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Appropriateness Criteria

Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. 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 appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 4 4 11
References Study Quality
1 (32809231) 4
2 (32463967) 4
25 (16012124) 3
26 (27068546) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 3 10 3 3
References Study Quality
15 (20513610) 4
16 (27918725) 4
MRI heart function and morphology without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 5 8 3 2
References Study Quality
16 (27918725) 4
Nuclear medicine ventriculography Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 2 3 10 2 1
References Study Quality
23 (28335788) 3
22 (22154116) 3
21 (32748278) 3
20 (3605130) 2
US echocardiography transesophageal May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 1 5 9 2 1 0 0 0
References Study Quality
1 (32809231) 4
2 (32463967) 4
US echocardiography transthoracic stress May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 8 4 4 2 0 0
References Study Quality
1 (32809231) 4
2 (32463967) 4
MRI heart function with stress without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 6 4 7 1 0 0
References Study Quality
16 (27918725) 4
MRI heart function with stress without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 0 5 9 3 2 0 0 0
CT coronary calcium May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 1 8 4 4 1 0 1
References Study Quality
14 (28342038) 2
13 (31272536) 4
12 (35441347) 4
11 (31784032) 4
10 (30894318) 4
CTA coronary arteries with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 3 6 4 4 1 0 0
N-13 ammonia PET/CT heart May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 0 1 3 10 2 3 0 0 0
References Study Quality
19 (34820770) 3
18 (31741325) 3
17 (32919154) 3
CT heart function and morphology with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 1 10 3 3 2 0 0
Rb-82 PET/CT heart May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 0 0 1 11 3 4 0 0 0
References Study Quality
19 (34820770) 3
SPECT or SPECT/CT heart May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 0 0 1 12 3 3 0 0 0
References Study Quality
24 (26072421) 2
US duplex Doppler lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 3 2 0 0 0 0 0
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 3 3 5 3 4 2 3 0 1 0 0
Arteriography coronary Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 3 2 0 1 0 0 0 0
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 5 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 5 3 0 2 1 0 0 0
References Study Quality
9 (36216699) 4
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 4 3 1 2 0 1 0 0
References Study Quality
9 (36216699) 4
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 3 3 2 1 0 1 0 0
References Study Quality
9 (36216699) 4
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 5 3 1 1 0 0 0 0
CTA chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 8 5 4 0 1 0 0 0 0
CTA pulmonary arteries with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 9 3 5 1 0 0 0 0 0
PYP scan heart Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 1 8 1 1 0 0 1 0
References Study Quality
2 (32463967) 4
PYP scan with SPECT or SPECT/CT heart Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 2 7 1 1 0 0 1 0
References Study Quality
2 (32463967) 4
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. 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 appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 2 3 13
References Study Quality
1 (32809231) 4
45 (30414755) 2
44 (29984789) 2
43 (27296561) 3
42 (22744937) 2
41 (30092972) 4
40 (12534739) 3
39 (23847385) 4
38 (26530752) 2
US echocardiography transthoracic stress Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 1 0 1 1 7 2 5
References Study Quality
1 (32809231) 4
42 (22744937) 2
41 (30092972) 4
40 (12534739) 3
39 (23847385) 4
38 (26530752) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 3 6 9
References Study Quality
37 (28395671) 2
36 (35730658) 4
35 (35718419) 4
34 (34536111) 2
33 (33606757) 3
32 (33404058) 4
31 (33029698) 4
30 (27183525) 4
MRI heart function and morphology without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 4 9 4 2
References Study Quality
37 (28395671) 2
36 (35730658) 4
35 (35718419) 4
34 (34536111) 2
33 (33606757) 3
32 (33404058) 4
31 (33029698) 4
30 (27183525) 4
MRI heart function with stress without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 2 9 5 3
References Study Quality
36 (35730658) 4
35 (35718419) 4
34 (34536111) 2
33 (33606757) 3
32 (33404058) 4
31 (33029698) 4
30 (27183525) 4
CTA coronary arteries with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 1 0 0 0 6 7 5
References Study Quality
9 (36216699) 4
29 (33555007) 4
Rb-82 PET/CT heart Usually appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 7 7 0 0 1 0 2 2 8 5 1
SPECT or SPECT/CT heart Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 1 1 3 2 6 5 1
References Study Quality
24 (26072421) 2
US echocardiography transesophageal May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 1 6 7 4 1 0 0
References Study Quality
1 (32809231) 4
45 (30414755) 2
44 (29984789) 2
43 (27296561) 3
42 (22744937) 2
41 (30092972) 4
40 (12534739) 3
39 (23847385) 4
38 (26530752) 2
Radiography chest May be appropriate (Disagreement) Expert Opinion ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 2 1 0 1 0 3 8 3 1
Arteriography coronary May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 0 5 7 6 1 0 0
References Study Quality
27 (30611123) 3
28 (32236322) 3
Arteriography coronary with ventriculography May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 7 5 6 1 0 0
MRI heart function with stress without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 1 1 10 4 0
References Study Quality
36 (35730658) 4
35 (35718419) 4
34 (34536111) 2
33 (33606757) 3
32 (33404058) 4
31 (33029698) 4
30 (27183525) 4
CTA pulmonary arteries with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 5 5 0 2 0 6 4 6 0 1 0
N-13 ammonia PET/CT heart May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 0 1 0 2 1 3 6 5 1
Nuclear medicine ventriculography May be appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 2 4 6 6 0 0
References Study Quality
20 (3605130) 2
23 (28335788) 3
CT heart function and morphology with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 5 4 5 4 0 0
References Study Quality
9 (36216699) 4
29 (33555007) 4
US duplex Doppler lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 4 4 1 1 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 5 8 1 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 6 3 1 4 2 0 2 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 6 6 0 0 0 0 0 0
CT coronary calcium Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 7 5 0 0 0 0 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 5 9 2 0 0 0 0 0
CTA chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 4 8 7 0 0 0 0 0 0
PYP scan heart Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 8 3 5 0 2 0 0 0 0
PYP scan with SPECT or SPECT/CT heart Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 3 5 0 2 1 0 0 0
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.