American College of Radiology
ACR Appropriateness Criteria®

Suspected New-Onset and Known Nonacute Heart Failure

Variant 1: Suspected new-onset nonacute heart failure, not previously diagnosed. 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 Moderate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 1 2 4 8
References Study Quality
36 (22713289) 4
40 (22104551) 3
41 (23500216) 4
42 (15808765) 3
43 (16510467) 2
44 (16115798) 2
45 (11263606) 3
46 (11348601) 2
47 (21722451) 4
48 (26910112) Good
49 (24286578) 4
50 (25572643) 2
51 (25783858) 3
52 (24813438) 2
53 (21155032) 3
54 (21944161) 2
Radiography chest Usually appropriate Strong ☢ <0.1 mSv ☢ <0.03 mSv [ped] 8 8 0 0 0 0 3 0 4 4 5
References Study Quality
37 (20045607) 3
38 (21517671) 2
39 (22994440) 2
40 (22104551) 3
CTA coronary arteries with IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 3 0 3 6 3 0 2 1 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 3 1 2 6 2 0 3 0 1 0
References Study Quality
41 (23500216) 4
58 (19755468) 2
MRI heart function and morphology without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 3 7 2 2 0 0 0 0
References Study Quality
41 (23500216) 4
58 (19755468) 2
Tc-99m ventriculography Usually not appropriate Strong ☢☢☢ 1-10 mSv 3 3 5 2 4 2 2 0 0 0 0
References Study Quality
41 (23500216) 4
55 (19443475) 2
56 (21029826) 1
57 (20299607) 1
US echocardiography transthoracic stress Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 3 2 6 2 2 0 0 0 0
References Study Quality
36 (22713289) 4
40 (22104551) 3
41 (23500216) 4
42 (15808765) 3
43 (16510467) 2
44 (16115798) 2
45 (11263606) 3
46 (11348601) 2
47 (21722451) 4
48 (26910112) Good
49 (24286578) 4
50 (25572643) 2
51 (25783858) 3
52 (24813438) 2
53 (21155032) 3
54 (21944161) 2
MRI heart with function and vasodilator stress perfusion without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 4 4 3 0 0 0 0 1
References Study Quality
41 (23500216) 4
58 (19755468) 2
MRI heart with function and inotropic stress without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 3 6 2 1 0 0 0 0
References Study Quality
41 (23500216) 4
58 (19755468) 2
FDG-PET/CT heart Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 4 2 6 0 2 2 0 0 0
References Study Quality
23 (19672592) 4
24 (24781009) 4
25 (26788807) 4
Rb-82 PET/CT heart stress Usually not appropriate Limited ☢☢☢☢ 10-30 mSv 3 3 3 3 6 1 0 0 1 0 1
References Study Quality
23 (19672592) 4
24 (24781009) 4
25 (26788807) 4
Tc-99m SPECT/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 3 3 6 1 1 0 0 0 1
Arteriography coronary Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 6 3 6 0 0 0 0 0 0
MRI heart with function and inotropic stress without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 3 5 6 1 0 0 0 0 0
References Study Quality
41 (23500216) 4
58 (19755468) 2
Variant 2: Differentiating new-onset heart failure with reduced ejection fraction (HFrEF) from new-onset heart failure with preserved ejection fraction (HFpEF).
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 Moderate O 0 mSv O 0 mSv [ped] 9 9 0 0 0 1 0 0 3 3 9
References Study Quality
51 (25783858) 3
61 (25119893) 3
62 (27118225) 4
63 (25355298) 4
64 (25187609) 2
65 (23769272) 2
66 (26805452) 2
67 (21778591) 3
68 (24863953) 4
69 (26058890) 2
70 (21602549) 3
71 (26559428) 4
72 (24184245) 1
73 (22874137) 2
74 (22383372) 2
75 (21601421) 2
76 (21458230) 2
77 (23747067) 3
78 (21685198) 4
79 (22291430) 2
80 (21788358) 2
81 (26811160) Inadequate
82 (24150723) 4
83 (26082167) 2
84 (26941415) 2
MRI heart function and morphology without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 1 5 6 2
References Study Quality
85 (26005800) 2
MRI heart function and morphology without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 4 3 3 4 1
References Study Quality
85 (26005800) 2
Tc-99m ventriculography May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 1 0 5 6 3 0 0 0
References Study Quality
41 (23500216) 4
CTA coronary arteries with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv 4 4 1 0 2 5 5 2 0 0 0
Arteriography coronary May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 1 2 2 6 3 1 0 0 0
References Study Quality
86 (23112002) 4
87 (23811839) 4
88 (24975907) 4
US echocardiography transthoracic stress Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 3 2 3 4 2 1 0 0 0
References Study Quality
51 (25783858) 3
61 (25119893) 3
62 (27118225) 4
63 (25355298) 4
64 (25187609) 2
65 (23769272) 2
66 (26805452) 2
67 (21778591) 3
68 (24863953) 4
69 (26058890) 2
70 (21602549) 3
71 (26559428) 4
72 (24184245) 1
73 (22874137) 2
74 (22383372) 2
75 (21601421) 2
76 (21458230) 2
77 (23747067) 3
78 (21685198) 4
79 (22291430) 2
80 (21788358) 2
81 (26811160) Inadequate
82 (24150723) 4
83 (26082167) 2
84 (26941415) 2
MRI heart with function and vasodilator stress perfusion without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 2 5 2 3 0 0 0 0
References Study Quality
85 (26005800) 2
MRI heart with function and inotropic stress without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 1 6 4 0 0 0 0 0
References Study Quality
85 (26005800) 2
MRI heart with function and inotropic stress without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 4 1 6 4 0 0 0 0 0
References Study Quality
85 (26005800) 2
FDG-PET/CT heart Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 5 3 4 2 2 0 0 0 0
Tc-99m SPECT/CT MPI rest and stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 3 3 5 1 5 3 1 0 0 0 0
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 8 1 2 0 4 0 1 0 0
Rb-82 PET/CT heart stress Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 2 2 5 4 1 2 2 1 1 0 0
Variant 3: Confirmed new-onset heart failure with reduced ejection fraction of uncertain etiology: ischemic versus nonischemic.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA coronary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 8 8 1 0 0 1 0 1 4 5 4
References Study Quality
101 (23759285) 2
102 (21257010) 2
103 (28041705) 4
104 (25281557) 3
MRI heart function and morphology without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 0 1 3 7 4
References Study Quality
98 (26251006) 2
99 (21900085) 2
100 (21789747) 1
MRI heart with function and vasodilator stress perfusion without and with IV contrast Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 8 8 0 0 0 2 1 1 3 5 4
References Study Quality
98 (26251006) 2
99 (21900085) 2
100 (21789747) 1
Tc-99m SPECT/CT MPI rest and stress Usually appropriate Limited ☢☢☢☢ 10-30 mSv 8 8 1 0 0 0 2 1 4 3 5
References Study Quality
93 (23990345) 4
94 (24948152) 4
95 (27331209) 3
Arteriography coronary Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 0 0 2 1 8 3 1
References Study Quality
1 (23741058) 4
99 (21900085) 2
105 (22499335) 4
US echocardiography transthoracic stress Usually appropriate Moderate O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 0 0 8 2 4
References Study Quality
90 (16098295) 2
91 (19609896) 2
92 (17336751) 2
Rb-82 PET/CT heart stress Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 1 0 0 0 2 1 6 2 4
References Study Quality
41 (23500216) 4
96 (18794272) 3
97 (19223407) 3
MRI heart with function and inotropic stress without IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 6 6 0 0 1 4 3 4 2 1 1
References Study Quality
98 (26251006) 2
99 (21900085) 2
100 (21789747) 1
MRI heart with function and inotropic stress without and with IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 6 3 6 0 0
References Study Quality
98 (26251006) 2
99 (21900085) 2
100 (21789747) 1
FDG-PET/CT heart May be appropriate (Disagreement) Expert Opinion ☢☢☢☢ 10-30 mSv 5 4 0 0 4 4 5 0 2 0 0
References Study Quality
41 (23500216) 4
96 (18794272) 3
97 (19223407) 3
MRI heart function and morphology without IV contrast May be appropriate Moderate O 0 mSv O 0 mSv [ped] 4 4 3 1 3 6 2 0 0 0 0
References Study Quality
98 (26251006) 2
99 (21900085) 2
100 (21789747) 1
Tc-99m ventriculography Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 3 5 6 1 1 0 0 0 0
References Study Quality
41 (23500216) 4
US echocardiography transthoracic resting Usually not appropriate Moderate O 0 mSv O 0 mSv [ped] 3 3 2 1 9 1 2 0 0 0 0
References Study Quality
90 (16098295) 2
91 (19609896) 2
92 (17336751) 2
Radiography chest Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 7 3 3 1 1 0 1 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.