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Appropriateness Criteria

Variant 1: Chest pain, low to intermediate probability for acute coronary syndrome. 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 stress Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 3 7 9 1 0
References Study Quality
42 (12671809) 4
40 (27865485) 3
46 (26511125) 2
43 (24768667) 3
41 (25635106) 4
44 (17884363) 2
45 (21562726) 3
47 (20554154) 2
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 0 0 1 1 2 8 6 2
References Study Quality
31 (24595499) 2
CTA coronary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 1 0 0 7 7
References Study Quality
19 (17692738) 4
64 (17549487) 4
59 (17010819) 4
60 (19406338) 2
61 (17320744) 2
62 (17075011) 2
63 (17398185) 3
92 (24486266) 2
71 (22449295) 1
75 (23255742) 3
70 (22830462) 1
74 (23538167) 4
69 (21939822) 3
90 (22032711) 2
91 (22922562) 1
65 (26052677) 2
72 (22055795) M
85 (24255127) 1
73 (19007693) 1
1 (28279382) 4
79 (27886161) 4
84 (27718140) 4
82 (28290782) 3
89 (27470449) 2
93 (27050025) 4
67 (27220653) 3
68 (27006119) 2
78 (26764061) 3
66 (26577263) 2
80 (26476506) 4
87 (25752898) 2
81 (25711274) 2
86 (23617513) 3
76 (25863305) Inadequate
77 (25713467) 2
83 (22895647) 4
88 (28109933) 3
SPECT or SPECT/CT MPI rest and stress Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
37 (24026478) 3
36 (23414823) 4
34 (14522503) 4
35 (23255769) 4
38 (21258084) 3
39 (22877811) 3
SPECT or SPECT/CT MPI rest and stress Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 7 1 0 0 1 2 0 7 4 1
References Study Quality
37 (24026478) 3
36 (23414823) 4
34 (14522503) 4
35 (23255769) 4
38 (21258084) 3
39 (22877811) 3
US echocardiography transthoracic resting May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 2 0 2 2 9 1 0 0 0
References Study Quality
51 (15215802) 2
57 (26349786) 3
48 (24745875) 4
54 (24612899) 4
41 (25635106) 4
49 (21111923) 4
50 (22014426) 2
52 (15917277) 3
53 (20159647) 4
55 (20185525) 3
56 (23582354) 3
MRI heart function and morphology without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 1 1 3 6 8 1 0 0 0
References Study Quality
111 (19787721) 2
110 (19772587) 4
124 (18678772) 2
122 (12566362) 2
131 (28005512) 4
129 (26590396) 3
123 (15582315) 2
125 (20510215) 4
126 (19332480) 4
127 (28645959) 4
128 (26146527) 4
130 (22309452) 3
MRI heart with function and inotropic stress without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 0 2 1 9 6 1 0 1 0
References Study Quality
116 (20883929) 3
111 (19787721) 2
110 (19772587) 4
114 (23664718) 2
113 (23578348) 4
112 (26268824) 2
45 (21562726) 3
115 (20977757) 4
MRI heart with function and inotropic stress without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 4 2 2 2 4 2 0 0 0
References Study Quality
116 (20883929) 3
111 (19787721) 2
110 (19772587) 4
114 (23664718) 2
113 (23578348) 4
112 (26268824) 2
45 (21562726) 3
115 (20977757) 4
MRI heart with function and vasodilator stress perfusion without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 3 9 7 0 1 0
References Study Quality
111 (19787721) 2
110 (19772587) 4
114 (23664718) 2
119 (22196944) 3
113 (23578348) 4
112 (26268824) 2
45 (21562726) 3
118 (18381373) 4
117 (17868810) 3
120 (18208849) 2
121 (22992411) 4
CT coronary calcium May be appropriate Moderate ☢☢☢ 1-10 mSv 4 4 3 2 2 3 6 0 0 0 0
References Study Quality
94 (20360291) 2
99 (22825529) 4
100 (24513880) 3
97 (25937196) 4
98 (28390834) 4
95 (27765299) Good
96 (22820732) 4
CTA chest with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 2 5 5 7 0 1 0 0
References Study Quality
27 (17996512) 3
103 (27819965) 4
104 (26781150) 4
SPECT or SPECT/CT MPI rest only May be appropriate Moderate ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
32 (14752467) 3
33 (12460092) 1
36 (23414823) 4
34 (14522503) 4
35 (23255769) 4
SPECT or SPECT/CT MPI rest only May be appropriate Moderate ☢☢☢ 1-10 mSv 5 5 0 1 0 2 10 4 3 0 0
References Study Quality
32 (14752467) 3
33 (12460092) 1
36 (23414823) 4
34 (14522503) 4
35 (23255769) 4
Rb-82 PET/CT MPI rest and stress May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
109 (22554604) M
108 (15937302) 3
105 (20660808) 1
106 (18342769) Good
107 (19618180) 2
Rb-82 PET/CT MPI rest and stress May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 5 0 1 1 1 4 10 3 0 0
References Study Quality
109 (22554604) M
108 (15937302) 3
105 (20660808) 1
106 (18342769) Good
107 (19618180) 2
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 3 6 1 0 0 0 0 0
References Study Quality
58 (15556822) 4
Arteriography coronary Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 4 5 4 0 1 1 1 0 0
References Study Quality
30 (26810814) 4
MRA coronary arteries without and with IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 4 10 6 0 0 0 0 0 0
References Study Quality
132 (18586979) 4
119 (22196944) 3
133 (20513610) 4
134 (20828652) 2
135 (26965732) 4
MRA coronary arteries without IV contrast Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 2 2 5 10 5 0 0 0 0 0 0
References Study Quality
132 (18586979) 4
119 (22196944) 3
133 (20513610) 4
134 (20828652) 2
135 (26965732) 4
MRI heart function and morphology without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 3 3 5 2 2 0 1 0 0
References Study Quality
111 (19787721) 2
110 (19772587) 4
124 (18678772) 2
122 (12566362) 2
131 (28005512) 4
129 (26590396) 3
123 (15582315) 2
125 (20510215) 4
126 (19332480) 4
127 (28645959) 4
128 (26146527) 4
130 (22309452) 3
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 1 8 8 2 1 0 0 0 0
References Study Quality
102 (26883335) 4
101 (27593539) 3
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 3 4 2 2 0 0 0 0
References Study Quality
102 (26883335) 4
101 (27593539) 3
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 7 2 0 0 0 0 1 0
References Study Quality
102 (26883335) 4
101 (27593539) 3
Variant 2: Chest pain, high probability for acute coronary syndrome. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 0 0 1 2 0 9 6 2
References Study Quality
31 (24595499) 2
Arteriography coronary Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 0 0 0 0 3 5 8
References Study Quality
7 (22923432) 4
136 (9103133) 4
137 (19393152) 4
138 (23247304) 4
139 (25260718) 4
140 (23395074) 4
141 (20045278) 2
142 (19458363) 1
143 (18594042) Good
US echocardiography transthoracic resting May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 2 2 11 4 1 0 0
References Study Quality
51 (15215802) 2
57 (26349786) 3
48 (24745875) 4
54 (24612899) 4
41 (25635106) 4
49 (21111923) 4
50 (22014426) 2
52 (15917277) 3
53 (20159647) 4
55 (20185525) 3
56 (23582354) 3
US echocardiography transthoracic stress May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 6 2 6 1 2 0 0
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 4 2 8 2 1 1 0
References Study Quality
145 (25782462) 3
125 (20510215) 4
126 (19332480) 4
127 (28645959) 4
128 (26146527) 4
144 (20117357) 4
CTA coronary arteries with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 4 4 5 6 1 0 0 0
SPECT or SPECT/CT MPI rest only May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
SPECT or SPECT/CT MPI rest only May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 3 1 4 4 5 2 1 0 0
SPECT or SPECT/CT MPI rest and stress May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
146 (17174181) 1
147 (10080466) 1
SPECT or SPECT/CT MPI rest and stress May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 4 4 0 2 3 10 3 1 1 0 0
References Study Quality
146 (17174181) 1
147 (10080466) 1
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 2 7 0 0 0 0 0 0
References Study Quality
58 (15556822) 4
MRA coronary arteries without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 5 0 0 0 0 1 0
MRA coronary arteries without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 4 0 0 0 0 1 0
MRI heart function and morphology without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 5 2 1 4 1 0 0 0
References Study Quality
145 (25782462) 3
125 (20510215) 4
126 (19332480) 4
127 (28645959) 4
128 (26146527) 4
144 (20117357) 4
MRI heart with function and inotropic stress without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 3 1 0 0 2 0 0
MRI heart with function and inotropic stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 3 0 0 1 1 0 0
MRI heart with function and vasodilator stress perfusion without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 3 3 1 0 0 2 0 0
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 5 5 1 2 0 0 0 0
References Study Quality
102 (26883335) 4
101 (27593539) 3
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 3 6 1 0 0 0 0 0
References Study Quality
102 (26883335) 4
101 (27593539) 3
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 3 5 0 1 0 0 0 0
References Study Quality
102 (26883335) 4
101 (27593539) 3
CT coronary calcium Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 8 2 3 1 1 1 0 0 0
CTA chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 4 7 5 1 0 1 0 0
References Study Quality
27 (17996512) 3
103 (27819965) 4
Rb-82 PET/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 n/a 0 0 0 0 0 0 0 0 0
Rb-82 PET/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 7 8 2 2 1 0 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.