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Appropriateness Criteria

Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 0 0 0 0 0 0 0 0 0
US echocardiography transthoracic stress Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
20 (17719283) Good
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
21 (25916321) 4
MRA coronary arteries without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
21 (25916321) 4
MRI heart function and morphology without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
22 (27550660) 4
MRI heart function and morphology without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
22 (27550660) 4
MRI heart function with stress without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
22 (27550660) 4
MRI heart function with stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
CT coronary calcium Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 0 0 0 0 0 0 0 0 0
References Study Quality
15 (28283309) 4
14 (26841074) 3
16 (30935842) 4
17 (29153576) 3
18 (28196265) 3
CTA coronary arteries with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
19 (18652943) 4
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 0 0 0 0 0 0 0 0 0
References Study Quality
23 (29200864) 4
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT coronary calcium Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 1 0 0 1 3 8 3
References Study Quality
29 (20424251) 3
24 (12743005) 4
26 (17481445) 3
30 (20946997) 3
25 (12869688) 3
31 (26724526) 3
28 (25459592) 3
27 (22974805) 4
32 (22718782) 3
33 (29713929) 4
3 (30423393) 4
CTA coronary arteries with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 0 10 4 1 0 0 0
References Study Quality
33 (29713929) 4
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 3 3 0 1 0 0 1 0
US echocardiography transthoracic stress Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 8 2 0 0 0 0 0 0
References Study Quality
34 (18565214) M
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 11 3 0 0 1 0 1 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 9 0 0 0 0 0 0 0
References Study Quality
35 (27221073) 3
36 (23878103) 3
MRA coronary arteries without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 6 0 0 0 0 0 0 0
References Study Quality
35 (27221073) 3
36 (23878103) 3
MRI heart function and morphology without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 7 1 0 0 0 0 0 0
MRI heart function and morphology without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 6 1 0 0 0 0 0 0
MRI heart function with stress without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 9 4 2 0 0 1 0 0 0
References Study Quality
37 (22390914) 2
MRI heart function with stress without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 1 1 9 6 1 0 0 0 0 0 0
References Study Quality
37 (22390914) 2
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 5 6 4 1 0 0 0 0 0
References Study Quality
38 (21181519) 4
39 (24556531) 4
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT coronary calcium May be appropriate Limited ☢☢☢ 1-10 mSv 6 6 0 0 0 1 3 5 6 1 0
References Study Quality
40 (19520336) 4
41 (21856482) 4
CTA coronary arteries with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 1 6 7 2 0 0
References Study Quality
43 (26754124) 2
42 (25205531) 2
46 (25402757) 3
45 (24468142) 2
48 (29778864) 3
44 (25332810) 2
47 (29604092) 2
49 (29685675) Good
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 3 4 0 2 1 0 0 1
US echocardiography transthoracic stress Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 8 2 0 0 0 0 0 0
References Study Quality
20 (17719283) Good
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 10 1 2 1 0 1 0 1 0
MRA coronary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 5 4 0 0 0 0 0 0
References Study Quality
35 (27221073) 3
36 (23878103) 3
MRA coronary arteries without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 9 5 2 0 0 0 0 0 0
References Study Quality
35 (27221073) 3
36 (23878103) 3
MRI heart function and morphology without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 4 2 0 0 0 0 0
MRI heart function and morphology without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 5 2 1 0 0 0 0 0
MRI heart function with stress without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 1 2 4 0 0 0 0
MRI heart function with stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 5 1 1 2 0 0 0 0
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 5 4 3 0 4 0 0 0 0
References Study Quality
51 (19366774) 2
52 (25240454) 1
38 (21181519) 4
50 (25596143) Good
53 (26846937) 4
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.