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Appropriateness Criteria

Variant 1: Adult. Suspected cardiac mass. No known cardiac mass. 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 1 0 0 0 0 0 2 2 8
References Study Quality
39 (21757159) 3
38 (2768712) 4
29 (16824834) 3
35 (32036237) 2
32 (19679285) 1
37 (32279620) 4
19 (26765302) 4
9 (34396236) 4
MRI heart function and morphology without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 1 0 0 0 2 7 3
References Study Quality
36 (25913472) 4
35 (32036237) 2
31 (26476503) 1
32 (19679285) 1
33 (12460863) 4
34 (18598895) 2
29 (16824834) 3
28 (36216604) 4
20 (32936016) 4
30 (25129516) 3
19 (26765302) 4
CT heart function and morphology with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 1 2 1 4 3 1
References Study Quality
26 (32900226) 4
25 (19179202) 2
24 (22495682) 1
22 (36779342) 2
21 (35918169) 1
23 (35935656) 1
20 (32936016) 4
19 (26765302) 4
US echocardiography transesophageal May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 2 0 3 6 2 1 0
References Study Quality
19 (26765302) 4
28 (36216604) 4
29 (16824834) 3
37 (32279620) 4
38 (2768712) 4
MRI heart function and morphology without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 1 0 2 4 6 0 0
References Study Quality
36 (25913472) 4
35 (32036237) 2
32 (19679285) 1
33 (12460863) 4
34 (18598895) 2
CTA chest with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 2 4 0 4 3 0 0 0
References Study Quality
27 (23406625) Good
22 (36779342) 2
19 (26765302) 4
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 4 1 0 2 0 0 0 0
MRA chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 4 6 0 0 0 0 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 5 0 0 0 0 0 0
MRI chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 6 5 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 2 7 5 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 6 3 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 6 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] 2 2 3 5 6 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 2 4 2 0 0 1 0 0
References Study Quality
18 (23926237) 4
CTA coronary arteries with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 5 0 1 0 0 0 0
DOTATATE PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 2 4 0 1 0 0 0 0
FDG-PET/MRI heart Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 4 4 1 2 0 1 0 0
References Study Quality
3 (34081218) 4
MIBG scan whole body with SPECT or SPECT/CT chest Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 4 2 0 0 0 0 0 0
FDG-PET/CT heart Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 4 5 2 1 0 0 0 0
References Study Quality
28 (36216604) 4
FDG-PET/CT skull base to mid-thigh Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 3 0 1 0 0 0 0
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 8 2 3 1 0 0 0 0 0
Variant 2: Adult. Known cardiac mass in echocardiography. Unknown etiology. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US echocardiography transesophageal Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 2 7 3 0
References Study Quality
46 (32040684) 3
82 (2131359) 4
86 (22283202) 4
87 (22805540) 4
US echocardiography transthoracic resting Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 3 7 2 1
References Study Quality
9 (34396236) 4
52 (22918770) 4
91 (28793276) 2
92 (32003068) 1
94 (24691169) 4
93 (25933602) 1
90 (29183343) 3
88 (36218203) 4
68 (34825795) 4
87 (22805540) 4
89 (36610495) 3
MRI heart function and morphology without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 1 1 3 7
References Study Quality
85 (33419643) 2
84 (27904982) 4
81 (28138817) 4
80 (26552505) 4
82 (2131359) 4
83 (38502734) 2
73 (27236529) 3
76 (27146445) 2
79 (34545397) 4
74 (30084570) 2
78 (30616453) 2
77 (30551963) 2
75 (26838354) 4
72 (22002687) 4
71 (28092290) 4
40 (33629237) 4
5 (35347934) 4
48 (30337716) 3
68 (34825795) 4
46 (32040684) 3
30 (25129516) 3
FDG-PET/MRI heart Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 0 0 1 0 11 1 1
References Study Quality
70 (25552667) 2
69 (34476778) 3
68 (34825795) 4
CT heart function and morphology with IV contrast Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 0 1 4 7 1
References Study Quality
43 (27352354) 3
50 (35581366) 2
48 (30337716) 3
46 (32040684) 3
47 (25011535) 2
49 (23828946) 4
24 (22495682) 1
44 (26178177) Good
51 (32444502) 4
45 (32563654) 3
23 (35935656) 1
FDG-PET/CT heart Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 1 0 1 3 5 3 0
References Study Quality
66 (35790691) 4
65 () 4
62 (33462788) 2
64 (34318397) 3
61 (31933156) 3
63 (22577239) 3
58 (31376028) 4
13 (23653245) 4
14 (35612548) Good
59 (28390532) 4
60 (31807883) 3
46 (32040684) 3
45 (32563654) 3
3 (34081218) 4
MRI heart function and morphology without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 3 4 3 1 0
References Study Quality
85 (33419643) 2
84 (27904982) 4
73 (27236529) 3
48 (30337716) 3
30 (25129516) 3
DOTATATE PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 2 0 3 4 3 1 0 0
References Study Quality
57 (25397775) 4
56 (34622428) 4
52 (22918770) 4
53 (30236163) 4
54 (31254038) 4
55 (20972943) 4
58 (31376028) 4
51 (32444502) 4
MIBG scan whole body with SPECT or SPECT/CT chest May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 3 7 2 0 0 0
References Study Quality
51 (32444502) 4
Octreotide scan with SPECT or SPECT/CT chest and abdomen May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 0 0 0 8 5 1 0 0 0
References Study Quality
52 (22918770) 4
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 12 0 0 2 0 0 0 0 0
Arteriography coronary with ventriculography Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 0 3 2 2 1 0 0 0
References Study Quality
42 (31749186) 3
43 (27352354) 3
MRA chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 4 6 0 0 0 0 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 4 1 0 0 0 0 0
MRI chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 5 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 5 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 6 5 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 5 2 0 0 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 4 2 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 3 3 2 0 0 0 0
References Study Quality
18 (23926237) 4
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 3 5 2 1 2 0 0 0
CTA coronary arteries with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 3 4 1 2 1 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 0 3 8 0 1 2 0 0 0
References Study Quality
3 (34081218) 4
60 (31807883) 3
67 (31072171) 2
59 (28390532) 4
68 (34825795) 4
Variant 3: Adult. Known cardiac mass. Established etiology. Follow-up 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] 8 8 0 0 1 0 1 0 2 5 5
References Study Quality
89 (36610495) 3
33 (12460863) 4
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 2 0 0 3 4 4
References Study Quality
5 (35347934) 4
MRI heart function and morphology without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 1 1 7 2 0
References Study Quality
49 (23828946) 4
31 (26476503) 1
FDG-PET/MRI heart Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 0 0 1 5 6 1 1
References Study Quality
96 (28401505) 4
CT heart function and morphology with IV contrast Usually appropriate Moderate ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 0 0 11 3 0
References Study Quality
5 (35347934) 4
44 (26178177) Good
US echocardiography transesophageal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 5 6 1 0 0
References Study Quality
28 (36216604) 4
82 (2131359) 4
DOTATATE PET/CT skull base to mid-thigh May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 1 0 0 4 6 2 1 0 0
References Study Quality
53 (30236163) 4
52 (22918770) 4
54 (31254038) 4
FDG-PET/CT heart May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 0 3 3 4 2 0
References Study Quality
95 (36995946) 4
13 (23653245) 4
8 (33040219) 4
5 (35347934) 4
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 1 1 9 2 1 0 1 0 0 0 0
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 3 1 0 0 0 0 0
MRA chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 0 7 0 0 0 0 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 0 6 1 0 0 0 0 0
MRI chest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 1 6 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 1 6 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 5 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 2 8 0 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 4 3 7 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 2 3 1 0 1 0 0
CTA chest with IV contrast Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 0 4 5 0 3 1 1 0 0
References Study Quality
44 (26178177) Good
CTA coronary arteries with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 4 4 0 3 0 0 0 0
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 0 9 2 0 0 0 0 0
References Study Quality
29 (16824834) 3
Octreotide scan with SPECT or SPECT/CT chest and abdomen Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 4 2 1 2 3 0 1 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.