ACR logo

Appropriateness Criteria

Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRA chest with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 4 2 6 0 0
References Study Quality
27 (21947513) 3
26 (21887483) 3
25 (21347594) 4
24 (23553735) 3
23 (20368649) 2
22 (12020524) 1
CTA pulmonary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 0 1 1 10
References Study Quality
21 (29846802) 2
20 (35738818) 4
19 (25445893) 2
18 (35774215) 2
17 (24147466) 2
16 (9280245) 3
15 (1732955) 4
14 (30962147) 2
V/Q scan lung Usually appropriate Moderate ☢☢☢ 1-10 mSv 7 7 0 0 0 1 3 2 2 4 0
References Study Quality
37 (17475953) 4
36 (18195380) 3
35 (18165667) 1
34 (19465853) 4
V/Q scan with SPECT or SPECT/CT lung Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 0 0 0 1 2 2 2 4 1
References Study Quality
43 (32198309) 2
42 (33433051) Good
41 (19525358) 2
40 (37487880) Good
39 (17625390) 2
38 (24852679) 2
US echocardiography transthoracic resting May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 2 3 3 2 1 0 0 0
References Study Quality
33 (34875048) 4
32 (26669928) 3
31 (8752195) 2
MRA chest without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 5 1 5 0 0
References Study Quality
28 (28116500) 2
27 (21947513) 3
26 (21887483) 3
25 (21347594) 4
23 (20368649) 2
22 (12020524) 1
MRA chest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 3 0 5 5 0 0 0 0
References Study Quality
28 (28116500) 2
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 4 3 1 0 1 0 0 0
References Study Quality
31 (8752195) 2
32 (26669928) 3
Radiography chest Usually not appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 6 4 2 0 0 0 1 0 0
References Study Quality
30 (28060193) 4
Arteriography pulmonary Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 1 4 3 2 1 0 1 0 0
Arteriography pulmonary with right heart catheterization Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 3 2 4 0 2 0 1 0 0
MRI heart function and morphology without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 2 4 3 1 0 0 0 0
References Study Quality
29 (36843875) 3
MRI heart function and morphology without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 2 6 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 2 5 5 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 4 2 3 1 1 1 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 7 2 2 1 0 0 0 0 0
CT heart function and morphology with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 3 2 0 0 1 0 0
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA pulmonary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 1 0 1 1 3 6
References Study Quality
60 (27501896) 2
59 (34459967) 2
58 (32991219) 3
57 (33532057) 3
56 (37423613) 3
55 (35800352) 3
54 (27501891) 2
53 (7962789) 3
52 (30897932) 2
51 (34712746) 2
49 (33334946) 4
30 (28060193) 4
19 (25445893) 2
US echocardiography transthoracic resting May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 1 0 4 2 2 0 4 0
References Study Quality
73 (36265185) 1
72 (26476768) 2
Arteriography pulmonary May be appropriate Limited ☢☢☢☢ 10-30 mSv 4 4 0 2 1 4 5 1 0 0 0
References Study Quality
46 (37470202) 4
45 (25828726) 3
44 (27729418) 2
Arteriography pulmonary with right heart catheterization May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 0 2 0 3 1 0 6 1 0
References Study Quality
49 (33334946) 4
48 (27327769) 3
47 (30545968) 4
MRA chest with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 2 3 2 4 0 0
References Study Quality
64 (30311032) 2
63 (26727392) 3
62 (32096280) 3
61 (15332240) 3
MRA chest without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 2 1 2 4 3 1 0 0
References Study Quality
64 (30311032) 2
63 (26727392) 3
62 (32096280) 3
61 (15332240) 3
MRI heart function and morphology without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 2 2 3 1 5 0 0 0
References Study Quality
71 (35185084) 4
70 (10478263) 3
69 (30159622) 2
68 (30790024) 2
67 (35111592) 3
66 (14760316) 3
12 (36372884) 3
MRI heart function and morphology without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 1 0 0 3 3 2 2 1 0
References Study Quality
12 (36372884) 3
71 (35185084) 4
70 (10478263) 3
69 (30159622) 2
68 (30790024) 2
67 (35111592) 3
66 (14760316) 3
V/Q scan lung May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 1 1 0 0 5 2 4 0 0
References Study Quality
76 (2245685) 2
75 (32531708) 2
74 (35194769) 3
V/Q scan with SPECT or SPECT/CT lung May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 1 1 0 0 5 2 4 0 0
References Study Quality
78 (34785945) 2
77 (33688452) 2
US echocardiography transesophageal Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 4 4 2 3 0 0 0 0 0
References Study Quality
72 (26476768) 2
73 (36265185) 1
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 5 2 3 0 1 0 1 0 0
MRA chest without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 3 1 2 2 1 0 0 0
References Study Quality
65 (15844148) 3
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 1 4 1 1 0 1 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 2 4 2 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 2 0 1 0 0 0 0
CT heart function and morphology with IV contrast Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 2 5 0 4 0 0 0 0
References Study Quality
51 (34712746) 2
50 (22843839) 3
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.