Ronan Grace, Wolk Michael J, Bailey Steven R, Doherty John U, Douglas Pamela S, Hendel Robert C, Kramer Christopher M, Min James K, Patel Manesh R, Rosenbaum Lisa, Shaw Leslee J, Stainback Raymond F, Allen Joseph M, Brindis Ralph G, Kramer Christopher M, Shaw Leslee J, Cerqueira Manuel D, Chen Jersey, Dean Larry S, Fazel Reza, Hundley W Gregory, Itchhaporia Dipti, Kligfield Paul, Lockwood Richard, Marine Joseph Edward, McCully Robert Benjamin, Messer Joseph V, O'Gara Patrick T, Shemin Richard J, Wann L Samuel, Wong John B, Patel Manesh R, Kramer Christopher M, Bailey Steven R, Brown Alan S, Doherty John U, Douglas Pamela S, Hendel Robert C, Lindsay Bruce D, Min James K, Shaw Leslee J, Stainback Raymond F, Wann L Samuel, Wolk Michael J, Allen Joseph M
Clinical Policy and Documents, American College of Cardiology, 2400 N Street, N.W., Washington, DC, 20036, USA,
J Nucl Cardiol. 2014 Feb;21(1):192-220. doi: 10.1007/s12350-013-9841-9.
The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1-9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram (ECG). Testing for the evaluation of new or worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patients who had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECG was suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.
美国心脏病学会基金会联合主要的专科和亚专科协会，对稳定型缺血性心脏病（SIHD）的常见临床表现进行了合理应用审查，以考量负荷试验和解剖诊断程序的使用情况。本文档反映了先前发布的关于SIHD的放射性核素成像（RNI）、负荷超声心动图（Echo）、钙化积分、冠状动脉计算机断层扫描血管造影（CCTA）、负荷心脏磁共振成像（CMR）以及有创冠状动脉造影的合理使用标准（AUC）的更新。这与定期修订和完善AUC的承诺相一致。本文档的一项重大创新是针对同一适应症对各项检查进行并列评级。并列评级消除了因先前针对每项检查使用单独文档而产生的关于适应症或解读差异的任何担忧。然而，由于比较证据有限、患者个体差异以及任何特定当地环境中可用的能力范围，这些评级明确不是竞争性排名。本次审查的适应症仅限于SIHD的检测和风险评估，取材于常见应用或预期用途以及当前临床实践指南。一个写作委员会制定了80种临床场景，并由一个单独的评级小组按照1 - 9分的等级进行评分，以根据最近更新的AUC制定方法，通过改良的德尔菲法指定为适当、可能适当或很少适当使用。在对表现为缺血等效症状、新诊断心力衰竭、心律失常和晕厥的患者进行初始评估时，发现使用某些检查方式通常是适当或可能适当的，但在低预测试概率或低风险限制了除运动心电图（ECG）外大多数检查益处的情况下除外。对于先前检查或操作后出现新症状或症状加重的评估进行检查被认为是适当的。此外，对于先前结果异常或不确定的患者在90天内进行检查被认为是适当或可能适当的。术前检查仅对功能能力差且正在接受血管手术或具有1个或更多临床风险因素的中危手术或器官移植的患者被评为适当或可能适当。运动心电图被建议作为心脏康复许可或运动处方目的的适当检查。在无症状患者中进行检查通常被认为很少适当，但中高危个体的钙化积分和运动试验以及高危个体的负荷或解剖成像除外，这些均被评为可能适当。在先前检查或经皮冠状动脉介入治疗（PCI）后2年内以及冠状动脉旁路移植术（CABG）后5年内且无新症状的所有随访检查方式均被评为很少适当。对于功能能力良好、1年内先前检查正常或低风险手术前的患者进行术前检查也被认为很少适当。除心力衰竭患者的心脏康复许可外，用于运动处方或心脏康复开始前的成像很少适当。
