ACR logo

Appropriateness Criteria

Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. 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 1 1 0 1 7 5 1
References Study Quality
71 (18565214) M
74 (19356420) 2
72 (12727146) M
70 (11028482) 3
73 (29768319) 2
47 (19356575) 2
Arteriography coronary Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 0 2 0 0 1 4 4 5
References Study Quality
8 (8409054) 1
10 (20579537) 3
9 (23273323) 2
MRI heart function with stress without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 0 10 3 1
References Study Quality
6 (22236462) 2
52 (20482819) M
47 (19356575) 2
46 (24342416) 3
49 (23771988) Good
48 (23804252) 3
51 (17903634) Good
50 (31216398) 3
MRI heart function with stress without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 3 1 2 10 0 0
References Study Quality
54 (10525488) 2
53 (9989961) 1
47 (19356575) 2
46 (24342416) 3
CTA coronary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 1 0 0 4 6 5
References Study Quality
36 (24486266) 2
30 (22261160) 2
31 (17981829) M
28 (21597986) M
33 (22032711) 2
34 (23562923) 4
26 (19095130) 2
27 (19038879) 1
25 (19007693) 1
35 (26475205) 2
32 (-3194082) 2
37 (27141095) Good
38 (31696294) Good
29 (31189617) Good
39 (31005540) 3
Rb-82 PET/CT heart Usually appropriate Strong ☢☢☢☢ 10-30 mSv 7 7 0 0 1 0 2 1 6 4 2
References Study Quality
61 (18022106) 2
52 (20482819) M
48 (23804252) 3
57 (17332611) 2
58 (23040573) Good
59 (19608135) 3
60 (23219297) 3
55 (19555834) 4
56 (16733686) 2
SPECT or SPECT/CT MPI rest and stress Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 7 7 0 0 0 1 0 1 8 3 3
References Study Quality
62 (11772873) 2
63 (11216963) 2
65 (19288163) 3
64 (11897441) 2
67 (17174808) 3
66 (22554604) M
69 (23086965) 2
68 (23291392) 2
US echocardiography transthoracic resting May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 0 6 2 3 3 2 0
MRI heart function and morphology without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 6 4 2 0 0
References Study Quality
43 (16904547) 4
45 (24083836) 2
44 (22607320) 2
CT coronary calcium May be appropriate Strong ☢☢☢ 1-10 mSv 4 4 3 2 3 2 5 1 0 0 0
References Study Quality
12 (19520336) 4
14 (28847895) 2
16 (26746631) 1
11 (11897220) 4
13 (31168373) 2
17 (18362235) 3
15 (20170786) 2
US echocardiography transesophageal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 3 6 0 1 0 0 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 2 5 8 1 0 0 0 0 0
References Study Quality
40 (17112982) 3
MRA coronary arteries without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 4 2 5 2 1 1 1 0 0
References Study Quality
42 (23833284) 2
41 (20828652) 2
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 2 4 0 0 0 0
CTA chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 4 2 3 3 3 0 0 0 1
References Study Quality
24 (24221182) 3
CTA triple rule out Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 5 2 5 2 1 1 0 0 0
Nuclear medicine ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 6 5 1 0 0 0 0 0
CT heart function and morphology with IV contrast Usually not appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 2 8 2 2 0 0 0 0
References Study Quality
21 (19808590) 2
18 (22447807) 2
19 (23375929) 1
23 (25977111) 2
20 (25726411) 3
22 (24865312) 2
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. 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 1 0 10 5 0
References Study Quality
71 (18565214) M
72 (12727146) M
70 (11028482) 3
73 (29768319) 2
47 (19356575) 2
Arteriography coronary Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 0 1 1 0 0 1 3 3 7
References Study Quality
77 (19144937) 1
76 (23946263) 1
8 (8409054) 1
75 (22924638) 1
78 (32227755) 1
79 (32227753) 1
MRI heart function and morphology without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 1 1 10 2 0
References Study Quality
90 (14557364) 3
70 (11028482) 3
98 (15117834) 2
95 (18212288) 2
94 (15193689) 3
96 (11078769) 3
91 (17361420) 3
92 (20865262) 2
97 (17437737) 3
93 (25846255) 3
MRI heart function with stress without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 1 0 2 4 6 2
References Study Quality
6 (22236462) 2
52 (20482819) M
47 (19356575) 2
46 (24342416) 3
49 (23771988) Good
48 (23804252) 3
51 (17903634) Good
MRI heart function with stress without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 2 3 1 9 1 0
References Study Quality
54 (10525488) 2
53 (9989961) 1
47 (19356575) 2
46 (24342416) 3
CTA coronary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 1 1 2 6 2 4
References Study Quality
36 (24486266) 2
30 (22261160) 2
28 (21597986) M
84 (27072303) M
33 (22032711) 2
34 (23562923) 4
26 (19095130) 2
27 (19038879) 1
25 (19007693) 1
35 (26475205) 2
85 (29322167) 2
83 (21835321) 2
86 (29305348) Good
87 (26205589) 2
37 (27141095) Good
38 (31696294) Good
88 (31833413) 2
89 (19539075) Inadequate
82 (32029127) 4
Rb-82 PET/CT heart Usually appropriate Strong ☢☢☢☢ 10-30 mSv 8 8 0 0 0 1 2 1 3 7 2
References Study Quality
61 (18022106) 2
48 (23804252) 3
57 (17332611) 2
58 (23040573) Good
59 (19608135) 3
60 (23219297) 3
55 (19555834) 4
56 (16733686) 2
SPECT or SPECT/CT MPI rest and stress Usually appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 8 8 0 0 0 0 1 2 5 5 3
References Study Quality
62 (11772873) 2
63 (11216963) 2
65 (19288163) 3
64 (11897441) 2
67 (17174808) 3
66 (22554604) M
69 (23086965) 2
68 (23291392) 2
US echocardiography transthoracic resting May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 2 4 1 3 4 2 0
MRI heart function and morphology without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 2 3 3 4 2 2 0 0 0
CT heart function and morphology with IV contrast May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 1 2 5 5 1 0 0 0
References Study Quality
21 (19808590) 2
18 (22447807) 2
80 (24255127) 1
19 (23375929) 1
23 (25977111) 2
20 (25726411) 3
22 (24865312) 2
81 (16860013) 3
US echocardiography transesophageal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 4 5 5 1 0 0 1 0 0
MRA coronary arteries without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 4 5 6 0 1 0 0 0 0
References Study Quality
40 (17112982) 3
MRA coronary arteries without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 5 4 6 1 0 0 0 0 0
References Study Quality
42 (23833284) 2
41 (20828652) 2
CT coronary calcium Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 8 2 3 2 1 0 0 0 0
CTA chest with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 2 4 3 3 2 1 0 0 1
References Study Quality
24 (24221182) 3
CTA triple rule out Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 3 3 4 3 8 0 1 0 0 0 0
Nuclear medicine ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 7 1 1 1 2 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.