Appropriateness Criteria Tackle Stress Echo Tests


The American College of Cardiology Foundation and key specialty societies have released new appropriateness criteria for the use of stress echocardiography in an ongoing effort to help physicians keep abreast of rapidly changing imaging technology.

The indications in the “2008 Appropriateness Criteria for Stress Echocardiography” are intended to identify common scenarios encompassing most of current practice and are part of a systematic evaluation of the utility of diagnostic imaging tests in common clinical situations (Circulation 2008 March 3 [doi:10.1161/circulationaha.107.189097]).

In all, 51 indications were considered. Of these, stress echocardiography was found to be appropriate for 22, uncertain for 10, and inappropriate for 19. The use of stress echocardiography for the detection of coronary artery disease (CAD) in symptomatic patients was generally deemed to be appropriate. Routine repeat testing, general screening, and postrevascularization risk assessment were generally viewed less favorably.

All indications were assumed to apply only to adult patients (18 years or older). It was also assumed that the test is performed and interpreted by qualified individuals in facilities that are proficient in the imaging technique.

Panelists were also instructed to make several assumptions specifically for stress echocardiography.

▸ All standard echocardiographic techniques for image acquisition are available for each indication; and stress echocardiography has a sensitivity and specificity similar to those in the published literature.

▸ The mode of stress testing is assumed to be exercise, unless the patient is unable to do so. For those patients who cannot exercise, it is assumed that dobutamine is used.

▸ Preoperative evaluation includes procedures such as organ transplantation. Panelists also were asked not to consider other imaging modalities or other appropriateness criteria while rating indications.

An imaging study was considered appropriate if the expected incremental information, combined with clinical judgment, “exceeded the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication,” the panel wrote. “Inappropriate use may be costly and may prompt potentially harmful and costly downstream testing and treatment such as unwarranted coronary revascularization or unnecessary repeat follow-up.”

Appropriateness was indicated by a score from 7 to 9. The test is generally acceptable and is a reasonable approach for the specific indication. Inappropriateness was indicated by a score of 1–3. The test is generally not acceptable and is not a reasonable approach for the indication. Tests scoring from 4 to 6 were considered uncertain for specific indications. The test may be generally acceptable and may be a reasonable approach for the indication; more research and/or patient information is needed to classify the indication definitively.

“Although the appropriateness ratings reflect a general expert consensus of when stress echocardiography may or may not be useful for specific patient populations, physicians and other stakeholders should understand the role of clinical judgment in determining whether to order a test for an individual patient.” For example, an inappropriate rating does not rule out the use of stress echocardiography when there are patient- and condition-specific data to support that decision.

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