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Appropriateness Criteria

Variant 1: Child. Chest pain. Limited to the chest wall. 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 0 3 2 4 3 2
References Study Quality
15 (35316339) 4
14 (24209723) 4
US chest May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 4 3 5 0 1
References Study Quality
17 (30612161) 2
16 (34117521) 4
15 (35316339) 4
Radiography rib views May be appropriate Limited ☢☢☢ 1-10 mSv ☢ <0.03 mSv [ped] 6 6 1 0 0 0 3 4 4 2 0
References Study Quality
16 (34117521) 4
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 2 0 0 0 1 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 2 1 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 1 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] 1 1 11 0 2 1 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 2 1 1 0 0 0 0
Variant 2: Child. Chest pain. Suspected pneumothorax or pneumomediastinum. 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] 9 9 0 0 0 0 0 0 0 0 14
References Study Quality
23 (38547031) 4
Radiography chest decubitus view Usually not appropriate Expert Consensus ☢ <0.03 mSv [ped] 2 2 5 3 6 0 0 0 0 0 0
US chest Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 2 1 3 0 2 0 0 0
References Study Quality
24 (24844730) 4
25 (25056671) 1
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 1 0 0 0 0 0
Fluoroscopy upper GI series Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 1 2 0 0 0 0 0 0
References Study Quality
22 (37089060) 4
21 (27320840) 4
20 (25053221) 4
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 2 0 1 1 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 0 2 1 0 0 1 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 1 0 2 0 0 1 0
Variant 3: Child. Chest pain. Suspected pulmonary embolism. 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 1 0 0 0 0 8 2 3
References Study Quality
28 (34836567) 4
34 (28473076) 4
CTA pulmonary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 3 2 9
References Study Quality
33 (30204073) 2
32 (27789203) 1
31 (28473073) 4
28 (34836567) 4
30 (28331932) 4
V/Q scan lung May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 5 1 1 2 3 1 1 0 0
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 3 0 0 0 0 0 0
US duplex Doppler lower extremity Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 1 0 0 0 0 0 0
US echocardiography transesophageal Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 1 0 0 0 0
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 1 0 0 0 0
Arteriography pulmonary with right heart catheterization Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 1 0 1 0 0 0 0
MRA pulmonary arteries without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 4 3 1 0 0 0 0 0
MRA pulmonary arteries without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 0 3 1 2 0 0 0 0
References Study Quality
28 (34836567) 4
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 3 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 8 1 3 1 0 0 0 1 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 1 3 0 0 0 0 0 0
CTA chest with IV contrast with CTV lower extremities Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 1 3 0 1 0 1 0 0
Variant 4: Child. Chest pain. Known or suspected cardiac 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 resting Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 0 0 7 2 4
References Study Quality
40 (34674303) 4
Radiography chest Usually appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 8 0 0 1 0 2 0 1 4 6
CTA chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 5 0 1 5 1 1 1 0 0
CTA coronary arteries with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 5 0 1 6 1 1 0 0 0
CT heart function and morphology with IV contrast May be appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 6 0 1 4 2 1 0 0 0
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 2 0 0 0 0 0 0
US echocardiography transesophageal Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 5 1 2 2 4 0 0 0 0
References Study Quality
39 (21481076) 4
US echocardiography transthoracic stress Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 1 4 1 0 0 0 1 0
Arteriography coronary with ventriculography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 1 0 1 1 0 0 0
Arteriography pulmonary Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 3 0 0 0 0 0 0
MRA chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 1 2 0 0 0 0 0
MRA chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 2 1 0 0 0 0 0
MRI heart function and morphology without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 2 0 2 0 1 0 0
MRI heart function and morphology without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 0 4 0 0 0 1 0 0
MRI heart function with stress without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 1 0 2 0 1 0 0
MRI heart function with stress without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 3 0 0 0 1 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 2 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 0 2 2 0 0 0 0 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 0 2 2 0 0 0 0 0
V/Q scan lung Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 3 0 0 0 0 0 0
FDG-PET/CT heart Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 1 1 0 0 0 0 0
SPECT or SPECT/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 11 0 1 0 2 0 0 0 0
Variant 5: Child. Chest pain. History of sickle cell disease. 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] 9 9 0 0 0 0 0 0 1 2 11
References Study Quality
41 (27404765) 4
US abdomen Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 2 2 0 0 0 0 0
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 2 1 0 0 0 1 0
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 0 1 2 1 0 0 0 0
US echocardiography transthoracic stress Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 2 1 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 1 1 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 2 0 1 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 2 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 0 2 0 0 1 0 1 0
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 2 1 0 0 1 0 0
CTA chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 0 2 1 1 1 0 0 0
Variant 6: Child. Chest pain. Suspected panic attack. 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 May be appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 6 6 0 0 0 2 2 5 3 0 2
US chest Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 1 0 1 0 0 0
US echocardiography transthoracic resting Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 0 0 1 0 0 0
US echocardiography transthoracic stress Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 2 0 0 0 0 0 0
MRI chest without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 0 0 0
MRI chest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 0 0 0 0 0
CT chest with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 3 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 12 0 2 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 12 1 1 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.