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Appropriateness Criteria

Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 9 7 1 1 0 0 0 0 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 2 0 0 0 0 0 0 1
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
US echocardiography transthoracic resting Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 5 1 0 1 0 0 0 1
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
Arteriography pulmonary with right heart catheterization Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 1 1 17 0 0 0 0 0 0 1 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
19 (8222808) 3
18 (6859705) 4
17 (16515356) 3
8 (21969343) M
MRA pulmonary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 4 2 0 0 0 1 0 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
MRA pulmonary arteries without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 4 3 0 0 0 0 1 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
CT chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 4 2 0 0 0 0 0 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
CT chest without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 2 1 1 0 0 1 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
CT chest without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 8 4 2 1 1 1 0 0 1
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
CTA chest with IV contrast with CTV lower extremities Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 5 2 2 0 0 1 0 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
CTA pulmonary arteries with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 5 5 0 0 0 0 0 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
V/Q scan lung Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 5 1 0 0 0 0 0 0
References Study Quality
12 (20592294) 4
13 (21047572) 4
14 (20740096) 1
15 (19620439) 3
16 (18343077) 3
8 (21969343) M
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
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 1 0 0 0 0 1 1 1 14
References Study Quality
20 (14657313) 1
22 (12500376) 4
23 (16097441) 3
21 (8284406) 2
24 (14658001) 3
V/Q scan lung Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 0 0 0 2 0 5 7 3 1
References Study Quality
59 (7152856) 4
10 (8372182) 3
61 (17060547) 1
58 (18165667) 1
1 (28671347) 4
60 (17625390) 2
MRA pulmonary arteries without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 1 13 1 2 0 0
References Study Quality
34 (16794142) 2
35 (16714660) 2
36 (12020524) 1
38 (16632150) 3
39 (22375614) 4
40 (21347594) 4
21 (8284406) 2
24 (14658001) 3
42 (22664742) 3
41 (23553735) 3
37 (18308025) 3
1 (28671347) 4
CTA triple rule out May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 1 6 3 2 2 3 0 0 1
References Study Quality
29 (16738268) 2
30 (9442137) 3
28 (17675613) 1
31 (26124909) 3
US duplex Doppler lower extremity Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 2 7 4 0 3 2 0 0 0
References Study Quality
46 (15845793) 3
45 (18043357) 3
49 (19427980) 1
47 (17555069) 4
48 (17179348) 1
US echocardiography transesophageal Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 9 5 3 0 0 1 0 0 0
References Study Quality
56 (8090877) 4
52 (17000366) 1
53 (12514752) 2
54 (10407975) 2
55 (8162798) 4
57 (2108571) 3
51 (26669928) 3
50 (8752195) 2
US echocardiography transthoracic resting Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 6 4 4 1 1 1 0 1 0
References Study Quality
56 (8090877) 4
52 (17000366) 1
53 (12514752) 2
54 (10407975) 2
55 (8162798) 4
57 (2108571) 3
51 (26669928) 3
50 (8752195) 2
Arteriography pulmonary with right heart catheterization Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 9 3 5 1 0 0 0 0 0
References Study Quality
19 (8222808) 3
18 (6859705) 4
17 (16515356) 3
32 (15333370) 3
33 (1735144) 3
MRA pulmonary arteries without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 5 4 4 2 1 1 1 0 0
References Study Quality
41 (23553735) 3
44 (20368649) 2
43 (28116500) 2
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 8 2 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 4 8 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 7 7 2 1 1 0 0 0 0
CTA chest with IV contrast with CTV lower extremities Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 2 7 4 4 1 0 0 0 0
References Study Quality
25 (11323478) 1
27 (18212216) 3
26 (10966705) 2
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
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 1 0 0 0 0 0 0 1 16
References Study Quality
20 (14657313) 1
22 (12500376) 4
23 (16097441) 3
21 (8284406) 2
24 (14658001) 3
V/Q scan lung Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 0 2 0 0 1 2 6 6 1
References Study Quality
59 (7152856) 4
10 (8372182) 3
61 (17060547) 1
58 (18165667) 1
1 (28671347) 4
60 (17625390) 2
US duplex Doppler lower extremity May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 6 2 1 2 3 0 0 0
References Study Quality
46 (15845793) 3
45 (18043357) 3
49 (19427980) 1
47 (17555069) 4
48 (17179348) 1
US echocardiography transthoracic resting May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 5 3 1 3 4 1 0 1 0
References Study Quality
56 (8090877) 4
52 (17000366) 1
53 (12514752) 2
54 (10407975) 2
55 (8162798) 4
57 (2108571) 3
51 (26669928) 3
50 (8752195) 2
MRA pulmonary arteries without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 11 2 1 0 0
References Study Quality
34 (16794142) 2
35 (16714660) 2
36 (12020524) 1
38 (16632150) 3
39 (22375614) 4
40 (21347594) 4
21 (8284406) 2
24 (14658001) 3
42 (22664742) 3
41 (23553735) 3
37 (18308025) 3
1 (28671347) 4
US echocardiography transesophageal Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 8 6 2 0 1 1 0 0 0
References Study Quality
56 (8090877) 4
52 (17000366) 1
53 (12514752) 2
54 (10407975) 2
55 (8162798) 4
57 (2108571) 3
51 (26669928) 3
50 (8752195) 2
Arteriography pulmonary with right heart catheterization Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 2 2 8 3 3 1 1 0 2 0 0
References Study Quality
19 (8222808) 3
18 (6859705) 4
17 (16515356) 3
32 (15333370) 3
33 (1735144) 3
MRA pulmonary arteries without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 3 9 2 3 0 1 0 0 0
References Study Quality
34 (16794142) 2
24 (14658001) 3
43 (28116500) 2
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 7 5 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] 2 2 7 6 4 0 0 0 0 0 1
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 4 3 1 0 0 0 0 0
CTA chest with IV contrast with CTV lower extremities Usually not appropriate Strong ☢☢☢ 1-10 mSv 2 2 6 7 3 1 0 1 0 0 0
References Study Quality
25 (11323478) 1
27 (18212216) 3
26 (10966705) 2
CTA triple rule out Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 2 6 3 2 3 2 0 0 0
References Study Quality
29 (16738268) 2
30 (9442137) 3
28 (17675613) 1
31 (26124909) 3
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler lower extremity Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 1 4 5 6
References Study Quality
46 (15845793) 3
45 (18043357) 3
49 (19427980) 1
47 (17555069) 4
48 (17179348) 1
67 (31557394) Good
Radiography chest Usually appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 8 0 0 0 0 0 1 3 9 5
CTA pulmonary arteries with IV contrast Usually appropriate Moderate ☢☢☢ 1-10 mSv 8 8 1 1 0 0 0 3 3 6 4
References Study Quality
64 (25811355) 4
63 (28500985) 3
65 (30357273) 2
62 (28487206) 4
V/Q scan lung Usually appropriate Strong ☢☢☢ 1-10 mSv 7 7 1 1 0 0 0 4 5 6 1
References Study Quality
61 (17060547) 1
68 (8284407) 2
69 (8134561) 4
74 (20729418) 2
58 (18165667) 1
3 (22086989) 4
1 (28671347) 4
70 (22347929) 4
71 (9530317) 4
72 (1575198) 4
73 (17342484) 3
US echocardiography transesophageal Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 5 1 0 0 1 0 0 0
References Study Quality
56 (8090877) 4
52 (17000366) 1
53 (12514752) 2
54 (10407975) 2
55 (8162798) 4
57 (2108571) 3
51 (26669928) 3
50 (8752195) 2
US echocardiography transthoracic resting Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 5 5 1 2 3 1 0 1 0
References Study Quality
56 (8090877) 4
52 (17000366) 1
53 (12514752) 2
54 (10407975) 2
55 (8162798) 4
57 (2108571) 3
51 (26669928) 3
50 (8752195) 2
Arteriography pulmonary with right heart catheterization Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 1 1 14 0 0 4 0 0 0 0 0
References Study Quality
32 (15333370) 3
33 (1735144) 3
MRA pulmonary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 2 4 0 0 1 1 0 0
References Study Quality
66 (-3188535) 4
MRA pulmonary arteries without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 4 7 4 3 0 0 0 0 0
References Study Quality
34 (16794142) 2
24 (14658001) 3
43 (28116500) 2
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 9 0 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] 1 1 10 5 3 0 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 4 1 0 1 1 0 0 0
CTA chest with IV contrast with CTV lower extremities Usually not appropriate Strong ☢☢☢ 1-10 mSv 1 1 10 4 2 0 1 1 0 0 0
References Study Quality
25 (11323478) 1
27 (18212216) 3
26 (10966705) 2
CTA triple rule out Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 7 8 3 0 0 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.