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 4 08 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 3 07 ☢ <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 2 ☢☢☢ 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 2 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 1 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 3 07 ☢☢☢ 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 4 08 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 1 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 1 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 3 ☢☢☢☢ 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 3 ☢☢☢☢ 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 1 ☢☢☢☢ 10-30 mSv 3 3 3 3 6 1 1 0 0 0 1
Arteriography coronary Usually not appropriate Expert Consensus 1 ☢☢☢ 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 1 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 6 08 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 1 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 1 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 3 ☢☢☢ 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 ☢☢☢ 1-10 mSv 4 4 1 0 2 5 5 2 0 0 0
Arteriography coronary May be appropriate Limited 3 ☢☢☢ 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 6 08 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 1 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 1 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 1 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 1 ☢☢☢☢ 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 1 ☢☢☢☢ 10-30 mSv 3 3 5 1 5 3 1 0 0 0 0
Radiography chest Usually not appropriate Expert Consensus 1 ☢ <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 1 ☢☢☢☢ 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 3 07 ☢☢☢ 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 6 08 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 6 08 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 3 ☢☢☢☢ 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 ☢☢☢ 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 6 08 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 3 ☢☢☢☢ 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 6 08 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 6 08 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 2 ☢☢☢☢ 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 6 08 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 3 ☢☢☢ 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 6 08 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 1 ☢ <0.1 mSv ☢ <0.03 mSv [ped] 2 2 7 3 3 1 1 0 1 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.