscoringin asymptomaticpatients:expertconsensusstatement fromtheSocietyofCardiovascularComputedTomography. JCardiovascComputTomogr.2017;11:157–168

9. GrundySM,StoneNJ,BaileyAL,etal.2018AHA/ ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/ NLA/PCNAguidelineonthemanagementofblood cholesterol:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceon ClinicalPracticeGuidelines. JAmCollCardiol.2019;73: e285–e350

10. ArnettDK,BlumenthalRS,AlbertMA,etal.2019 ACC/AHAguidelineontheprimarypreventionofcardiovasculardisease:areportoftheAmericanCollege ofCardiology/AmericanHeartAssociationTaskForce onClinicalPracticeGuidelines. JAmCollCardiol 2019;74:e177–e232

11. TheIntersocietalAccreditationCommission.EchocardiographyStandards.AccessedJune9,2017. https://intersocietal.org/wp-content/uploads/2021/ 07/IACAdultEchocardiographyStandards2023.pdf

12. PellikkaPA,Arruda-OlsonA,ChaudhryF,etal. Guidelinesforperformance,interpretation,application ofstressechocardiographyinischemicheartdisease: AmericanSocietyofEchocardiography. JAmSoc Echocardiogr.2020;33:1–41.e8

13. PicardMH,AdamsD,BierigSM,etal.American SocietyofEchocardiographyrecommendationsfor qualityechocardiographylaboratoryoperations. JAm SocEchocardiogr.2011;24:1–10

14. TheIntersocietalAccreditationCommission.Nuclear PETStandards.AccessedMay10,2018. https://www. intersocietal.org/nuclear/seeking/nuclear_standards.htm

15. TheAmericanCollegeofRadiology.Nuclearmedicine&PETaccreditation.AccessedMay10,2018. https://www.acraccreditation.org/modalities/nuclearmedicine-and-pet

16. HenzlovaMJ,DuvallWL,EinsteinAJ,etal.ASNC imagingguidelinesforSPECTnuclearcardiologyprocedures:stress,protocols,andtracers. JNuclCardiol 2016;23:606–639

17. DorbalaS,AnanthasubramaniamK,ArmstrongIS, etal.Singlephotonemissioncomputedtomography (SPECT)myocardialperfusionimagingguidelines: instrumentation,acquisition,processing,andinterpretation. JNuclCardiol.2018;25:1784–1846

18. DilsizianV,BacharachSL,BeanlandsRS,etal. ASNCimagingguidelines/SNMMIprocedurestandard forpositronemissiontomography(PET)nuclearcardiologyprocedures. JNuclCardiol.2016;23:1187–1226

19. TheIntersocietalAccreditationCommission.MRI standards.AccessedMay10,2018. https://www. intersocietal.org/mri/seeking/mri_standards.htm

20. TheAmericanCollegeofRadiology.Accreditation MRIprogramrequirements.AccessedMay10,2018. https://www.acraccreditation.org/modalities/mri

21. KramerCM,BarkhausenJ,FlammSD,etal.Standardizedcardiovascularmagneticresonance(CMR) protocols2013update. JCardiovascMagnReson 2013;15:91

22. HundleyWG,BluemkeD,BogaertJG,etal.Society forCardiovascularMagneticResonanceguidelinesfor reportingcardiovascularmagneticresonanceexaminations. JCardiovascMagnReson.2009;11:5

23. TheIntersocietalAccreditationCommission.CT/ dentalCTaccreditation.AccessedMay10,2018. https:// www.intersocietal.org/ct/seeking/ct_standards.htm

24. TheAmericanCollegeofRadiology.CTaccreditation.AccessedMay10,2018. https://www. acraccreditation.org/modalities/ct

25. LeipsicJ,AbbaraS,AchenbachS,etal.SCCT guidelinesfortheinterpretationandreportingofcoronaryCTangiography:areportoftheSocietyofCardiovascularComputedTomographyGuidelines Committee. JCardiovascComputTomogr.2014;8(5): 342–358

26. AbbaraS,BlankeP,MaroulesCD,etal.JSCCT guidelinesfortheperformanceandacquisitionofcoronarycomputedtomographicangiography:areportof thesocietyofCardiovascularComputedTomography

GuidelinesCommittee:endorsedbytheNorthAmericanSocietyforCardiovascularImaging(NASCI). JCardiovascComputTomogr.2016;10:435–449

27. CuryRC,AbbaraS,AchenbachS,etal.CADRADSTMCoronaryArteryDisease – ReportingandData System.AnexpertconsensusdocumentoftheSociety ofCardiovascularComputedTomography(SCCT),the AmericanCollegeofRadiology(ACR)andtheNorth AmericanSocietyforCardiovascularImaging(NASCI). EndorsedbytheAmericanCollegeofCardiology. JCardiovascComputTomogr.2016;10:269–281

28. NaiduSS,AronowHD,BoxLC,etal.SCAIexpert consensusstatement:2016bestpracticesinthecardiaccatheterizationlaboratory. CatheterCardiovasc Interv.2016;88:407–423

29. TheAccreditationforCardiovascularExcellence. 2015Cath/PCIstandards.AccessedMay10,2018. http://www.cvexcel.org/CathPCI/Standards.aspx

30. LancellottiP,PellikkaPA,BudtsW,etal.The clinicaluseofstressechocardiographyinnonischaemicheartdisease:recommendationsfromthe EuropeanAssociationofCardiovascularImagingand theAmericanSocietyofEchocardiography. JAmSoc Echocardiogr.2017;30(2):101–138. https://doi.org/10. 1016/j.echo.2016.10.016

31. ChambersCE,FetterlyKA,HolzerR,etal.Radiation safetyprogramforthecardiaccatheterizationlaboratory. CatheterCardiovascInterv.2011;77:546–556

32. DouglasPS,CarrJJ,CerqueiraMD,etal.Developinganactionplanforpatientradiationsafetyin adultcardiovascularmedicine:proceedingsfromthe DukeUniversityClinicalResearchInstitute/American CollegeofCardiologyFoundation/AmericanHeartAssociationThinkTankheldonFebruary28,2011.JAm CollCardiol.2012;59:1833–1847.

33. HalliburtonSS,AbbaraS,ChenMY,etal.SCCT guidelinesonradiationdoseanddose-optimization strategiesincardiovascularCT. JCardiovascComput Tomogr.2011;5:198–224

34. AmericanAssociationofPhysicistsinMedicine.The AAPMPositionStatementonRadiationRisksfrom MedicalImagingProcedures.AccessedJanuary20, 2018. http://www.aapm.org/org/policies/details.asp? id¼318&type¼pp&current¼true

35. MieresJH,GulatiM,MerzNB,etal.2014roleof noninvasivetestingintheclinicalevaluationofwomen withsuspectedischemicheartdisease. Circulation 2014;130:350–379

36. BikkinaM,LarsonMG,LevyD.Prognosticimplicationsofasymptomaticventriculararrhythmias:the FraminghamHeartStudy. AnnInternMed.1992;117: 990–996

37. Al-KhatibSM,StevensonWG,AckermanMJ,etal. 2017AHA/ACC/HRSguidelineformanagementofpatientswithventriculararrhythmiasandtheprevention ofsuddencardiacdeath:areportoftheAmerican CollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonClinicalPracticeGuidelinesand theHeartRhythmSociety. JAmCollCardiol.2018;72: e91

e220

38. AtaklteF,ErqouS,LaukkanenJ,etal.Meta-analysisofventricularprematurecomplexesandtheir relationtocardiacmortalityingeneralpopulations. Am JCardiol.2013;112:1263–1270

–

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 – 2467 2462

39. YancyCW,JessupM,BozkurtB,etal.2013ACCF/ AHAguidelineforthemanagementofheartfailure:a reportoftheAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonPractice Guidelines. JAmCollCardiol.2013;62:e147–e239

40. SheldonRS,GrubbBP,OlshanskyB,etal.2015 HeartRhythmSocietyexpertconsensusstatementon thediagnosisandtreatmentofposturaltachycardia syndrome,inappropriatesinustachycardia,andvasovagalsyncope. HeartRhythm.2015;12:e41–e63.34b

41. MoyaA,SuttonR,AmmiratiF,etal.Guidelinesfor thediagnosisandmanagementofsyncope(version 2009). EurHeartJ.2009;30:2631–2671

42. ShenWK,SheldonRS,BendittDG,etal.2017ACC/ AHA/HRSguidelinefortheevaluationandmanagementofpatientswithsyncope:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociation TaskForceonClinicalPracticeGuidelinesandtheHeart RhythmSociety. JAmCollCardiol.2017;70(5):e39–e110

43. LawtonJS,Tamis-HollandJE,BangaloreS,etal. 2021ACC/AHA/SCAIguidelineforcoronaryartery revascularization:areportoftheAmericanCollegeof Cardiology/AmericanHeartAssociationJointCommitteeonClinicalPracticeGuidelines. JAmCollCardiol 2022;79:e21–e129

44. DohertyJU,KortS,MehranR,etal.ACC/AATS/ AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS2017 appropriateusecriteriaformultimodalityimagingin

valvularheartdisease:areportoftheAmericanCollegeofCardiologyAppropriateUseCriteriaTaskForce, AmericanAssociationforThoracicSurgery,American HeartAssociation,AmericanSocietyofEchocardiography,AmericanSocietyofNuclearCardiology,Heart RhythmSociety,SocietyforCardiovascularAngiographyandInterventions,SocietyofCardiovascular ComputedTomography,SocietyforCardiovascular MagneticResonance,andSocietyofThoracicSurgeons. JAmCollCardiol.2017;70:1647–1672

45. AmericanCollegeofRadiology.ACRAppropriatenessCriteria.AccessedAugust6,2021. https://www.acr. org/Clinical-Resources/ACR-Appropriateness-Criteria

46. WinchesterDE,WolinksyD,BeythRJ,etal. Discordancebetweenappropriateusecriteriafornuclearmyocardialperfusionimagingfromdifferent specialtysocieties:apotentialconcernforhealthpolicy. JAMACardiol.2016;1:207–210

47. BaileySR,BeckmanJA,DaoTD,etal.ACC/ AHA/SCAI/SIR/SVM2018appropriateusecriteriafor peripheralarteryintervention:areportofthe AmericanCollegeofCardiologyAppropriateUse CriteriaTaskForce,AmericanHeartAssociation, SocietyforCardiovascularAngiographyandInterventions,SocietyofInterventionalRadiology, andSocietyforVascularMedicine. JAmCollCardiol.2019;73:214– 237

48. KnuutiJ,WijnsW,SarasteA,etal.ESCScientiﬁc DocumentGroup.2019ESCguidelinesforthe

diagnosisandmanagementofchroniccoronarysyndromes:TheTaskForceforthediagnosisandmanagementofchroniccoronarysyndromesofthe EuropeanSocietyofCardiology(ESC),. EurHeartJ 2020;41:407–477

49. KnuutiJ,BalloH,Juarez-OrozcoLE,etal.The performanceofnon-invasiveteststorule-inandruleoutsigniﬁcantcoronaryarterystenosisinpatientswith stableangina:ameta-analysisfocusedonpost-test diseaseprobability. EurHeartJ.2018;39(35):3322–3330

50. MaronDJ,HochmanJS,ReynoldsHR,etal, ISCHEMIAResearchGroup.Initialinvasiveorconservativestrategyforstablecoronarydisease. NEnglJ Med.2020;382:1395–1407

51. SpertusJA,JonesPG,MaronDJ,etal,ISCHEMIA ResearchGroup.Health-statusoutcomeswithinvasive orconservativecareincoronarydisease. NEnglJMed 2020;382:1408–1419

52. GulatiM,LevyPD,MukherjeeD,etal.2021AHA/ ACC/ASE/CHEST/SAEM/SCCT/SCMRguidelineforthe evaluationanddiagnosisofchestpain:areportofthe AmericanCollegeofCardiology/AmericanHeartAssociationJointCommitteeonClinicalPracticeGuidelines. JAmCollCardiol.2021;78:e187–e285

KEYWORDS AppropriateUseCriteria,CCD, chroniccoronarydisease,multimodality

APPENDIX.AUTHORRELATIONSHIPSWITHINDUSTRY(RWI)ANDOTHERENTITIES(RELEVANT) — 2023

MULTIMODALITYAPPROPRIATEUSECRITERIAFORTHEDETECTIONANDRISKASSESSMENTOF CHRONICCORONARYDISEASE

TheACCandtheSolutionSetOversightCommittee (SSOC)recognizetheimportanceofavoidingrealor perceivedrelationshipswithindustry(RWI)orotherentitiesthatmayaffectclinic alpolicy.TheACCmaintainsa databasethattracksallrelevantrelationshipsforACC membersandpersonswhoparticipateinACCactivities, includingthoseinvolvedinthedevelopmentofAUC.AUC documentsfollow ACCRWIPolicy indeterminingwhat constitutesarelevantrelationship,withadditionalvettingbytheSSOC.

Anevenmorespeci ﬁ cRWIpolicyappliestothewriting groupandratingpanelforAUC:

n AUCwritinggroupsmustbechairedorcochairedbyan individualwithnorelevantRWI.Vicechairs,however, mayhaverelevantRWI,alongwiththeotherwriting groupmembers.Whilewritinggroupmembersplayan

importantroleinthedevelopmentand ﬁ nalpublication ofAUC,theydonothaveanyinvolvementintherating processordeterminationofthe ﬁ nalscores.

n AUCratingpanelmembersareinvolvedintheactual ratingofscenariosandassuch, <50%mayhaverelevantRWI.Furthermore,themoderatoroftherating panelmaynothaverelevantRWI.

Relevantdisclosuresforthewritinggroup,rating panel,reviewers,andSSOCmemberscanbefoundin this Appendix .Toensurecompletetransparency,afull listofdisclosureinformation ,includingrelationships notpertinenttothisdocument,isavailablein SupplementalAppendix2 .Participantsarediscouraged fromacquiringrelevantRWIthroughoutthewritingand ratingprocess.

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 – 2467 AUCforMMIofChronicCoronaryDisease 2463

UniversityofFlorida,Divisionof Cardiology ProfessorofMedicineand Radiology

ACCNoneNoneNoneNoneNoneNone

SCCT n Amgen,Inc n CaristoDiagnostics n Novartis * NoneNone n Amgen,Inc † n Novartis n SCCT(Of ﬁ cer)None

ACCNoneNoneNoneNoneNoneNone

SCAI n IMDSNoneNone n AbbottVascular * n Amgen,Inc * n BostonScienti ﬁ c * n Cardiovascular Systems,Inc * n CSI * n Medtronic * n Philips/ Spectranetics * n ReCorMedical * NoneNone

RaymondY.KwongBrighamandWomen’sHospital Directorof CardiacMagneticResonanceImaging

PatriciaA.PellikkaMayoClinicCollegeofMedicine Professor ofMedicine

AlexanderT.

University ProfessorofMedicine

presentingConsultant Speakers Bureau Ownership/ Partnership/ PrincipalPersonalResearch Institutional, Organizational, orOther FinancialBene ﬁ t Expert Witness WritingGroup

ParticipantEmploymentRe

DavidE. Winchester, Co-Chair ACCNoneNoneNoneNoneNoneNone

DavidJ.Maron, Co-Chair StanfordUniversitySchoolofMedicine ProfessorofMedicine,Cardiovascular, Director,PreventiveCardiology

RonBlanksteinBrighamandWomen’sHospital Associate Director,CardiovascularImagingProgram, ProfessorofMedicine,HarvardMedical School

IanC.ChangMayoClinic AssistantProfessorof Medicine,andGeorgetownUniversity AssistantProfessorofMedicine

SCMRNoneNoneNone n Alnylam,Inc * n MyoKardia,Inc * n SCMR(Of ﬁ cer)None

ASE n Ultromics n UpToDate * NoneNone n Bracco † n Edwards Lifesciences n GEHealthcare † n LantheusMedical Imaging † n OxThera † n Ultromics n ASEFoundation † n NationalHeart, Lung,andBlood Institute † None

HRSNoneNoneNoneNone n UpToDate * None RaymondRussellAlpertMedicalSchoolofBrown

ASNCNoneNone n Dicerna * n Terns Pharmaceutical * None n Dicerna * n Terns Pharmaceutical * None

ACCNoneNoneNoneNoneNoneNone Continuedonthenextpage APPENDIX.CONTINUED Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 –2467 2464

AjayJ.KirtaneColumbiaUniversityMedicalCenter ProfessorofMedicine,ChiefAcademic Ofﬁce,DirectorNYP/ColumbiaCardiacCath

JordanM.PrutkinWashingtonMedicalUniversity ProfessorofMedicine

Sandhu StanfordUniversitySchoolofMedicine InstructorofMedicine

ParticipantEmploymentRepresentingConsultant

W.Patricia Bandettini NationalInstitutesofHealth Medical Ofﬁcer,HeartFailure&ArrhythmiasBranch

DennisA.CalnonOhioHealthHeartandVascular Physicians RiversideMethodistHospital, CardiacImaging,Director

ManuelD. Cerqueira ClevelandClinicFoundation Chairman, DepartmentofMolecularand FunctionalImaging

LarryS.DeanMedicineRegionalHeartCenterUniversity ofWashingtonSchoolofMedicine ProfessorofMedicineandSurgery,Director

MilindY.DesaiClevelandClinicFoundation,Heartand VascularInstitute ProfessorofMedicine

HowardJ.EisenPennsylvaniaStateHeartandVascular Institute MedicalDirector,Advanced HeartFailure,CardiacTransplantPrograms

StephenE.FremesSunnybrookHealthSciencesCentre, DivisionofCardiacandVascularSurgery Professor,DepartmentofSurgery

n Bayer(COMPASS) ‡

n Bayer(Galileo) ‡

n BostonScienti ﬁ c (NeoAcurateII Study) ‡

n Edwards(The Multidisciplinary, Multimodalitybut Minimalist[3M] Approachto TransfemoralTranscatheterAorticValve Replacement) ‡

n HLT,Inc(Radiant study) ‡

n Medtronic (MedtronicTAVR LowRisk) ‡

n Medtronic (SURTAVI) ‡

n Medtronic(Evolut-R FORWARD) ‡

n BernardGoldman ChairinCardiovascularSurgery *

Speakers Bureau Ownership/ Partnership/ PrincipalPersonalResearch Institutional, Organizational, orOther FinancialBene ﬁ t Expert Witness RatingPanel

SCMRNoneNoneNoneNoneNoneNone

ASNCNoneNoneNoneNone n ASNC(Of ﬁ cer)None

ACCImaging Council n AstellasPharma * n AstellasPharma * NoneNoneNoneNone

ACC n Tele ﬂ exNone n Emageon n Edwards Lifesciences * NoneNone

ACC n BristolMyersSquibb

n Medtronic NoneNoneNoneNoneNone

CaristoDiagnostics

ACCNoneNoneNoneNoneNoneNone

ACCNoneNoneNoneNone

None

STSNoneNoneNoneNoneNoneNone Continuedonthenextpage APPENDIX.CONTINUED JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 –2467 AUCforMMIofChronicCoronaryDisease 2465

MarioF.L.GaudinoWeillCornellMedicalCollege Stephenand SuzanneWeissProfessorinCardiothoracic Surgery,ProfessorofCardiothoracic Surgery

LindaD.GillamMorristownMedicalCenter,Departmentof CardiovascularMedicine Chair

NicoleL.LohrMedicalCollegeofWisconsin, CardiovascularMedicine Professorof Medicine

JosephE.MarineJohnsHopkinsUniversitySchoolof Medicine,CardiovascularMedicine ProfessorofMedicine

KhurramNasirHoustonMethodistDeBakeyCardiology Associates,PreventiveCardiology ProfessorofCardiology

LesleeJ.ShawIcahnSchoolofMedicineatMountSinai HospitalMountSinai Director,Blavatnik FamilyWomen’sHealthResearchInstitute, ProfessorofMedicine

JacquelineE. Tamis-Holland IcahnSchoolofMedicineatMountSinai HospitalMountSinai Director,Women s HeartNY,AssistantProfessorofMedicine, Director,InterventionalCardiology Fellowship

NitiR.AggarwalMayoClinic AssistantProfessorof Medicine

DanielS.BermanCedars-SinaiMedicalCenter,Department ofImaging Director,CardiacImaging

MatthewJ.BudoffLosAngelesBiomedicalResearch Institute ProgramDirector,Divisionof Cardiology

Reviewer

Council&SCCT

ter SoftwareRoyalties *

ParticipantEmploymentRepresentingConsultant Speakers Bureau Ownership/ Partnership/ PrincipalPersonalResearch Institutional, Organizational, orOther FinancialBene ﬁ t Expert Witness

ASE n EdwardsLifesciences * n Egnite n Medtronic * n Philips * NoneNone n Edwards Lifesciences * n Medtronic * n CirculationImaging (Of ﬁ cer) None

AHANoneNoneNoneNoneNoneNone

HRSNoneNoneNoneNoneNoneNone

ASPC n Amgen,Inc * n

n Novartis n Amgen,IncNoneNoneNoneNone

Esperion

SCCTNoneNoneNoneNoneNoneNone

SCAINoneNoneNoneNoneNoneNone L.SamuelWannCardiovascularDiseaseConsultantACCNoneNoneNoneNoneNoneNone

ProfessorofMedicine ACC n InformedMedicalDe-

n AnnalsofInternal

CollegeofPhysicians)

NoneNone n Patient-Centered OutcomesResearch Institute(PI) * n UnitedStatesPreventiveServices TaskForce(Member) None Reviewers

JohnB.WongTuftsUniversitySchoolofMedicine

cisionsFoundation: Healthwise

Medicine(American

LeadSSOC

NoneNoneNoneNoneNoneNone

ACCImaging

NoneNoneNoneNoneNone

CedarsSinaiMedicalCen-

GeneralElectronic

SCCT n

n Amarin * n

n AstraZeneca

NoneNoneNoneNone Continuedonthenextpage

Winchester etal JACCVOL.81,NO.25,2023 AUCforMMIofChronicCoronaryDisease JUNE27,2023:2445 –2467 2466

Esperion *

Amgen,Inc *

Pharmaceuticals *

Boehringer Ingelheim Pharmaceuticals * n NovoNordisk *

APPENDIX.CONTINUED

ParticipantEmploymentRepresentingConsultant

AndrewJ.EinsteinColumbiaUniversityIrvingMedicalCenter, DepartmentofMedicine

AssociateProfessorofMedicineinRadiology

VictorA.FerrariHospitaloftheUniversityofPennsylvania ProfessorofMedicine;AssociateDirector, CardiovascularImaging

TheodoreJ.KoliasUniversityofMichiganCardiovascular Center AssociateProfessorofMedicine

JonathonLeipsicUniversityofBritishColumbia,Department ofRadiology ProfessorofRadiologyand Cardiology

BrianOlshanskyUniversityofIowaCarverCollege,Division ofElectrophysiology EmeritusProfessor ofMedicine

HarmonyR. Reynolds NYUGrossmanSchoolofMedicine, DepartmentofMedicine Associate ProfessorofMedicine

PeterP.TothUniversityofIllinoisCollegeofMedicine, DivisionofCardiology AdjunctProfessor ofMedicine

HowardS. Weintraub NYUGrossmanSchoolofMedicine, DepartmentofMedicine ClinicalProfessor ofMedicine

DavidH.WienerJeffersonMedicalCollege,JeffersonHeart Institute ProfessorofMedicine

RWIanddisclosurestatementsformembersoftheSSOCcanbefoundhere:

https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/guidelines-and-documents-task-forces

Thistablerepresents relevant relationshipsofparticipantswithindustryandotherentitiesthatwerereportedatthetimethisdocumentwasunderdevelopment.Thetabledoesnot necessarilyreflectrelationshipswithindustryatthetimeofpublication. Apersonhasa relevant relationshipIF:therelationshiporinterestrelatestothesameorsimilarsubjectmatter,intellectualpropertyorasset,topic,orissueaddressedinthedocument;thecompany/entity(withwhomtherelationshipexists)makesa drug,drugclass,ordeviceaddressedinthedocument,ormakesacompetingdrugordeviceaddressedinthedocument;orthepersonoramemberoftheperson’shouseholdhasareasonablepotentialfor financial,professional,orotherpersonalgainor lossasaresultoftheissues/contentaddressedinthedocument.Apersonisdeemedtohavea significant interestinabusinessiftheinterestrepresentsownershipof $5%ofthevotingstockorshareofthebusinessentity,orownershipof $$5,000of thefairmarketvalueofthebusinessentity;oriffundsreceivedbythepersonfromthebusinessentityexceed5%oftheperson’sgrossincomeforthepreviousyear.Relationshipsinthistablewithnosymbolareconsidered modest (lessthansignificant undertheprecedingdefinition).Relationshipsthatexistwith no financialbenefit arealsoincludedforthepurposeoftransparency.Pleasereferto http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industrypolicy fordefinitionsofdisclosurecategoriesoradditionalinformationabouttheACCDisclosurePolicyforWritingCommittees.

*Signiﬁcantrelationship.

†No ﬁnancialbeneﬁt.

‡Clinicaltrialenroller.

ACC ¼ AmericanCollegeofCardiology;AHA ¼ AmericanHeartAssociation;ASE ¼ AmericanSocietyofEchocardiography;ASNC ¼ AmericanSocietyofNuclearCardiology;ASPC ¼ AmericanSocietyofPreventiveCardiology;AUC ¼ appropriateuse criteria;HRS ¼ HeartRhythmSociety;SCAI ¼ SocietyforCardiovascularAngiographyandInterventions;SCCT ¼ SocietyofCardiovascularComputedTomography;SCMR ¼ SocietyforCardiovascularMagneticResonance;SSOC ¼ SolutionSetOversight Committee.

Speakers Bureau Ownership/ Partnership/ PrincipalPersonalResearch Institutional, Organizational, orOther FinancialBene ﬁ t Expert Witness

ASNC n ActiniaNoneNone n CanonMedical Systems * n GEHealthcare * n RocheMedical Systems * n W.L.Goreand Associates * n NovoNordisk * n ASNC(Of fi cer) † n JACCImaging (Of fi cer) † n JournalofNuclear Cardiology(Of fi cer) † None

SCMRNoneNoneNoneNone n JournalofCardiovascularMagnetic Resonance(Of ﬁ cer) † None

ASENoneNoneNoneNoneNoneNone

SCCT n CIRCL * n MVRX * n GEHealthcare n Philips n CIRCLCVI * n Heart fl ow * . n Heart fl owInc * n Abbott n BostonScienti fi c n Edwards n Medtronic None

HRSNoneNoneNoneNone n AstraZeneca(DSMB)None

AHANoneNoneNoneNoneNoneNone

ASPC n Amarin n Kowa * n Amgen,Inc * n Esperion n Amgen,Inc * NoneNoneNoneNone

ASPC n Amgen,Inc n Novartis NoneNone n Akcea * n Amarin n Amgen,Inc * NoneNone

ASENoneNoneNoneNoneNoneNone

SolutionSetOversightCommittee

JACCVOL.81,NO.25,2023 Winchester etal JUNE27,2023:2445 –2467 AUCforMMIofChronicCoronaryDisease 2467