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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Kovacs G, Berghold A, Scheidl S, Olschewski H. Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review. Eur Respir J. 2009; 34(4):888-894. Review/Other-Dx 1,187 individuals from 47 studies in 13 countries Literature review and analysis of all accessible data obtained by right heart catheter studies from healthy individuals was performed to determine normal pulmonary arterial pressure (Ppa) at rest and during exercise. Pulmonary arterial pressure at rest was 14.0+/-3.3 mmHg and this value was independent of sex and ethnicity. Resting pulmonary arterial pressure was slightly influenced by posture (supine 14.0+/-3.3 mmHg, upright 13.6+/-3.1 mmHg) and age (<30 years: 12.8+/- 3.1 mmHg; 30-50 years: 12.9+/-3.0 mmHg; =50 years: 14.7+/-4.0 mmHg). Pulmonary arterial pressure during exercise was dependent on exercise level and age. During mild exercise, pulmonary arterial pressure was 19.4+/-4.8 mmHg in subjects aged <50 years compared with 29.4+/-8.4 mmHg in subjects =50 years (P<0.001). While pulmonary arterial pressure at rest is virtually independent of age and rarely exceeds 20 mmHg, exercise pulmonary arterial pressure is age-related and frequently exceeds 30 mmHg, especially in elderly individuals, which makes it difficult to define normal pulmonary arterial pressure values during exercise. 4
2. Simonneau G, Montani D, Celermajer DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension. [Review]. Eur Respir J. 53(1), 2019 01. Review/Other-Dx NA To discuss the classification of pulmonary hypertension. No results state din the abstract 4
3. Hoeper MM, Barbera JA, Channick RN, et al. Diagnosis, assessment, and treatment of non-pulmonary arterial hypertension pulmonary hypertension. J Am Coll Cardiol. 2009; 54(1 Suppl):S85-96. Review/Other-Dx N/A To review medical literature regarding the role of PH in chronic obstructive lung disease, interstitial lung disease, chronic thromboembolic PH, and left heart disease, and review recommendations regarding diagnosis and treatment of PH in these conditions. Given the lack of robust clinical trials addressing PH in any of these conditions, it is important to conduct further studies to establish the role of medical therapy in non-PAH PH. 4
4. Sahay S.. Evaluation and classification of pulmonary arterial hypertension. [Review]. J. thorac. dis.. 11(Suppl 14):S1789-S1799, 2019 Sep. Review/Other-Dx N/A To highlight the evaluation and diagnosis of PAH based on the proceedings of the 6th WSPH. No results stated in the abstract. 4
5. Hatano S, Strasser T. Primary pulmonary hypertension : report on a WHO meeting, Geneva, 15-17 October 1973. Geneva; Albany, N.Y.: World Health Organization; distributed by Q Corporation; 1975. Review/Other-Dx N/A Report on primary pulmonary hypertension. N/A 4
6. Rich S, editor. Primary Pulmonary Hypertension: Executive Summary from the World Symposium - Primary Pulmonary Hypertension 1998.  Available from the World Health Organization via the Internet (http://www.wsphassociation.org/wp-content/uploads/2019/04/Primary-Pulmonary-Hypertension-Evian-1998.pdf). Review/Other-Dx N/A Executive summary from the World Symposium on primary pulmonary hypertension. N/A 4
7. Simonneau G, Galie N, Rubin LJ, et al. Clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2004; 43(12 Suppl S):5S-12S. Review/Other-Dx N/A Review clinical classification of pulmonary hypertension. Evian classification is well accepted and widely used in clinical practice, especially in specialized centers. In 2003, during the Third World Symposium on Pulmonary Arterial Hypertension held in Venice, Italy, it was decided to maintain the general architecture and philosophy of the Evian classification. However, some modifications have been proposed, mainly to abandon the term "primary pulmonary hypertension" and to replace it with "idiopathic pulmonary hypertension"; to reclassify pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis; to update risk factors and associated conditions for pulmonary arterial hypertension and to propose guidelines in order to improve the classification of congenital systemic-to-pulmonary shunts. 4
8. Simonneau G, Gatzoulis MA, Adatia I, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34-41. Review/Other-Dx N/A To update clinical classification of pulmonary hypertension by adding some specific items related to pediatric pulmonary hypertension in order to have a comprehensive classification common for adults and children. No results stated in abstract. 4
9. Simonneau G, Robbins IM, Beghetti M, et al. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2009; 54(1 Suppl):S43-54. Review/Other-Dx N/A A review on the updated clinical classification of pulmonary hypertension (PH). In 2003, the clinical classification of PH initially adopted was slightly modified. During the 4th World Symposium held in 2008, it was decided to maintain the general architecture and philosophy of the previous clinical classifications. The modifications adopted during this meeting principally concern Group 1, PAH. This subgroup includes patients with PAH with a family history or patients with idiopathic PAH with germline mutations . In the new classification, schistosomiasis and chronic hemolytic anemia appear as separate entities in the subgroup of PAH associated with identified diseases. Finally, it was decided to place pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis in a separate group, distinct from but very close to Group 1 (now called Group 1'). Thus, Group 1 of PAH is now more homogeneous. 4
10. McCann C, Gopalan D, Sheares K, Screaton N. Imaging in pulmonary hypertension, part 1: clinical perspectives, classification, imaging techniques and imaging algorithm. [Review]. Postgrad Med J. 88(1039):271-9, 2012 May. Review/Other-Dx N/A To describe the clinical signs and symptoms of PH, explain the current PH classification and illustrate various imaging techniques that are available to investigate this condition. The strengths and weaknesses of each of these techniques will also be highlighted. No results stated in abstract. 4
11. McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 126(1 Suppl):14S-34S, 2004 Jul. Review/Other-Dx N/A Review evidence for screening in susceptible patient groups and the approach to diagnosing PAH when it is suspected, and provide specific recommendations for applying this evidence to clinical practice. A high level of suspicion is of paramount importance for the diagnosis of PAH, regardless of the underlying cause. Once suspected, a methodical workup using commonly employed diagnostic interventions allows both confirmation of the presence of PAH and elucidation of its etiology. Clarification of etiology is necessary to ensure that the proper therapeutic interventions are implemented. A diagnostic algorithm that is accepted among experienced centers can guide the evaluation of PAH. 4
12. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
13. Algeo S, Morrison D, Ovitt T, Goldman S. Noninvasive detection of pulmonary hypertension. Clin Cardiol. 1984; 7(3):148-156. Observational-Dx 79 consecutive patients and 50 consecutive control patients Plain chest x-rays, twelve-lead electrocardiograms, and M-mode echocardiograms were analyzed in control patients and patients with pulmonary hypertension documented at cardiac catheterization in order to determine the relative values of these noninvasive techniques as screening tests in detecting pulmonary hypertension. The sensitivity and specificity of selected findings previously described as being associated with pulmonary hypertension were calculated for each test. All test results were found to have sensitivities too low to function as satisfactory noninvasive screening techniques. Most findings were highly specific for pulmonary hypertension when present. Patients with pulmonary vascular disease were detected more frequently than those with pulmonary hypertension due to pulmonary venous congestion. 3
14. Chetty KG, Brown SE, Light RW. Identification of pulmonary hypertension in chronic obstructive pulmonary disease from routine chest radiographs. Am Rev Respir Dis. 1982; 126(2):338-341. Observational-Dx 34 patients To determine the value of routine chest radiographs in the identification of pulmonay hypertension in chronic obstructive pulmonary disease. Mean pulmonary artery pressure (PAP) was measured in patients with moderate to severe chronic obstructive pulmonary disease (FEV1, 1,010 +/- 460 ml)) and was correlated with the following 3 indexes derived from the chest roentgenogram: (1) the hilar thoracic index, (2) the diameter of the descending branch of the right pulmonary artery, (3) the hilar width, and (4) the cardiothoracic ratio. The PAP best correlated with the hilar thoracic index (r = 0.74, p less than 0.01) and was significantly correlated with the other 3 indexes. However, the accuracy with which the PAP could be predicted was only +/- 21 mm Hg. Authors conclude that the chest radiograph is useful in screening patients with COPD for elevated PAP, but that it cannot be used to predict the PAP accurately. 4
15. Lupi E, Dumont C, Tejada VM, Horwitz S, Galland F. A radiologic index of pulmonary arterial hypertension. Chest. 1975; 68(1):28-31. Observational-Dx 250 patients A new index derived from the plain chest radiograph is provided for assessing normal and elevated pulmonary artery pressure. The index was significantly different in groups with and without pulmonary hypertension and was abnormal (above 38 percent in 111 of 150 patients with cardiovascular disease and PAH. None of the cases with increased pulmonary flow from cardiac shunts but normal PAP had an anbormal index. Thus, an abnormal index suggested PAH but correlated poorly with the extent of hypertension. 4
16. Matthay RA, Schwarz MI, Ellis JH, Jr., et al. Pulmonary artery hypertension in chronic obstructive pulmonary disease: determination by chest radiography. Invest Radiol. 1981; 16(2):95-100. Observational-Dx 61 men and 42 normal control subjects To determine whether analysis of the chest radiograph can reveal the presence of pulmonary artery hypertension in COPD. The right descending pulmonary artery (RDPA) was enlarged (greater than 16 mm) in 43 of 46 patients (93%) with an elevated mean pulmonary artery pressure, and the left descending pulmonary artery (LDPA) diameter also was enlarged (greater than 18 mm) in 43 of 46. Combined increased RDPA and increased LDPA diameter measurements permitted correct diagnosis in 45 of 46 patients (98%) with pulmonary artery hypertension, including all 26 a mild elevation of mean pulmonary artery pressure (21-30 mmHg). There was a significant correlation between pulmonary artery pressure and both RDPA and LDPA measurements. Analysis of RDPA and LDPA diameters on the plain chest radiograph is a sensitive and accurate method of detecting the presence and severity of pulmonary artery hypertension in COPD. 4
17. Schmidt HC, Kauczor HU, Schild HH, et al. Pulmonary hypertension in patients with chronic pulmonary thromboembolism: chest radiograph and CT evaluation before and after surgery. Eur Radiol. 1996; 6(6):817-825. Observational-Dx 50 patients To assess the value of morphometric data on conventional radiography and CT predicting the presence and degree of pulmonary hypertension and to assess the reversibility after surgery. In 14 X-ray patients and 18 CT patients, with follow-up after surgical thromboendarterectomy the reversibility of these changes was assessed. A dilated pulmonary trunk was the most common abnormality (96% each on X-ray and CT). Pulmonary arteries were dilated on X-ray in 40% (right) and 14% (left), and on CT in 92% (right) and 96% (left). The best correlation with mean arterial pressure was found measuring the pulmonary trunk on CT (r = 0.43, p < 0.01). After surgery, reversibility was most significant for the pulmonary trunk on CT (p < 0.0001). In patients with chronic pulmonary embolism, pulmonary hypertension can best be predicted by assessing the diameter of the pulmonary trunk both on X-ray and CT. No close correlation is present between the extent of any parameter and the level of pulmonary pressure. 4
18. Teichmann V, Jezek V, Herles F. Relevance of width of right descending branch of pulmonary artery as a radiological sign of pulmonary hypertension. Thorax. 1970; 25(1):91-96. Observational-Dx 112 healthy subjects To elucidate the diagnostic importance of the right descending branch (RBD), the authors investigated the relation between its diameter and any pulmonary hypertension. Catheterization data was compared with the width of the RDB and the authors tried to find out the difference, if any, between the radiographic appearance of pulmonary hypertension in chronic bronchitis and in other diseases. Considering (in men over 40 years of age) a diameter of the RDB of 18 mm. or more as pathological, the reliability of the diagnosis of pulmonary hypertension in chronic bronchitis was 72-2% with readable films, or 64-2% when not reliably readable chest films were included. Nevertheless, a similar comparison in patients with mitral stenosis indicates that the radiographic picture of pulmonary hypertension differs according to the initial disease. 4
19. Woodruff WW, 3rd, Hoeck BE, Chitwood WR, Jr., Lyerly HK, Sabiston DC, Jr., Chen JT. Radiographic findings in pulmonary hypertension from unresolved embolism. AJR. 1985; 144(4):681-686. Observational-Dx 22 patients To evaluate plain chest radiographs in a series of patients with pulmonary artery hypertension and concomitant chronic pulmonary embolism seen at Duke University Medical Center between 1 968 and 1984. In 22 patients, no normal radiographs were seen. Findings included cardiomegaly (86.4%) with right-sided enlargement (68.4%), right descending pulmonary artery enlargement (54.5%), azygos vein enlargement (27.3%), mosaic oligemia (68.2%), chronic volume loss (27.3%), atelectasis and/or effusion (22.7%), and pleural thickening (13.6%). Good correlation with specific areas of diminished vascularity was seen on chest radiographs compared with pulmonary angiograms. 3
20. Miniati M, Monti S, Airo E, et al. Accuracy of chest radiography in predicting pulmonary hypertension: a case-control study. Thromb Res. 2014;133(3):345-351. Observational-Dx 108 patients To assess the accuracy of chest radiography (CXR) in predicting pulmonary hypertension (PH). Eighty-two patients had PH confirmed at RHC. Weighted sensitivity of CXR was 96.9% (95% confidence interval, 94.9 to 98.2%), and weighted specificity 99.8% (95% confidence interval, 99.6 to 99.9%). By considering the 165 patients who underwent RHC, weighted sensitivity of CXR was unchanged, and weighted specificity decreased to 99.1%. None of the patients with PH were misclassified as having LHF, and vice versa. 2
21. Barbosa EJ, Jr., Gupta NK, Torigian DA, Gefter WB. Current role of imaging in the diagnosis and management of pulmonary hypertension. AJR Am J Roentgenol. 2012;198(6):1320-1331. Review/Other-Dx N/A To describe classification schemes and imaging findings in the diagnosis and management of pulmonary hypertension. Pulmonary hypertension is a complex pathophysiologic condition in which several clinical entities increase pressure in the pulmonary circulation, progressively impairing cardiopulmonary function and, if untreated, causing right ventricular failure. Current classification schemes emphasize the necessity of an early, accurate etiologic diagnosis for a tailored therapeutic approach. Imaging plays an increasingly important role in the diagnosis and management of suspected pulmonary hypertension. 4
22. Cordina RL, Playford D, Lang I, Celermajer DS. State-of-the-Art Review: Echocardiography in Pulmonary Hypertension. Heart Lung Circ. 28(9):1351-1364, 2019 Sep. Review/Other-Dx NA To discuss traditional methods as well as newer echocardiographic methods in the setting of pulmonary hypertension. No results stated in the abstract. 4
23. Ni JR, Yan PJ, Liu SD, et al. Diagnostic accuracy of transthoracic echocardiography for pulmonary hypertension: a systematic review and meta-analysis. BMJ Open 2019;9:e033084. Meta-analysis 27 studies To evaluate the diagnostic accuracy of transthoracic echocardiography (TTE) in patients with pulmonary hypertension (PH). A total of 27 studies involving 4386 subjects were considered as eligible for analysis. TTE had a pooled sensitivity of 85%, a pooled specificity of 74%, a pooled positive likelihood ratio of 3.2, a pooled negative likelihood ratio of 0.20, a pooled diagnostic OR of 16 and finally an area under the summary receiver operating characteristic curve of 0.88. The subgroup with the shortest time interval between TTE and RHC had the best diagnostic effect, with sensitivity, specificity and area under the curve (AUC) of 88%, 90% and 0.94, respectively. TTE had lower sensitivity (81%), specificity (61%) and AUC (0.73) in the subgroup of patients with definite lung diseases. Subgroup analysis also showed that different thresholds of TTE resulted in a different diagnostic performance in the diagnosis of PH. Good
24. Galie N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J. 37(1):67-119, 2016 Jan 01. Review/Other-Dx N/A To provide Guidelines for the diagnosis and treatment of pulmonary hypertension. No results stated in abstract. 4
25. Schneider M, Ran H, Pistritto AM, et al. Pulmonary artery to ascending aorta ratio by echocardiography: A strong predictor for presence and severity of pulmonary hypertension. PLoS ONE. 15(7):e0235716, 2020. Observational-Dx 84 patients To evaluate (1) the feasibility to image the pulmonary trunk in a prospective cohort, and (2) the ability of PA:A derived by TTE to predict pulmonary hypertension (PH). A total of 84 patients were included in the analysis, median age was 70.5 years (IQR 58-75), 46 (55%) were female. The PA was significantly wider in the PH group (28mm vs. 22.5mm, p<0.001) with a resulting median PA:A of 0.84 vs. 0.66 (p<0.001). Both PA diameter (r = 0.524 and r = 0.44, both p<0.001) and PA:A (r = 0.652 and 0.697, both p<0.001) significantly correlated with mPAP and with PVR, respectively. Area under the curve for the detection of PH was 0.853 (95%CI 0.739-0.967, p<0.001). 2
26. Yagi M, Taniguchi H, Kondoh Y, et al. CT-determined pulmonary artery to aorta ratio as a predictor of elevated pulmonary artery pressure and survival in idiopathic pulmonary fibrosis. Respirology. 22(7):1393-1399, 2017 10. Observational-Dx 177 patients To examine the association between the pulmonary artery to the aorta (PA:A) and pulmonary artery pressure (mPAP) in these patients, and performed a receiver operating characteristic (ROC) analysis to test the diagnostic accuracy of the PA:A in predicting mPAP > 20 mm Hg (pulmonary hypertension (PH) or borderline PH) in relation to survival. In a multivariate linear regression analysis, the PA:A, 6-min walk distance and diffusion capacity for carbon monoxide (DLCO ) % predicted were independent explanatory variables of elevated mPAP (P < 0.0001, P = 0.009 and P = 0.002, respectively). ROC analysis revealed a PA:A > 0.9 to be optimal for predicting mPAP > 20 mmHg (area under the curve (AUC) = 0.75; 95% CI: 0.65-0.84). Patients with a PA:A > 0.9 also had a worse prognosis (P = 0.009). 2
27. Madonna R, Bonitatibus G, Vitulli P, Pierdomenico SD, Galie N, De Caterina R. Association of the European Society of Cardiology echocardiographic probability grading for pulmonary hypertension with short and mid-term clinical outcomes after heart valve surgery. Vascul Pharmacol. 125-126:106648, 2020 Feb - Mar. Observational-Dx 60 patients To evaluate the impact of such score on short- and mid-term outcomes in patients undergoing left heart valvular surgery. We included 60 consecutive patients (mean age 70 ± 9 years) undergoing left heart valvular surgery with or without coronary artery bypass. Patients were divided into 3 groups according to the PH probability: "low" (n = 18), "intermediate" (n = 18), or "high" (n = 24). The high PH probability group had higher rate of World Health Organization-Functional Class (WHO-FC) III and IV, hemodynamic complications, deaths, major bleeding events and infections after heart surgery than the other groups. A "high" PH probability was associated with reduced right ventricular systolic function, as measured by the fractional area change (FAC), but not with the tricuspid annular plane systolic excursion (TAPSE). 2
28. Di Bello V, Conte L, Delle Donne MG, et al. Advantages of real time three-dimensional echocardiography in the assessment of right ventricular volumes and function in patients with pulmonary hypertension compared with conventional two-dimensional echocardiography. Echocardiography. 2013;30(7):820-828. Observational-Dx 54 patients To point out the value of real time three-dimensional echocardiography (RT3DE) and tissue Doppler imaging (TDI) in the evaluation of patients affected by pulmonary hypertension (PH), compared with conventional two-dimensional (2D) echocardiography. In this study, RV FAC, and TAPSE showed marked alterations in patients with PH compared to the control group (C): (RVFAC: [PH] 0.29 +/- 0.07 vs. [C] 0.49 +/- 0.05%, P < 0.0001; TAPSE: [PH] 15.3 +/- 3.2 vs. [C] 21.1 +/- 2.6 mm, P > 0.0001). The 3D RV end-diastolic volume was significantly higher in PH than in C (PH) (138.7 +/- 25.3 vs. [C] 82.8 +/- 12.5 mL, P < 0.0001] as well as 3D RV end-systolic volume (PH) (97.6 +/- 21.5 vs. [C] 39.3 +/- 9.5 mL, P < 0.0001). The 3D RV ejection fraction (EF) was significantly lower in the pulmonary hypertension group than in healthy subjects (31.8 +/- 6.8 vs. [C] 52.5 +/- 4.7%, P < 0.0001). 2
29. Huang KC, Lin LY, Hwang JJ, Lin LC. Three-Dimensional Echocardiography-Derived Non-Invasive Right Ventricular Pressure-Volume Analysis. Ultrasound Med Biol. 43(9):2045-2053, 2017 09. Observational-Dx 12 patients To discuss the three-Dimensional Echocardiography-Derived Non-Invasive Right Ventricular Pressure-Volume Analysis. We enrolled 12 patients with pulmonary arterial hypertension (PAH) and 10 with pulmonary venous hypertension (PVH) May 2016-October 2016. All patients underwent a clinically indicated right heart catheterization (RHC), from which the yielded right ventricular pressure recordings were conjugated with RV volume by 3-D echocardiography to generate a pressure-volume loop. A continuous-wave Doppler envelope of tricuspid regurgitation was transformed into a pressure gradient recording by the simplified Bernoulli equation, and then a systolic pressure gradient-volume (PG-V) diagram was generated from similar methods. The area enclosed by the pressure-volume loop was calculated to represent semi-invasive right ventricular stroke work (RVSWRHC). The area between the PG-V diagram and x-axis was calculated to estimate non-invasive RVSW (RVSWecho). Patients with PAH have higher RV pressure, lower pulmonary arterial wedge pressure and larger RV volume that was contributed by the dilation of RV mid-cavity minor dimension. We found no significant difference of traditional parameters between these two groups, but RVSW values were significantly higher in PAH patients. The RVSW values of these two methods were significantly correlated by the equation RVSWecho = 0.8447 RVSWRHC + 129.38 (R2 = 0.9151, p < 0.001). The linearity remained satisfactory in both groups. We conclude that a PG-V diagram is a reliable method to estimate RVSW and to depict pathophysiological status. 2
30. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc.; and the Pulmonary Hypertension Association. J Am Coll Cardiol 2009;53:1573-619. Review/Other-Dx N/A To discuss the report on the consensus document document on Pulmonary hypertension. No results stated in the abstract. 4
31. Kleczynski P, Dziewierz A, Wiktorowicz A, et al. Prognostic value of tricuspid regurgitation velocity and probability of pulmonary hypertension in patients undergoing transcatheter aortic valve implantation. Int J Cardiovasc Imaging. 33(12):1931-1938, 2017 Dec. Observational-Dx 148 patients To investigate the effects of tricuspid regurgitant velocity (TRV) and echocardiographic probability of PH on clinical outcomes of patients undergoing transcatheter aortic valve implantation (TAVI). Only the patients from the "high" probability group were considered as patients with PH. All-cause mortality, complications rate and quality of life (QoL) were assessed according to VARC-2 recommendations. Of 148 patients, 65 (43.9%) were considered as patients with PH. These presented with higher NYHA class at baseline (p = 0.027) and had more frequently a history of previous stroke/transient ischemic attack (p = 0.019). A difference in all-cause mortality was noted at 12 months [PH (-) vs. PH (+): 9.6 vs. 21.5%; p = 0.043]; however, it was no longer significant after adjustment for age and gender (OR 2.39, 95% CI 0.91-6.24; p = 0.08). Unadjusted and adjusted rates of all-cause death at maximal follow-up of 13.3 (6.0-31.1) months were higher in patients with PH. However, the presence of PH was not identified as an independent predictor of all-cause mortality at follow-up. No difference in other complications rates and QoL were noted. The presence of TRV >3.4 m/s indicating "high" probability of PH may predict impaired clinical outcomes after TAVI. No impact of PH on QoL outcomes was confirmed 2
32. Narendra Kumar K, Singh NG, P S N, Patil TA, N M. Transesophageal Echocardiographic Assessment of Pulmonary Artery-to-Ascending Aorta Ratio for the Detection of Pulmonary Hypertension in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth. 31(5):1702-1706, 2017 Oct. Observational-Dx 54 patients To investigate if the main pulmonary artery (mPA)-to-ascending aorta (AscAo), (mPA:AscAo) ratio could serve as a screening tool in identifying pulmonary artery hypertension (PAH). mPA:AscAo ratio demonstrated significant linear correlation with mPAP measured by pulmonary artery catheterization (ie, r = 0.61, confidence interval [CI] = 0.5352-0.6736, p < 0.0001). Receiver operating characteristic curves were performed to evaluate sensitivity and specificity of mPA:AscAo ratio =1 for diagnosing PAH (mPAP =25 mmHg). Area under the curve for mPA:AscAo ratio was 0.91 (95% CI, 0.869-0.936, p < 0.0001), with a sensitivity of 84.27%, specificity of 83.92%, positive-predictive value of 87.6% and negative-predictive value of 81.1% for a mPAP =25 mmHg. 2
33. Moradi F, Morris TA, Hoh CK. Perfusion Scintigraphy in Diagnosis and Management of Thromboembolic Pulmonary Hypertension. [Review]. Radiographics. 39(1):169-185, 2019 Jan-Feb. Review/Other-Dx NA To discuss the perfusion scintigraphy in diagnosis and management of Thromboembolic Pulmonary Hypertension. No results stated in the abstract 4
34. Nachand D, Huang S, Bullen J, Heresi GA, Renapurkar RD. Assessment of ventilation-perfusion scans in patients with chronic thromboembolic pulmonary hypertension before and after surgery and correlation with clinical parameters. Clin Imaging. 66:147-152, 2020 Oct. Observational-Dx 27 patients To discuss the comparative analysis of matched and mismatched defects in pre- and post-operative V/Q scans in CTEPH patients. On a segmental basis, 176 mismatched defects were noted in 27 patients, of which 111 improved post-surgery (63%). 22 of the 34 matched defects improved following surgery (64%). 31 new mismatched defects were observed. The number of pre-operative matched defects per patient ranged from 0 to 6. No statistically significant associations were observed between the number of pre-operative matched defects and pre-operative clinical parameters. No statistically significant associations were observed between the number of improved matched defects and the change in clinical parameters (pre- to post-surgery). 2
35. Mehari A, Igbineweka N, Allen D, Nichols J, Thein SL, Weir NA. Abnormal Ventilation-Perfusion Scan Is Associated with Pulmonary Hypertension in Sickle Cell Adults. J Nucl Med. 60(1):86-92, 2019 01. Observational-Dx 142 patients To compare the performance of V/Q scanning with that of CT pulmonary angiography (CTPA) and to report clinical outcomes associated with abnormal V/Q findings. V/Q results were abnormal in 65 of 142 patients (45.8%). CTPA was positive for pulmonary embolism in 16 of 60 (26.7%). RHC confirmed PH (mean pulmonary artery pressure = 25 mmHg) in 46 of 64 (71.9%), of whom 34 (73.9%) had abnormal V/Q findings. Among those without PH by RHC (n = 18), 2 of 18 patients had abnormal V/Q findings. Thirty-three patients had a complete dataset (V/Q scanning, CTPA, and RHC); 29 of 33 had abnormal RHC findings, of whom 26 had abnormal V/Q findings, compared with 11 who had abnormal CTPA findings. There was greater concordance between V/Q findings and RHC (?-value = 0.53; P < 0.001) than between CTPA and RHC (?-value = 0.13; P = 0.065). The sensitivity and specificity for V/Q scanning was 89.7% and 75.0%, respectively, whereas CTPA had sensitivity of 37.3% and specificity of 100%. Abnormal V/Q finding swere associated with hemodynamic severity (mean pulmonary artery pressure, 35.2 ± 9.6 vs. 26.9 ± 10.5 mm Hg, P = 0.002; transpulmonary gradient, 21.5 ± 9.7 vs. 12.16 ± 11 mmHg, P = 0.005; and pulmonary vascular resistance, 226.5 ± 135 vs. 140.7 ± 123.7 dynes·s·cm-5, P = 0.013) and exercise capacity (6-min-walk distance, 382.8 ± 122.3 vs. 442.3 ± 110.6 m, P < 0.010). Thirty-four deaths were observed over 15 y. All-cause mortality was higher in the abnormal-V/Q group (21 [61.8%]) than in the normal-V/Q group (13 [38.2%]) (log-rank test, P = 0.006; hazard ratio, 2.54). 2
36. Tunariu N, Gibbs SJ, Win Z, et al. Ventilation-perfusion scintigraphy is more sensitive than multidetector CTPA in detecting chronic thromboembolic pulmonary disease as a treatable cause of pulmonary hypertension. J Nucl Med. 2007; 48(5):680-684. Observational-Dx 227 patients Retrospective study to compare the value of ventilation-perfusion (V/Q) scintigraphy with CT pulmonary angiography (CTPA) in detecting chronic thromboembolic pulmonary disease. 78 patients (group A) had a final diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) and 149 (group B) had non-CTEPH etiology. Among group A, V/Q scintigraphy was reported as high probability in 75 patients, intermediate probability in 1 patient, and low probability in 2 patients. CTPA was positive in 40 patients and negative in 38 patients. Among group B, V/Q scintigraphy was reported as low probability in 134, intermediate probability in 7, and high probability in 8 patients. CTPA was negative in 148 patients and false-positive in 1 patient. Statistical analysis showed V/Q scintigraphy to have a sensitivity of 96%-97.4% and a specificity of 90%-95%. CTPA showed a sensitivity of 51% and a specificity of 99%. Results demonstrate that V/Q scintigraphy has a higher sensitivity than CTPA in detecting CTEPH as a potential curable cause of PH. 4
37. He J, Fang W, Lv B, et al. Diagnosis of chronic thromboembolic pulmonary hypertension: comparison of ventilation/perfusion scanning and multidetector computed tomography pulmonary angiography with pulmonary angiography. Nucl Med Commun. 33(5):459-63, 2012 May. Observational-Dx 51 patients To compare the diagnostic efficacy of pulmonary ventilation/perfusion (V/Q) scanning and computed tomography pulmonary angiography (CTPA) using pulmonary angiography as the gold standard. Fifty-one patients (44.7%) had a final diagnosis of CTEPH. V/Q scan showed high probability, intermediate probability, and low probability/normal scan in 52, three, and 59 patients, respectively. CTPA revealed 50 patients with CTEPH and 64 patients without CTEPH. The sensitivity, specificity, and accuracy of the V/Q scan were 100, 93.7, and 96.5%, respectively, with threshold 1, and 96.1, 95.2, and 95.6%, respectively, with threshold 2; similarly, the sensitivity, specificity, and accuracy of CTPA were 92.2, 95.2, and 93.9%, respectively. 2
38. Chan K, Ioannidis S, Coghlan JG, Hall M, Schreiber BE. Pulmonary Arterial Hypertension With Abnormal V/Q Single-Photon Emission Computed Tomography. JACC Cardiovasc Imaging. 11(10):1487-1493, 2018 10. Observational-Dx 136 patients To evaluate the incidence and clinical outcomes of abnormal ventilation/perfusion (V/Q) single-photon emission computed tomography (SPECT) without thromboembolism, especially in patients with group I pulmonary arterial hypertension (PAH). V/Q SPECT showed thromboembolic disease in 44 patients, but 19 of these patients had no thromboembolism demonstrated by pulmonary angiography. Among these patients, 15 of 19 (78.9%) had group I PAH, and the majority had diffuse, patchy perfusion defects. After redefining V/Q SPECT images according to the perfusion pattern, those patients with global perfusion defects had higher mean pulmonary arterial pressure compared with patients with focal perfusion defects and normal scans (mean difference +13.9 and +6.2 mm Hg, respectively; p = 0.0002), as well as higher pulmonary vascular resistance (mean difference +316.6 and +226.3 absolute resistance units, respectively; p = 0.004). Among patients with PAH, global perfusion defects were associated with higher all-cause mortality with a hazard ratio of 5.63 (95% confidence interval: 1.11 to 28.5) compared with patients with focal or no perfusion abnormalities. 2
39. Tan RT, Kuzo R, Goodman LR, Siegel R, Haasler GB, Presberg KW. Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease. Medical College of Wisconsin Lung Transplant Group. Chest. 1998; 113(5):1250-1256. Observational-Dx 45 patients To determine the utility of CT-determined main pulmonary artery diameter (MPAD) for predicting PH in patients with parenchymal lung disease. CT-determined MPAD was 35+/-6 mm in patients with PH and 27+/-2 mm in control subjects. MPAD > or =29 mm had a sensitivity of 87%, specificity of 89%, PPV of 0.97, and positive likelihood ratio (LR) of 7.91 for predicting PH; in the subgroup of patients with parenchymal lung disease (n=28, PH and control subjects), MPAD > or =29 mm had a sensitivity of 84%, specificity of 75%, PPV of 0.95, and positive LR of 3.36 for predicting PH. The most specific findings for the presence of PH were both MPAD > or =29 mm and segmental artery-to-bronchus ratio > 1:1 in three or four lobes (specificity, 100%). There was no linear correlation between the degree of PH and MPAD (r=0.124). CT-determined MPAD has excellent diagnostic value for detection of PH in patients with advanced lung disease. Therefore, standard chest CT scans can be used to screen for PH as a cause of exertional limitation in patients with parenchymal lung disease. Because CT is commonly used to evaluate parenchymal lung disease, this information is readily available. 4
40. Zisman DA, Karlamangla AS, Ross DJ, et al. High-resolution chest CT findings do not predict the presence of pulmonary hypertension in advanced idiopathic pulmonary fibrosis. Chest. 2007; 132(3):773-779. Observational-Dx 65 patients To determine whether the CT-determined extent and severity of pulmonary fibrosis and diameter of the main pulmonary artery could be used to diagnose PH in advanced IPF patients. Chest CT-determined fibrosis score, ground-glass opacity score, honeycombing score, total profusion score, diameter of the main pulmonary artery, and the ratio of the pulmonary artery to aorta diameter did not differ between those with and without pulmonary hypertension. There was no significant correlation between mean pulmonary artery pressure and any of the chest CT-determined measures. 4
41. Chan AL, Juarez MM, Shelton DK, et al. Novel computed tomographic chest metrics to detect pulmonary hypertension. BMC Med Imaging. 2011;11:7. Observational-Dx 101 patients To determine whether PH can be assessed by measuring a set of CT chest-based metrics that have a relationship to RHC. Multiple regression analyses controlling for age, sex, ascending aortic diameter, body surface area, thoracic diameter and pulmonary wedge pressure showed that a main pulmonary artery (PA) diameter >/=29 mm (odds ratio (OR)=4.8), right descending PA diameter >/=19 mm (OR=7.0), true right descending PA diameter >/=16 mm (OR=4.1), true left descending PA diameter >/=21 mm (OR=15.5), right ventricular (RV) free wall >/=6 mm (OR=30.5), RV wall/left ventricular (LV) wall ratio >/=0.32 (OR=8.8), RV/LV lumen ratio >/=1.28 (OR=28.8), main PA/ascending aorta ratio >/=0.84 (OR=6.0) and main PA/descending aorta ratio >/=1.29 (OR=5.7) were significant predictors of PH in this population of hospitalized patients. 3
42. Truong QA, Bhatia HS, Szymonifka J, et al. A four-tier classification system of pulmonary artery metrics on computed tomography for the diagnosis and prognosis of pulmonary hypertension. J Cardiovasc Comput Tomogr. 12(1):60-66, 2018 Jan - Feb. Observational-Dx 228 patients To develop a severity classification system of the main pulmonary artery diameter (mPA) and its ratio to the ascending aorta diameter (ratio PA) for the diagnosis and prognosis of pulmonary hypertension (PH) on computed tomography (CT) scans. Sensitivities for normal tier were 99% for mPA and 93% for ratio PA; while specificities for severe tier were 98% for mPA>34 mm and 100% for ratio PA>1.1. C-statistics for four-tier mPA and ratio PA were both 0.90 (derivation) and both 0.85 (validation). Severity of mPA and ratio PA corresponded to hemodynamics by RHC and echocardiography (both p < 0.001). Moderate-severe mPA values of =31 mm and ratio PA>1.1 had worse survival than normal values (all p = 0.01). 2
43. Yaghi S, Novikov A, Trandafirescu T. Clinical update on pulmonary hypertension. [Review]. J Investig Med. 68(4):821-827, 2020 04. Review/Other-Dx NA To discuss the clinical update on pulmonary hypertension. No results stated in the abstract. 4
44. Bax S, Jacob J, Ahmed R, et al. Right Ventricular to Left Ventricular Ratio at CT Pulmonary Angiogram Predicts Mortality in Interstitial Lung Disease. Chest. 157(1):89-98, 2020 01. Observational-Dx 92 patients To discuss the results from the right ventricular to left ventricular diameter (RV:LV) ratio measured at CT pulmonary angiogram (CTPA) in patients with pulmonary arterial hypertension and to predict death or deterioration in acute pulmonary embolism. A total of 92 patients were included (64% male; mean age 65 ± 11 years) with an FVC 57 ± 20% predicted, corrected transfer factor of the lung for carbon monoxide 22 ± 8% predicted, and corrected transfer coefficient of the lung for carbon monoxide 51 ± 17% predicted. PH was confirmed at right heart catheterization in 78%. Of all the CTPA-derived measures, an RV:LV ratio = 1.0 strongly predicted mortality or transplantation at univariate analysis (hazard ratio, 3.26; 95% CI, 1.49-7.13; P = .003), whereas invasive hemodynamic data did not. The RV:LV ratio remained an independent predictor at multivariate analysis (hazard ratio, 3.19; 95% CI, 1.44-7.10; P = .004), adjusting for an ILD diagnosis of idiopathic pulmonary fibrosis and CT imaging-derived ILD severity. 2
45. Remy-Jardin M, Duhamel A, Deken V, Bouaziz N, Dumont P, Remy J. Systemic collateral supply in patients with chronic thromboembolic and primary pulmonary hypertension: assessment with multi-detector row helical CT angiography. Radiology. 2005; 235(1):274-281. Observational-Dx 36 patients To compare retrospectively the frequency of systemic collateral supply in patients who have chronic thromboembolic pulmonary hypertension with the frequency of systemic collateral supply in patients who have primary pulmonary hypertension by using multi–detector row helical CT angiography. The degree of pulmonary hypertension was comparable in groups 1 and 2. Abnormally enlarged systemic arteries were identified in 16 (73%) of 22 patients from group 1 and in two (14%) of 14 patients from group 2 (P = .002). The systemic collateral supply in group 1 comprised enlargement of both bronchial and nonbronchial systemic arteries in nine (56%) of the 16 patients; the remaining seven patients had an exclusive enlargement of bronchial systemic arteries (n = 6, 38%) or nonbronchial (n = 1, 6%) systemic arteries. A total of 31 enlarged nonbronchial systemic arteries were depicted, including 13 inferior phrenic arteries, 10 intercostal arteries, seven internal mammary arteries, and one lateral thoracic artery. The mean ± standard deviation of abnormal nonbronchial systemic arteries per patient was 1.4 ± 1.9. No relationship was found between the mean number of abnormally enlarged nonbronchial systemic arteries and the CT angiographic features of chronic pulmonary embolism. The results demonstrate the higher frequency of abnormally enlarged bronchial and nonbronchial systemic arteries in patients who have chronic thromboembolic pulmonary hypertension compared with patients who have primary pulmonary hypertension; this finding could help distinguish these two entities on CT angiograms. 4
46. Aluja Jaramillo F, Gutierrez FR, Diaz Telli FG, Yevenes Aravena S, Javidan-Nejad C, Bhalla S. Approach to Pulmonary Hypertension: From CT to Clinical Diagnosis. [Review]. Radiographics. 38(2):357-373, 2018 Mar-Apr. Review/Other-Dx NA To discuss the approach to approach to Pulmonary Hypertension: From CT to Clinical Diagnosis. No results state din the abstract. 4
47. Frazier AA, Burke AP. The imaging of pulmonary hypertension. Semin Ultrasound CT MR. 2012;33(6):535-551. Review/Other-Dx N/A To discuss the value of different imaging modalities in the diagnosis pulmonary hypertension. Radiologic imaging provides an essential tool for the comprehensive analysis of the pulmonary vasculature, lung parenchyma, and cardiac morphology and function in PH. Chest radiography, VQ imaging, and CT help to localize the primary site of disease as either precapillary or postcapillary, and further may provide insight into the underlying etiology of PH. 4
48. Frazier AA, Franks TJ, Mohammed TL, Ozbudak IH, Galvin JR. From the Archives of the AFIP: pulmonary veno-occlusive disease and pulmonary capillary hemangiomatosis. Radiographics. 2007;27(3):867-882. Review/Other-Dx N/A To discuss the radiologic manifestations that help to distinguish PVOD and PCH from PAH. PVOD and PCH are clinically indistinguishable from a primary PAH disorder such as PPH or chronic thromboembolic pulmonary hypertension. This distinction, however, is essential for appropriate pharmacologic intervention as well as for timely evaluation for lung transplantation. 4
49. McComb BL, Ravenel JG, Steiner RM, et al. ACR Appropriateness Criteria® Chronic Dyspnea-Noncardiovascular Origin. J Am Coll Radiol 2018;15:S291-S301. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for chronic dyspnea-noncardiovascular origin. No results stated in abstract. 4
50. American College of Radiology. ACR Appropriateness Criteria®: Dyspnea-Suspected Cardiac Origin. Available at: https://acsearch.acr.org/docs/69407/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No results stated in abstract. 4
51. Melzig C, Worz S, Egenlauf B, et al. Combined automated 3D volumetry by pulmonary CT angiography and echocardiography for detection of pulmonary hypertension. Eur Radiol. 29(11):6059-6068, 2019 Nov. Observational-Dx 70 patients To assess the diagnostic accuracy of automated 3D volumetry of central pulmonary arteries using computed tomography pulmonary angiography (CTPA) for suspected pulmonary hypertension alone and in combination with echocardiography MPA, RPA and LPA volumes were significantly increased in patients with vs. without pulmonary hypertension (all p < 0.001). Of all measures, MPA volume demonstrated the strongest correlation with invasive mPAP (r = 0.76, p < 0.001). Predicted mPAP using MPA volume and echocardiographic PASP as covariates showed excellent correlation with invasive mPAP (r = 0.89, p < 0.001). Area under the curves for predicting pulmonary hypertension were 0.94 for predicted mPAP, compared to 0.90 for MPA volume and 0.92 for echocardiographic PASP alone. A predicted mPAP > 25.8 mmHg identified pulmonary hypertension with sensitivity, specificity, positive and negative predictive values of 86%, 93%, 95% and 81%, respectively. 2
52. Akbal OY, Kaymaz C, Tanboga IH, et al. Extrinsic compression of left main coronary artery by aneurysmal pulmonary artery in severe pulmonary hypertension: its correlates, clinical impact, and management strategies. Eur Heart J Cardiovasc Imaging. 19(11):1302-1308, 2018 11 01. Observational-Dx 498 patients In this single-centre prospective study, the aim was to evaluate incidence, clinical, and haemodynamic correlates and management strategies of Left Main Coronary Artery Compression (LMCA-Co) in patients with Pulmonary Arterial Hypertension (PAH) Our study group comprised 269 (female 166, age 52.9 ± 17.3 years) out of 498 patients with confirmed PH who underwent coronary angiography (CA) because of the PAA on echocardiography, angina or incidentally detected LMCA-Co during diagnostic evaluation with multidetector computed tomography. The LMCA-Co = 50% was documented in 22 patients (8.2%) who underwent CA, and stenosis were between 70% and 90% in 14 of these. Univariate comparisons revealed that a younger age, a D-shaped septum, a higher PA systolic, diastolic, and mean pressures and pulmonary vascular resistance, a larger PA diameter, a smaller aortic diameter and pulmonary arterial hypertension associated with patent-ductus arteriosus, atrial or ventricular septal defects were significantly associated with LMCA-Co. Bare-metal stents were implanted in 12 patients and 1 patient underwent PAA and atrial septal defect surgery and another one declined LMCA stenting procedure. 2
53. Galie N, Saia F, Palazzini M, et al. Left Main Coronary Artery Compression in Patients With Pulmonary Arterial Hypertension and Angina. J Am Coll Cardiol. 69(23):2808-2817, 2017 Jun 13. Observational-Dx 765 patients To evaluate the prevalence of LMCA extrinsic compression from a dilated pulmonary artery (PA) in patients with PAH and angina or angina-like symptoms, determine the usefulness of screening with computed tomography coronary angiography (CTCA), and assess the safety and efficacy of percutaneous coronary interventions (PCIs). Of 765 patients with PAH, 121 had angina or angina-like symptoms. Ninety-four patients had abnormal CTCA based on the relationship between the PA and the LMCA and underwent selective coronary angiography. LMCA stenosis =50% was detected in 48 of the 94 patients. Forty-five patients underwent PCI with stenting, of whom 41 had sustained angina symptom relief. The 3 other patients had surgical PA reduction plasty. Nine months after PCI, 5 patients had LMCA restenosis and PCI was successfully repeated. The best predictor of LMCA stenosis =50% was a PA diameter =40 mm. Rates for death or double-lung transplant and the composite rates for death, double-lung transplant, or restenosis at 36 months were 5% and 30%, respectively. 2
54. Dournes G, Verdier D, Montaudon M, et al. Dual-energy CT perfusion and angiography in chronic thromboembolic pulmonary hypertension: diagnostic accuracy and concordance with radionuclide scintigraphy. Eur Radiol. 24(1):42-51, 2014 Jan. Observational-Dx 40 patients To evaluate the diagnostic accuracy of dual-energy computed tomography (DECT) perfusion and angiography versus ventilation/perfusion (V/Q) scintigraphy in chronic thromboembolic pulmonary hypertension (CTEPH), and to assess the per-segment concordance rate of DECT and scintigraphy. Fourteen patients were diagnosed with CTEPH and 26 with other aetiologies. DECT perfusion and angiography correctly identified all CTEPH patients with sensitivity/specificity values of 1/0.92 and 1/0.93, respectively. At a segmental level, DECT perfusion showed moderate agreement (kappa = 0.44) with scintigraphy. Agreement between CT angiography and scintigraphy ranged from fair (kappa = 0.31) to slight (kappa = 0.09) depending on whether completely or partially occlusive patterns were considered, respectively. 2
55. Masy M, Giordano J, Petyt G, et al. Dual-energy CT (DECT) lung perfusion in pulmonary hypertension: concordance rate with V/Q scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol. 28(12):5100-5110, 2018 Dec. Observational-Dx 80 patients To evaluate the concordance between DECT perfusion and ventilation/perfusion (V/Q) scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). Based on multidisciplinary expert decisions that did not include DECT perfusion, 36 patients were diagnosed with CTEPH and 44 patients with other aetiologies of PH. On DECT perfusion studies, there were 35 true positives, 6 false positives and 1 false negative (sensitivity 0.97, specificity 0.86, PPV 0.85, NPV 0.97). On V/Q scans, there were 35 true positives and 1 false negative (sensitivity 0.97, specificity 1, PPV 1, NPV 0.98). There was excellent agreement between CT perfusion and scintigraphy in diagnosing CTEPH (kappa value 0.80). Combined information from DECT perfusion and CT angiographic images enabled correct reclassification of the 6 false positives and the unique false negative case of DECT perfusion. 2
56. Nakazawa T, Watanabe Y, Hori Y, et al. Lung perfused blood volume images with dual-energy computed tomography for chronic thromboembolic pulmonary hypertension: correlation to scintigraphy with single-photon emission computed tomography. J Comput Assist Tomogr. 2011;35(5):590-595. Observational-Dx 51 patients To evaluate the feasibility and diagnostic utility of lung perfused blood volume (LPBV) images generated by dual-energy computed tomography (CT), as compared with pulmonary perfusion scintigraphy, for patients with chronic thromboembolic pulmonary hypertension. All examinations were acquired without complications, and the contrast enhancement of the pulmonary artery was sufficient for diagnosis of vascular thromboses. In the LPBV images, in 76 (8.3%) of 918 segments, it was difficult to assess perfusion because of artifacts. The agreement between the 2 modalities was good (kappa = 0.70). The sensitivity of LPBV in detecting perfusion defects was 96%; the specificity was 76%; the positive predictive value was 94%, and the negative predictive value was 29%. 2
57. Nallasamy N, Bullen J, Karim W, Heresi GA, Renapurkar RD. Evaluation of Vascular Parameters in Patients With Pulmonary Thromboembolic Disease Using Dual-energy Computed Tomography. J Thorac Imaging. 34(6):367-372, 2019 Nov. Observational-Dx 186 patients To evaluate patterns of vascular and lung parenchymal enhancement in patients with suspected chronic thromboembolic pulmonary hypertension (CTEPH) and in those with acute pulmonary embolism (PE) and compare those two groups. Compared with patients with negative CT, patients with CTED/CTEPH tended to have lower LungHU (median: 27 vs. 38, P<0.001), lower PBV (median: 39 vs. 51, P=0.003), and higher PApeak/LungHU ratio (median: 17 vs. 13, P=0.003). Compared with patients with acute PE, patients with CTED/CTEPH tended to have lower LungHU (median: 27 vs. 39, P=0.006), lower PBV (median: 39 vs. 62, P=0.023), and higher PApeak/LungHU ratio (median: 17 vs. 11, P=0.023). No statistically significant differences were observed between patients with acute PE and those with negative CT. 2
58. Tsutsumi Y, Iwano S, Okumura N, et al. Assessment of Severity in Chronic Thromboembolic Pulmonary Hypertension by Quantitative Parameters of Dual-Energy Computed Tomography. J Comput Assist Tomogr. 44(4):578-585, 2020 Jul/Aug. Observational-Dx 52 patients to assess the correlation between dual-energy computed tomography quantitative parameters and hemodynamics in patients with chronic thromboembolic pulmonary hypertension. Lung PBV was correlated with mean pulmonary arterial pressure (rs = 0.47, P < 0.001). Pulmonary artery enhancement was correlated with cardiac index (rs = -0.49, P < 0.001) and pulmonary vascular resistance (rs = 0.48, P < 0.001). The areas under the curves were 0.86 for lung PBV to predict mean pulmonary arterial pressure of >50 mm Hg and 0.86 for PA enhancement to predict pulmonary vascular resistance of >1000 dyne·s/cm. 2
59. Abe N, Kato M, Kono M, et al. Right ventricular dimension index by cardiac magnetic resonance for prognostication in connective tissue diseases and pulmonary hypertension. Rheumatology (Oxford). 59(3):622-633, 2020 03 01. Observational-Dx 84 patients, To analyse prognostic factors in Pulmonary hypertension (PH) in patients with CTD. Of 84 patients, 65 had right heart catheterization-confirmed PH (54 pulmonary arterial hypertension, 11 non-pulmonary arterial hypertension). Nine out of these PH patients died during a median follow-up period of 25 months. In 65 patients with PH, right ventricular end-diastolic dimension index (RVEDDI) evaluated by CMR was independently associated with mortality (hazard ratio 1.24; 95% CI: 1.08-1.46; P = 0.003). In a receiver operating characteristic analysis, RVEDDI highly predicted mortality, with area under the curve of 0.87. The 0.5-2-year follow-up data revealed that RVEDDI in both survivors and non-survivors did not significantly change over the clinical course, leading to the possibility that an early determination of RVEDDI could predict the prognosis. 1
60. Dellegrottaglie S, Ostenfeld E, Sanz J, Scatteia A, Perrone-Filardi P, Bossone E. Imaging the Right Heart-Pulmonary Circulation Unit: The Role of MRI and Computed Tomography. [Review]. Heart Fail Clin. 14(3):377-391, 2018 Jul. Review/Other-Dx NA To discuss the role of MRI and Computed Tomography. No results stated in the abstract. 4
61. Johns CS, Swift AJ, Rajaram S, et al. Lung perfusion: MRI vs. SPECT for screening in suspected chronic thromboembolic pulmonary hypertension. J Magn Reson Imaging. 46(6):1693-1697, 2017 12. Observational-Dx 74 patients To assess the diagnostic accuracy of magnetic resonance imaging (MRI) perfusion against perfusion single photon emission tomography (SPECT) screening for chronic thromboembolic pulmonary hypertension (CTEPH). In all, 74 patients with suspected CTEPH underwent all three modalities. Forty-six were diagnosed with CTEPH (36) or chronic thromboembolic disease (CTED) (10). 3D DCE perfusion MRI correctly identified all patients (sensitivity of 100%), compared with a 97% sensitivity for SPECT. 1
62. Lopez-Costa I, Bhalla S, Raptis C. Magnetic resonance imaging for pulmonary hypertension: methods, applications, and outcomes. Top Magn Reson Imaging. 2014;23(1):43-50. Review/Other-Dx N/A To describe the utility of magnetic resonance imaging in pulmonary hypertension. No results stated in abstract. 4
63. Iwasawa T. Diagnosis and management of pulmonary arterial hypertension using MR imaging. Magn Reson Med Sci. 2013;12(1):1-9. Review/Other-Dx N/A To review the current status of MR imaging of the right side of the heart and pulmonary circulation in patients with PAH and other associated pulmonary diseases. No results stated in abstract. 4
64. Swift AJ, Rajaram S, Condliffe R, et al. Diagnostic accuracy of cardiovascular magnetic resonance imaging of right ventricular morphology and function in the assessment of suspected pulmonary hypertension results from the ASPIRE registry. J Cardiovasc Magn Reson. 2012;14:40. Observational-Dx 233 patients To compare the diagnostic accuracy of a variety of CMR parameters to identify PH confirmed at cardiac catheterisation in unselected patients with suspected PH attending a referral centre. Ventricular mass index (VMI) was the CMR measurement with the strongest correlation with mPAP (r = 0.78) and the highest diagnostic accuracy for the detection of PH (area under the ROC curve of 0.91) compared to an ROC of 0.88 for echocardiography calculated mPAP. Late gadolinium enhancement, VMI >/= 0.4, retrograde flow >/= 0.3 L/min/m(2) and PA relative area change </= 15% predicted the presence of PH with a high degree of diagnostic certainty with a positive predictive value of 98%, 97%, 95% and 94% respectively. No single CMR parameter could confidently exclude the presence of PH. 3
65. Francois CJ, Schiebler ML. Imaging of Pulmonary Hypertension. [Review]. Radiol Clin North Am. 54(6):1133-1149, 2016 Nov. Review/Other-Dx NA To describe the noninvasive imaging techniques and findings, particularly CT and MR imaging, used in the diagnosis and management of suspected or known PH. No results stated in the abstract. 4
66. Ley S, Ley-Zaporozhan J, Pitton MB, et al. Diagnostic performance of state-of-the-art imaging techniques for morphological assessment of vascular abnormalities in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol. 22(3):607-16, 2012 Mar. Observational-Dx 24 patients To determine the most comprehensive imaging technique for the assessment of pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Based on image quality, there was no non-diagnostic examination by either imaging technique. DSA did not sufficiently display 1 main, 3 lobar and 4 segmental arteries. The pulmonary trunk was not assessable by DSA. One patient showed thrombotic material at this level only by MD-CTA and MRA. Sensitivity and specificity of MD-CTA regarding CTEPH-related changes at the main/lobar and at the segmental levels were 100%/100% and 100%/99%, of ce-MRA 83.1%/98.6% and 87.7%/98.1%, and of DSA 65.7%/100% and 75.8%/100%, respectively. ECG-gated MD-CTA proved the most adequate technique for assessment of the pulmonary arteries in the diagnostic work-up of CTEPH patients. 3
67. Swift AJ, Rajaram S, Capener D, et al. LGE patterns in pulmonary hypertension do not impact overall mortality. JACC Cardiovasc Imaging 2014;7:1209-17. Observational-Dx 194 patients To determine the prognostic value of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) features in patients with pulmonary hypertension. Of 194 patients, 162 had pulmonary hypertension. LGE was identified in 135 of 162 (83%) patients with pulmonary hypertension, and 47 (29%) of patients demonstrated LGE-S. Patients with LGE-S had significantly higher right ventricular end-diastolic volume index (p = 0.013) and lower mixed venous oxygen saturation (p = 0.045) than patients with LGE-IP alone. The presence of LGE-S (p = 0.022), but not LGE-IP alone, right ventricular end-systolic volume (p = 0.045), right ventricular ejection fraction (p = 0.034), mixed venous oxygen saturation (p = 0.021), mean right atrial pressure (0.027), and male sex (p = 0.002) predicted mortality. At multivariate analysis, male sex was the only significant predictor of mortality independent of covariate predictors (p = 0.027). 2
68. Reiter U, Reiter G, Kovacs G, et al. Native myocardial T1 mapping in pulmonary hypertension: correlations with cardiac function and hemodynamics. Eur Radiol. 27(1):157-166, 2017 Jan. Observational-Dx 58 patients To analyze alterations in left ventricular (LV) myocardial T1 times in patients with pulmonary hypertension (PH) and to investigate their associations with ventricular function, mass, geometry and hemodynamics. Septal, lateral, global and VIP T1 times were significantly higher in PH than in non-PH subjects (septal, 1249 ± 58 ms vs. 1186 ± 33 ms, p < 0.0001; lateral, 1190 ± 45 ms vs. 1150 ± 33 ms, p = 0.0003; global, 1220 ± 52 ms vs. 1171 ± 29 ms, p < 0.0001; VIP, 1298 ± 78 ms vs. 1193 ± 31 ms, p < 0.0001). In PH, LV eccentricity index was the strongest linear predictor of VIP T1 (r = 0.72). Septal, lateral and global T1 showed strong correlations with VIP T1 (r = 0.81, r = 0.59 and r = 0.75, respectively). 1
69. Saunders LC, Johns CS, Stewart NJ, et al. Diagnostic and prognostic significance of cardiovascular magnetic resonance native myocardial T1 mapping in patients with pulmonary hypertension. J Cardiovasc Magn Reson. 20(1):78, 2018 12 03. Observational-Dx 490 patients To determine whether elevation of native T1 in myocardial tissue in pulmonary hypertension: (a) varies according to pulmonary hypertension subtype; (b) has prognostic value and (c) is associated with ventricular function and interaction Patients with pulmonary artery hypertension had elevated T1 in the right ventricular (RV) insertion point (pulmonary hypertension patients: T1 = 1060 ± 90 ms; No pulmonary hypertension patients: T1 = 1020 ± 80 ms p < 0.001; healthy subjects T1 = 940 ± 50 ms p < 0.001) with no significant difference between the major pulmonary hypertension subtypes. The RV insertion point was the most successful T1 region for discriminating patients with pulmonary hypertension from healthy subjects (area under the curve = 0.863) however it could not accurately discriminate between patients with and without pulmonary hypertension (area under the curve = 0.654). T1 metrics did not contribute to prediction of overall mortality (septal: p = 0.552; RV insertion point: p = 0.688; left ventricular free wall: p = 0.258). Systolic interventricular septal angle was a significant predictor of T1 in patients with pulmonary hypertension (p < 0.001). 2
70. Kreitner KF, Wirth GM, Krummenauer F, et al. Noninvasive assessment of pulmonary hemodynamics in patients with chronic thromboembolic pulmonary hypertension by high temporal resolution phase-contrast MRI: correlation with simultaneous invasive pressure recordings. Circ Cardiovasc Imaging. 6(5):722-9, 2013 Sep. Observational-Dx 19 patients To create a model for estimating mPAP and pulmonary vascular resistance in patients with chronic thromboembolic pulmonary hypertension by high temporal resolution phase-contrast MRI (PC-MRI) and to correlate the results with simultaneously acquired, invasive catheter-based measurements (simultaneously measured mPAP) and with right heart catheterization measurements. Velocity- and flow-time curves of PC-MRI were used to calculate absolute acceleration time (Ata), maximum of mean velocities (MV), volume of acceleration (AV), and maximum flow acceleration (dQ/dt). On the basis of these parameters, multiple linear regression analysis revealed maximum achievable model fit (B=0.902) for the following linear combination equation to calculate mPAP (mPAP_cal): mPAP_cal=69.446-(0.521 x Ata)-(0.570 x MV)+(1.507 x AV)+(0.002 x dQ/dt). There was a statistically significant equivalence of mPAP_cal and simultaneously measured mPAP with a goodness of fit of 0.892. Pulmonary vascular resistance was overestimated by calculated pulmonary vascular resistance on the basis of PC-MRI in comparison with right heart catheterization-based measurements by a median of -112 dyn.s.cm(-5), the pairwise regression formula revealed a goodness of fit of 0.792 3
71. Wang HH, Tseng WI, Yu HY, Chang MC, Peng HH. Phase-contrast magnetic resonance imaging for analyzing hemodynamic parameters and wall shear stress of pulmonary arteries in patients with pulmonary arterial hypertension. Magma. 32(6):617-627, 2019 Dec. Observational-Dx 12 patients To investigate flow-related parameters in pulmonary arteries of patients with pulmonary arterial hypertension (PAH). PAH patients displayed prolonged acceleration time (Tacce) and increased ratio of flow change to acceleration volume in pulmonary arteries (both P < 0.001). The temporally averaged WSS values of MPA, RPA, and LPA in PAH patients were significantly lower than those of control participants (P < 0.001). The OSI in the pulmonary arteries was higher in PAH patients than control participants (P < 0.05). The ROC analysis indicated the ratio of maximum flow change to acceleration volume, WSS, and Tacce exhibited sufficient sensitivity and specificity to detect patients with PAH. The WSS demonstrated strong correlations with Tacce and the ratio value in the two groups (R2 = 0.78-0.96). 2
72. Barker AJ, Roldan-Alzate A, Entezari P, et al. Four-dimensional flow assessment of pulmonary artery flow and wall shear stress in adult pulmonary arterial hypertension: results from two institutions. Magn Reson Med. 73(5):1904-13, 2015 May. Observational-Dx 19healthy subjects and 17 pulmonary arterial hypertension (PAH) subjects To compare pulmonary artery flow using Cartesian and radially sampled four-dimensional flow-sensitive (4D flow) MRI at two institutions. Vmax, Qmax, SV, and WSS at all locations were significantly lower (P < 0.05) in PAH compared with healthy subjects. The limits of agreement were 0.16 m/s, 2.4 L/min, 10 mL, and 0.31 N/m(2) for Vmax, Qmax, SV, and WSS, respectively. Differences between Qmax and SV using Cartesian and radial sequences were not significant. Plane placement and acquisition exhibited isolated, site-based differences between Vmax and WSS. 3
73. Odagiri K, Inui N, Miyakawa S, et al. Abnormal hemodynamics in the pulmonary artery seen on time-resolved 3-dimensional phase-contrast magnetic resonance imaging (4D-flow) in a young patient with idiopathic pulmonary arterial hypertension. Circ J. 2014;78(7):1770-1772. Review/Other-Dx 1 To present a patient’s pulmonary arterial hemodynamics, gadolinium-enhanced magnetic resonance angiography and phase-resolved 3-dimensional (3-D) phase-contrast magnetic resonance imaging (MRI; 4D-flow) of the PA. The present report shows that 4D-flow is a useful noninvasivenmethod for the qualitative and quantitative characterization of not only blood flow but also WSS in PAH patients. 4
74. Roldan-Alzate A, Frydrychowicz A, Johnson KM, et al. Non-invasive assessment of cardiac function and pulmonary vascular resistance in an canine model of acute thromboembolic pulmonary hypertension using 4D flow cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2014;16:23. Observational-Dx 6 adult female beagles To quantify right (RV) and left (LV) ventricular function, pulmonary artery flow (QP), tricuspid valve regurgitation velocity (TRV), and aorta flow (QS) from a single 4D flow cardiovascular magnetic resonance (CMR) (time-resolved three-directionally motion encoded CMR) sequence in a canine model of acute thromboembolic pulmonary hypertension (PH). Biases between 4D flow CMR and bSSFP were 0.8 mL and 1.6 mL for RV EDV and RV ESV, respectively, and 0.8 mL and 4 mL for LV EDV and LV ESV, respectively. Flow in the MPA, RPA, and LPA did not change after induction of acute PAH (p = 0.42-0.81). MPA, RPA, and LPA flow determined with 4D flow CMR was significantly lower than with 2D flow (p < 0.05). The correlation between QP/TRV and PVRRHC was 0.95. The average QP/QS was 0.96 +/- 0.11. 3
75. Meyer GMB, Spilimbergo FB, Altmayer S, et al. Multiparametric Magnetic Resonance Imaging in the Assessment of Pulmonary Hypertension: Initial Experience of a One-Stop Study. Lung. 196(2):165-171, 2018 04. Observational-Dx 35 patients To assess the diagnostic performance of magnetic resonance imaging (MRI) as a single method to diagnose pulmonary hypertension (PH) compared to right heart catheterization (RHC), computed tomography (CT), and ventilation/perfusion (V/Q) scintigraphy Our results showed a good correlation between the hemodynamic parameters of cardiac MRI and RHC. Pulmonary vascular resistance had the best correlation between both methods (r = 0.923). The sensitivity and specificity of MRI to diagnose CTEPH was 100 and 96.8%, respectively. For the ILD-related PH, the MRI yielded a sensitivity of 60.0% and a specificity of 100%. Additionally, cardiac MRI was able to confirm all cases of PAH due to congenital heart disease initially detected by echocardiography. 2
76. Ray JC, Burger C, Mergo P, et al. Pulmonary arterial stiffness assessed by cardiovascular magnetic resonance imaging is a predictor of mild pulmonary arterial hypertension. Int J Cardiovasc Imaging. 35(10):1881-1892, 2019 Oct. Observational-Dx 51 patients To assess the utility of measuring PA pulsatility by CMR as a potential early maker in pulmonary arterial hypertension (PAH). Of the 51 subjects, 20 had mild PAH, and 31 moderate-severe based on hemodynamic criteria. PA pulsatility demonstrated a progressive decline from normal controls (53%), mild PAH (22%), to moderate-severe PAH (17%; p < 0.001). There was no difference in RV size, function or mass between mild PAH and normal controls. PA pulsatility below 40% had an excellent ability to discriminate between mild PAH and normal controls with a sensitivity of 95% and specificity of 94%. CMR assessment of PA stiffness may noninvasively detect adverse pulmonary vascular remodeling and mild PAH, and thus be a valuable tool for early detection of PAH. Trial Registration: ClinicalTrials.gov Identifier: NCT01451255; https://clinicaltrials.gov/ct2/show/NCT01451255 . 2
77. Johns CS, Rajaram S, Capener DA, et al. Non-invasive methods for estimating mPAP in COPD using cardiovascular magnetic resonance imaging. Eur Radiol. 28(4):1438-1448, 2018 Apr. Observational-Dx 102 patients To assess the diagnostic accuracy and prognostic value of non-invasive cardiovascular magnetic resonance (CMR) models. Of 102 COPD patients, 87 had PH. The CMR-PA/RV model had the strongest diagnostic accuracy (sensitivity 92%, specificity 80%, positive predictive value 96% and negative predictive value 63%, AUC 0.93, p<0.0001). Splitting RHC-mPAP, CMR-RV and CMR-PA/RV models by 35mmHg gave a significant difference in survival, with log-rank chi-squared 5.03, 5.47 and 7.10. RV mass and PA relative area change were the independent predictors of mortality at multivariate Cox regression (p=0.002 and 0.030). 2
78. Pagnamenta A, Azzola A, Beghetti M, Lador F, On Behalf Of The Swiss Society Of Pulmonary Hypertension. Invasive haemodynamic evaluation of the pulmonary circulation in pulmonary hypertension. [Review]. Swiss Med Wkly. 147:w14445, 2017. Review/Other-Dx NA To discuss the invasive haemodynamic evaluation of the pulmonary circulation in pulmonary hypertension. No results is stated in the abstract. 4
79. Rosenkranz S. Pulmonary hypertension: current diagnosis and treatment. Clin Res Cardiol. 2007; 96(8):527-541. Review/Other-Dx N/A The article provides an overview of the definition, classification, pathophysiology, and clinical presentation of various forms of PH. Furthermore, it summarizes the recommended diagnostic work-up and the current treatment options particularly in PAH, with special emphasis on prostanoids, endothelin receptor antagonists (ERAs), and phosphopdiesterase type 5 (PDE5) inhibitors such as sildenafil. Finally, novel developments are being discussed which currently represent an exciting field of research. No results stated in abstract. 4
80. Tang WHW, Wilcox JD, Jacob MS, et al. Comprehensive Diagnostic Evaluation of Cardiovascular Physiology in Patients With Pulmonary Vascular Disease: Insights From the PVDOMICS Program. Circ. Heart fail.. 13(3):e006363, 2020 03. Review/Other-Dx NA To describe the methods applied for invasive hemodynamic characterization in the (Redefining Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics) PVDOMICS program When coupled with other physiological testing and blood -omic analyses involved in the PVDOMICS study, the comprehensive right heart catheterization protocol described here holds promise to clarify the diagnosis and clustering of pulmonary hypertension patients into cohorts beyond the traditional 5 World Symposium on Pulmonary Hypertension groups. 4
81. Hoeper MM, Lee SH, Voswinckel R, et al. Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers. J Am Coll Cardiol. 2006; 48(12):2546-2552. Observational-Dx 7,218 total right heart catheter procedures Retrospective period - 5,727 Prospective period - 1,491 To assess the risks associated with right heart catheter procedures in patients with pulmonary hypertension. The overall number of serious adverse events was 76 (1.1%, 95% CI 0.8% to 1.3%). The most frequent complications were related to venous access , followed by arrhythmias and hypotensive episodes related to vagal reactions or pulmonary vasoreactivity testing. The vast majority of these complications were mild to moderate in intensity and resolved either spontaneously or after appropriate intervention. Four fatal events were recorded in association with any of the catheter procedures, resulting in an overall procedure-related mortality of 0.055% (95% CI 0.01% to 0.099%). When performed in experienced centers, right heart catheter procedures in patients with pulmonary hypertension are associated with low morbidity and mortality rates. 4
82. Reichelt A, Hoeper MM, Galanski M, Keberle M. Chronic thromboembolic pulmonary hypertension: evaluation with 64-detector row CT versus digital substraction angiography. Eur J Radiol. 71(1):49-54, 2009 Jul. Observational-Dx 27 patients To evaluate the role of 64-row CT in the diagnostic workup of patients with chronic thromboembolic pulmonary hypertension (CTEPH) using digital substraction angiography (DSA) as the method of diagnostic reference. Sensitivity and specificity of CT regarding CTEPH-related pathological changes in general were 98.3% and 94.8% at main/lobar level and 94.1% and 92.9% at segmental level, respectively. Sensitivity and specificity of CT regarding the different pathological criteria of CTEPH (complete obstruction, intimal irregularities, bands and webs, indirect signs) were 88.9-100% and 96.1-100% at main/lobar level and 84.3-90.5% and 92-98.7% at segmental level, respectively. Results show that CT is an accurate and reliable non-invasive alternative to conventional DSA in the diagnostic workup in patients with CTEPH. 3
83. Renapurkar RD, Shrikanthan S, Heresi GA, Lau CT, Gopalan D. Imaging in Chronic Thromboembolic Pulmonary Hypertension. [Review]. J Thorac Imaging. 32(2):71-88, 2017 Mar. Review/Other-Dx NA To discuss the roles of various imaging techniques and discuss their merits, limitations, and relative strengths in depicting the structural and functional changes of CTEPH.To explore newer imaging techniques and the potential value they may offer. No results stated in the abstract. 4
84. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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