R. Parker Ward

ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging

Peter Alagona, JR, MD, FACC* Timothy M. Bateman, MD, FACC† Manuel D. Cerqueira, MD, FACC, FAHA, FASNC† James R. Corbett, MD, FACC‡ Anthony J. Dean, MD, FACEP§ Gregory J. Dehmer, MD, FACC, FAHA* Peter Goldbach, MD, FACC Leonie Gordon, MB, CHB¶ Frederick G. Kushner, MD, FACC# Raymond Y. Kwong, MD, MPH, FACC** James Min, MD, FACC†† Miguel A. Quinones, MD, FACC‡‡ R. Parker Ward, MD, FACC† Michael J. Wolk, MD, MACC* Scott H. Yang, MD, PHD, FACC*

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1128 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1128

Female Gender Is an Independent Predictor of Operative Mortality After Coronary Artery Bypass Graft Surgery Contemporary Analysis of 31 Midwestern Hospitals

Background—Women have a higher operative mortality (OM) after coronary artery bypass graft (CABG) surgery than men. Suggested contributing factors have included women’s increased age, advanced disease, comorbidities, and smaller body surface area (BSA). It is unclear whether women’s increased risk factors fully account for this difference or whether female gender within itself is associated with increased OM. We attempted to determine whether, all other factors being equal, there is a significant difference in OM between men and women undergoing CABG. Methods and Results—We retrospectively reviewed a clinical database of 15,440 patients who underwent CABG at 31 Midwestern hospitals in 1999–2000. Each patient record consisted of >400 data elements. Risk-adjusted mortality rates were computed using a predictive equation derived by stepwise logistic regression. Overall, women were older, had a higher incidence of diabetes and valvular disease, and were more likely to be presenting in shock. The OM for the entire population was 2.88% (women 4.24% versus men 2.23%, P<0.0001). Lower BSA was found to be an independent predictor of increased mortality, and a direct inverse relationship between BSA and OM was noted. After adjusting for all comorbidities including BSA, female gender remained an independent predictor of increased mortality (risk-adjusted OM was 3.81% for women and 2.43% for men). Thus, whereas risk adjustment reduced women’s OM from 90% higher than men’s to 22% higher, a significant difference remained. Conclusions—In this contemporary data set from 31 Midwestern hospitals, female gender was an independent predictor of perioperative mortality, even after accounting for all comorbidities, including low BSA.

ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria for Diagnostic Catheterization

The American College of Cardiology Foundation, in collaboration with the Society for Cardiovascular Angiography and Interventions and key specialty and subspecialty societies, conducted a review of common clinical scenarios where diagnostic catheterization is frequently considered. The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of noninvasive imaging appropriate use criteria. The 166 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3). Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease with other procedure components (e.g., hemodynamic measurements, ventriculography) at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the use of coronary angiography at the discretion of the operator. Seventy-five indications were rated as appropriate, 49 were rated as uncertain, and 42 were rated as inappropriate. The appropriate use criteria for diagnostic catheterization have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

Evaluation of the American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria for SPECT myocardial perfusion imaging.

Background. The American College of Cardiology Foundation/American Society of Nuclear Cardiology appropriateness criteria (AC) were created to guide responsible use of single photon emission computed tomography (SPECT). Clinical applicability of the AC has not been evaluated.Methods and Results. Indications for testing were determined in 1209 patients and categorized as having appropriate, uncertain, or inappropriate indications; the specialty of the ordering physician was noted. There were 940 (80%) appropriate, 154 (13%) inappropriate, and 79 (7%) uncertain tests; 36 tests were labeled “no category,” as these were ordered for indications not clearly addressed in the AC. Inappropriate studies had more normal and lower summed stress scores, although there remained a high proportion of abnormal SPECT studies in this group (26% of women and 50% of men). Women had lower summed stress scores and more normal tests in the appropriate and inappropriate groups. Studies ordered by anesthesiologists for preoperative evaluation were more likely to be deemed inappropriate than other specialty groups.Conclusion. In evaluating the AC in a single-center academic setting, the majority of studies are appropriate, but a large proportion of ordered SPECT studies were categorized as uncertain, inappropriate, or no category. Although the inappropriate studies showed less ischemia than other groups, especially in women, a substantial portion of these studies (32%) were abnormal.

Prospective evaluation of the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria for transthoracic echocardiography.

We sought to prospectively evaluate the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria (AC) for transthoracic echocardiography in a single-center university hospital. Indications for transthoracic echocardiograms (TTE) were prospectively determined for consecutive studies by 2 reviewers and categorized, according to the AC for TTE, as appropriate (A) or inappropriate (I). The overall level of agreement in characterizing appropriateness between reviewers was high (kappa = 0.83). Among the 1,553 studies for which a primary indication was determined, 89% were covered in the AC for TTE. Of these studies, 89% were A, and 11% were I. New important TTE abnormalities were more common on A compared with I studies (40% vs. 17%, p < 0.001), and noncardiac specialists more frequently ordered I studies (13% vs. 9%, p = 0.04). In conclusion, the AC for TTE encompasses the majority of clinical indications for TTE and appears to reasonably stratify TTE ordering. However, revisions will be needed to fully capture and stratify appropriate clinical practice.

The association between erectile dysfunction and peripheral arterial disease as determined by screening ankle-brachial index testing

BACKGROUND Peripheral arterial disease (PAD) is a potent marker of adverse cardiovascular prognosis, yet PAD frequently remains asymptomatic or undiagnosed. Erectile dysfunction (ED) has been associated with atherosclerosis, but whether ED is an independent predictor of PAD is unknown. We hypothesized that ED is a marker for previously undiagnosed PAD, and thus ED may identify men who would benefit from screening ankle-brachial index (ABI). METHODS 690 male patients (pts) who had been referred for stress testing, and were without known PAD were prospectively screened for ED and PAD, using the International Index of Erectile Function (IIEF) questionnaire, and ABI, respectively. ED was defined by a score of <or=25 on the ED domain of the IIEF, PAD was defined as an ABI<or=0.9. RESULTS ED was present in 45% of pts and PAD was present in 23%. Of pts found to have PAD, 66% reported no lower extremity symptoms. Men with ED were found to have significantly more PAD than men without ED (32% vs. 16%, p<0.01), and there was a stepwise increase in the prevalence of PAD with increasing ED severity (28% of men with mild ED, 33% with moderate ED, 40% with severe ED, p<0.001). On multivariate logistic regression analysis ED (OR 1.97, 95% CI 1.32-2.94, p=0.002), was an independent predictor of PAD. CONCLUSIONS In men referred for stress testing, erectile dysfunction is an independent predictor of PAD as determined by screening ABI examination, and increasing severity of ED is associated with increasing prevalence of PAD. These results suggest that men with ED might be targeted for screening ABI evaluation.

Comparison of the Clinical Application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria for Outpatient Transthoracic Echocardiography in Academic and Community Practice Settings

BACKGROUND We sought to compare the clinical application of the American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Criteria (AC) for outpatient transthoracic echocardiography (TTE) in academic and community practice settings. METHODS Indications for TTE ordered in both academic and community practice settings were determined by 2 reviewers and categorized according to the AC for TTE as Appropriate, Inappropriate, or Not Addressed. Patient characteristics, ordering physician specialty, and TTE findings were also recorded. RESULTS Overall, 814 academic and 319 community TTEs were analyzed. Interobserver variability for indication determination was high and did not differ between studies ordered at the 2 practice settings. Compared with the academic practice, community practice TTE indications were more likely to be classified in the AC for TTE (88% vs 82%, P = .04), but were ordered for a similar frequency of Appropriate (71% vs 68%, P = not significant) and Inappropriate (17% vs 15%, P = not significant) indications. New important TTE abnormalities were more frequently found in Appropriate studies compared with Inappropriate studies in both academic (35% vs 16%, P < .001) and community practice (29% vs 15%, P = .04) settings. CONCLUSION The clinical application of the AC for TTE is feasible, and the frequency of Appropriate and Inappropriate outpatient TTEs is similar in academic and community practice settings. However, limitations of the AC for TTE are identified that suggest revisions will be needed to fully encompass and stratify the broad clinical practice of echocardiography.

ACC/AHA/ASE/ASNC/HRS/IAC/Mended Hearts/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SNMMI 2014 health policy statement on use of noninvasive cardiovascular imaging: a report of the American College of Cardiology Clinical Quality Committee.

Joseph P. Drozda, Jr, MD, FACC, Chair Deepak L. Bhatt, MD, MPH, FACC Joseph G. Cacchione, MD, FACC Blair D. Erb, Jr, MD, FACC Thomas A. Haffey, DO, FACC Robert A. Harrington, MD, FACC[†††][1] Jerry D. Kennett, MD, MACC Richard J. Kovacs, MD, FACC Harlan M. Krumholz, MD, SM, FACC

ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/ SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging

The American College of Cardiology (ACC) and the American Heart Association (AHA) support their members’ goal to improve the prevention and care of cardiovascular diseases through professional education, research, development of guidelines and standards, and by fostering policy that supports optimal patient outcomes. The ACC and AHA recognize the importance of the use of clinical data standards for patient management, to assess outcomes, and conduct research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform …