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Imaging Appropriateness Criteria: Coronary Computed Tomography Angiography

chest pain

Coronary artery disease affects 18 million adults in the United States each year. In patients with stable chest pain, a standard exercise treadmill or nuclear medicine stress test have traditionally been the mainstay of diagnostic testing. A growing body of evidence demonstrates that use of coronary computed tomography angiography for patients with stable chest pain can improves outcomes without an increase in interventional procedures, through improved medical management and optimized percutaneous coronary interventions. Cardiac events and emergency department visits are decreased. Additionally, coronary CTA use can decrease cost of care through reductions in downstream testing and hospital admissions.

Johns Hopkins University School of Medicine (JHUSOM) is one of only 22 qualified provider-led entities designated by CMS to develop appropriate use criteria for their advanced imaging regulation, which includes imaging for patients with coronary artery disease. A multispecialty committee of physicians evaluated the evidence from a systematic literature review to design AUCs for advanced imaging, as detailed in the table below. A complete diagnostic imaging guideline is available in Epic (search for Guidelines), through which orders can be placed.

Downloadable chart.

TitleClinical scenario 1:  Low pretest probability and able to perform ETTClinical scenario 2:  Intermediate pretest probability and able to perform ETTClinical scenario 3:  High pretest probability and able to perform ETTClinical scenario 4:  Low pretest probability and unable to perform ETTClinical scenario 5:  Intermediate pretest probability and unable to perform ETTClinical scenario 6:  High pretest probability and unable to perform ETT
DefinitionAll of the following
• able to exercise
• EKG interpretable
• low pretest probability of CAD
All of the following
• able to exercise
• EKG interpretable
• intermediate pretest probability of CAD
All of the following
• able to exercise
• EKG interpretable
• high pretest probability of CAD
All of the following
• unable to exercise OR EKG interpretable or abnormal
• low pretest probability of CAD
All of the following
• unable to exercise OR EKG interpretable or abnormal
• intermediate pretest probability of CAD
All of the following
• unable to exercise OR EKG interpretable or abnormal
• high pretest probability of CAD
Consistent with AUC

• Coronary CTA
• Exercise Treadmill Test
• Stress Echocardiography

• Coronary CTA
• Nuclear Medicine MPI 
• Stress MRI
• Stress echocardiography
• Coronary CTA 

• Coronary CTA
•  Stress echocardiography

• Coronary CTA
• Nuclear Medicine MPI 
• Stress MRI
• Stress echocardiography
• Coronary CTA  
Allowable by AUC  

• Exercise Treadmill Test
• Cardiac PET

• Stress Echocardiography
• Stress MRI
• Nuclear Medicine MPI
• Cardiac PET

• Nuclear Medicine MPI 
• Stress MRI
• Stress echocardiography
• Cardiac PET 
• Cardiac PET • Nuclear Medicine MPI 
• Stress MRI
• Stress echocardiography
• Cardiac PET  
Does not meet AUC

• Nuclear Medicine MPI
• Stress MRI
• Cardiac PET
• Coronary artery calcium screening

• Coronary artery calcium screening • Coronary artery calcium screening   • Coronary artery calcium screening • Coronary artery calcium screening • Coronary artery calcium screening

 

Reference:

England R, Sheikhbahaei S, Solomon A, Zadeh A, Solnes L, Bronner J, Johnson PT, When more is better:  Underused advanced imaging exams that can improve outcomes and reduce cost of care. American Journal of Medicine in press.