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Appropriateness Criteria

Variant 1: Dyspnea due to suspected valvular heart disease. Ischemia excluded. 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 0 2 18
References Study Quality
54 (28330654) 2
61 (30826295) 4
57 (29420834) 4
59 (31260141) 4
21 (28586420) 4
58 (27539645) 3
53 (26847283) 4
23 (30834578) 4
52 (26275752) 4
55 (27354049) 2
51 (28864719) 3
49 (29346529) 2
56 (29794244) 3
60 (28117492) 3
50 (30376591) 3
Radiography chest Usually appropriate Limited ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 0 0 1 0 1 16 4 0
References Study Quality
44 (27548877) 4
US echocardiography transesophageal May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 4 6 11 1 0 0
References Study Quality
46 (30560601) 4
45 (27184953) 4
24 (29066081) 4
47 (28488097) 4
US echocardiography transthoracic stress May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 2 15 4 0 0 0
References Study Quality
21 (28586420) 4
62 (28395281) 4
MRI heart function and morphology without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 6 13 3 0 0
References Study Quality
41 (27515954) 3
33 (27878504) 4
43 (31385360) 4
39 (28611119) 2
38 (30134000) 4
35 (26965931) 4
21 (28586420) 4
37 (26212514) 3
23 (30834578) 4
42 (30261961) 2
36 (31592729) 3
40 (26377908) 3
34 (29292243) 4
31 (22879371) 3
32 (25790878) 2
MRI heart function and morphology without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 4 12 3 1 0
References Study Quality
41 (27515954) 3
33 (27878504) 4
43 (31385360) 4
39 (28611119) 2
38 (30134000) 4
35 (26965931) 4
21 (28586420) 4
37 (26212514) 3
23 (30834578) 4
42 (30261961) 2
36 (31592729) 3
40 (26377908) 3
34 (29292243) 4
31 (22879371) 3
32 (25790878) 2
CT heart function and morphology with IV contrast May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 2 2 2 8 6 0 0 1
References Study Quality
29 (27654407) 4
22 (25424562) 3
26 (30153438) 4
27 (27337529) 4
21 (28586420) 4
23 (30834578) 4
28 (32471541) 4
25 (29101983) 4
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 5 0 0 0 0 1 0 1
MRI heart function with stress without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 7 5 1 1 0 0 0 1
MRI heart function with stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 9 3 1 1 0 0 0 1
CT coronary calcium Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 6 1 4 1 0 0 0 1
References Study Quality
20 (26188533) 3
CTA coronary arteries with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 7 3 2 1 0 0 0 1
References Study Quality
25 (29101983) 4
FDG-PET/CT heart Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 5 1 0 2 0 0 1 0
Rb-82 PET/CT heart Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 4 2 0 0 0 0 0 1
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 12 5 1 0 1 1 0 0 1
Variant 2: Dyspnea due to suspected cardiac arrhythmia. Ischemia excluded. 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] 8 8 2 0 0 0 0 1 3 5 10
References Study Quality
83 (20172912) 4
87 (28882335) 3
94 (25735868) 3
91 (26833338) 3
92 (26467363) 2
95 (26864458) 2
89 (27252359) 2
96 (30387182) 1
93 (26321238) 1
90 (26164406) 2
97 (31347351) 3
98 (29523135) 4
88 (27334231) 3
MRI heart function and morphology without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 3 4 3 6 4
References Study Quality
83 (20172912) 4
80 (28838961) 3
71 (26175568) 4
76 (27139734) 3
79 (28780194) 2
77 (31658247) 3
78 (30690570) 4
81 (31427780) 4
82 (28011840) 4
72 (29467354) 3
66 (31584472) 4
US echocardiography transesophageal May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 1 4 5 3 6 1 0 0 1
References Study Quality
86 (28233335) 3
Radiography chest May be appropriate (Disagreement) Expert Opinion ☢ <0.1 mSv ☢ <0.03 mSv [ped] 5 5 0 0 1 2 6 3 6 4 0
MRI heart function and morphology without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 6 11 3 0 0
References Study Quality
83 (20172912) 4
80 (28838961) 3
71 (26175568) 4
76 (27139734) 3
79 (28780194) 2
77 (31658247) 3
78 (30690570) 4
81 (31427780) 4
82 (28011840) 4
72 (29467354) 3
66 (31584472) 4
CT heart function and morphology with IV contrast May be appropriate Strong ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 0 17 4 0 0 0
References Study Quality
64 (25559233) 1
63 (23992839) 3
67 (26897692) 3
65 (30129902) 3
28 (32471541) 4
66 (31584472) 4
69 (30402702) 2
68 (25713213) 3
FDG-PET/CT heart May be appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 0 1 11 5 5 0 0 0
References Study Quality
70 (30236394) 3
US echocardiography transthoracic stress Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 4 3 4 4 0 2 0 0
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 4 2 0 1 0 0 1 0
MRI heart function with stress without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 7 2 1 2 0 0 0 2
MRI heart function with stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 9 1 2 1 0 0 0 1
CT coronary calcium Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 3 1 0 0 0 0 0 1
CTA coronary arteries with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 5 3 0 2 0 1 0 1
Rb-82 PET/CT heart Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 12 6 1 0 1 0 0 0 1
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 2 2 8 6 2 2 3 0 0 0 0
References Study Quality
85 (27804074) 2
84 (27221816) 3
Variant 3: Dyspnea due to suspected pericardial disease. Ischemia excluded. 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 Limited O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 0 1 3 16
References Study Quality
100 (30993456) 4
107 (27884251) 4
102 (29025541) 4
110 (28315124) 4
Radiography chest Usually appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 7 7 0 0 0 0 0 3 13 5 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 0 5 3 7 5 2
References Study Quality
108 (25547939) 2
107 (27884251) 4
109 (28330665) 3
101 (29025549) 4
102 (29025541) 4
110 (28315124) 4
106 (25672267) 2
CT heart function and morphology with IV contrast Usually appropriate Limited ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 1 0 1 4 2 11 2 0
References Study Quality
103 (27931089) 2
100 (30993456) 4
101 (29025549) 4
102 (29025541) 4
US echocardiography transesophageal May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 3 8 6 2 1 0
References Study Quality
102 (29025541) 4
MRI heart function and morphology without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 8 10 3 1 0
References Study Quality
108 (25547939) 2
107 (27884251) 4
109 (28330665) 3
101 (29025549) 4
102 (29025541) 4
110 (28315124) 4
106 (25672267) 2
CT chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 2 15 4 1 0 0
CT chest without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 1 9 9 1 1 0 0
References Study Quality
99 (30868443) 2
CTA chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 0 3 13 4 1 0 0
FDG-PET/CT heart May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 2 1 8 2 6 3 0 0 0
References Study Quality
105 (31376028) 4
104 (28183513) 3
US echocardiography transthoracic stress Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 9 3 1 0 0 0 1 0
References Study Quality
111 (31202741) 4
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 1 3 0 0 0 0 1
MRI heart function with stress without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 10 6 2 1 1 0 0 0 1
MRI heart function with stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 10 6 2 1 1 0 0 0 1
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 2 10 8 0 1 0 1 0 0
CT coronary calcium Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 4 2 1 0 0 0 0 1
CTA coronary arteries with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 8 3 0 1 1 0 0 0
Rb-82 PET/CT heart Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 1 4 0 1 0 1 0 0
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 14 3 3 0 0 0 0 1 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.