Laboratory of Cardiovascular CT, Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
Laboratory of Cardiovascular CT, Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Austin Heart and St. David's Healthcare, Austin, TX, USA.
J Cardiovasc Comput Tomogr. 2020 Nov-Dec;14(6):478-482. doi: 10.1016/j.jcct.2020.01.014. Epub 2020 Feb 3.
Multiple appropriate use criteria (AUC) exist for the evaluation of coronary artery disease (CAD), but there is little data on the agreement between AUC from different professional medical societies. The aim of this study is to compare the appropriateness of coronary computed tomography angiography (CCTA) exams assessed using multimodality AUC from the American College of Cardiology Foundation (ACCF) versus the American College of Radiology (ACR).
In a single-center prospective cohort study from June 2014 to 2016, 1005 consecutive subjects referred for evaluation of known or suspected CAD received a contrast-enhanced CCTA. The primary outcome was the agreement of appropriateness ratings using ACCF and ACR guidelines, measured by the kappa statistic. A secondary outcome was the rate of obstructive CAD by appropriateness rating.
Among 1005 subjects, the median (5-95th percentile) age was 59 (37-76) years with 59.0% male. The ACCF criteria classified 39.6% (n = 398) appropriate, 24.2% (n = 243) maybe appropriate, and 36.2% (n = 364) rarely appropriate. The ACR guidelines classified 72.3% (n = 727) appropriate, 2.6% (n = 26) maybe appropriate, and 25.1% (n = 252) rarely appropriate. ACCF and ACR appropriateness ratings were in agreement for 55.0% (n = 553). Overall, there was poor agreement (kappa 0.27 [95% confidence interval 0.23-0.31]). By both AUC methods, a low rate of obstructive CAD was observed in the rarely appropriate exams (ACCF 7.1% [n = 26 of 364] and ACR 13.5% [n = 34 of 252]).
Compared to ACCF criteria, the ACR guidelines of appropriateness were broader and classified significantly more CCTA exams as appropriate. The poor agreement between appropriateness ratings from the ACCF and ACR AUC guidelines evokes implications for reimbursement and future test utilization.
有多种合适的使用标准（AUC）可用于评估冠状动脉疾病（CAD），但关于不同专业医学协会的 AUC 之间的一致性的数据很少。本研究的目的是比较美国心脏病学会基金会（ACCF）与美国放射学会（ACR）多模态 AUC 评估的冠状动脉计算机断层血管造影术（CCTA）检查的适当性。
在 2014 年 6 月至 2016 年期间进行的一项单中心前瞻性队列研究中，1005 例连续就诊于已知或疑似 CAD 的患者接受了增强型 CCTA。主要结局是使用 ACCF 和 ACR 指南评估的适当性评分的一致性，通过kappa 统计量进行测量。次要结局是适当性评分的阻塞性 CAD 发生率。
在 1005 例患者中，中位（5-95 百分位数）年龄为 59（37-76）岁，59.0%为男性。ACCF 标准将 39.6%（n=398）评为适当，24.2%（n=243）评为可能适当，36.2%（n=364）评为很少适当。ACR 指南将 72.3%（n=727）评为适当，2.6%（n=26）评为可能适当，25.1%（n=252）评为很少适当。ACCF 和 ACR 适当性评分的一致性为 55.0%（n=553）。总体而言，一致性较差（kappa 值为 0.27[95%置信区间为 0.23-0.31]）。根据两种 AUC 方法，很少适当的检查中观察到阻塞性 CAD 的发生率较低（ACCF 为 7.1%[n=364 中的 26 例]和 ACR 为 13.5%[n=252 中的 34 例]）。
与 ACCF 标准相比，ACR 适宜性指南更广泛，将更多的 CCTA 检查归类为适宜。ACCF 和 ACR AUC 指南的适宜性评分之间的一致性较差，这对报销和未来的测试利用产生了影响。
