cardiac computed tomography (CCT)

Cardiac Computed Tomography Writing Group; Allen J. Taylor, MD, FACC, FAHA, Chair^*;Manuel Cerqueira, MD, FACC, FASNC; John McB. Hodgson, MD, FACC, FSCAI;Daniel Mark, MD, MPH, FACC, FAHA^*; James Min, MD, FACC; Patrick O'Gara, MD, FACC, FAHA^||;Geoffrey D. Rubin, MD, FSCBTMR^¶,#

^* Official American College of Cardiology Foundation Representative.
 Official American Society of Nuclear Cardiology Representative.
 Official Society for Cardiovascular Angiography and Interventions Representative.
 Official Society of Cardiovascular Computed Tomography Representative.
^|| Official American Heart Association Representative.
^¶ Official American College of Radiology Representative.
^# Official North American Society for Cardiovascular Imaging Representative.
Christopher M. Kramer, MD, FACC, FAHA; Michael J. Wolk, MD, MACC
Moderator, Cardiac Computed Tomography Technical Panel
Chair, Appropriate Use Criteria Task Force


Key Words: AHA Scientific Statements • coronary artery bypass graft surgery • coronary artery disease • coronary heart disease • coronary calcium score • computed tomography • computed tomographic angiography • electrocardiogram • heart failure • estimated metabolic equivalents of exercise • myocardial infarction • percutaneous coronary intervention • perioperative evaluation

	Abstract

The American College of Cardiology Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac computed tomography (CCT) is frequently considered. The present document is an update to the original CCT/cardiac magnetic resonanceappropriateness criteria published in 2006, written to reflect changes in test utilization, to incorporate new clinical data, and to clarify CCT use where omissions or lack of clarity existed in the original criteria.¹
The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Ninety-three clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use.
In general, use of CCT angiography for diagnosis and risk assessment in patients with low or intermediate risk or pretest probability for coronary artery disease was viewed favorably, whereas testing in high-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Use of noncontrast computed tomography for calcium scoring was rated as appropriate within intermediate- and selected low-risk patients. Appropriate applications of CCT are also within the category of cardiac structural and functional evaluation. It is anticipated that these results will have an impact on physician decision making, performance, and reimbursement policy, and that they will help guide future research./.../

Cardiac imaging definitions

Cardiac imaging is an integral part of the evaluation and management of patients with known or suspected heart disease. These techniques offer insight into morphologic features and physiologic functioning of the myocardium, valves, pericardium, coronary arteries, and great vessels. Substantial advances in technology have occurred within the past decade, advancing clinical applications and enhancing diagnostic accuracy.

Many options for imaging the heart and adjacent structures are available such as, echocardiography, single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), positron emission tomography (PET), cardiac magnetic resonance (CMR), cardiac computed tomography (CCT), invasive coronary angiography (ICA), and left ventriculography (LVG). Major specialty societies, such as the ACC, the AHA, the Radiological Society of North American (RSNA), and the American College of Radiology (ACR) have demonstrated leadership in promoting research and written guidelines and practice standards for the performance of cardiac imaging. In many cases, each modality has developed rather independently and has strong advocacy by dedicated clinicians/researchers and their own subspecialty societies, including the American Society of Nuclear Cardiology (ASNC), the American Society of Echocardiography (ASE), the Society for Atherosclerosis Imaging and Prevention (SAIP), the Society for Cardiovascular Computed Tomography (SCCT), the Society for Cardiovascular Magnetic Resonance (SCMR), the Society for Cardiovascular Angiography and Interventions (SCAI), the Society of Interventional Radiology (SIR), the North American Society for Cardiovascular Imaging (NASCI), and the Heart Rhythm Society (HRS).

Cardiac imaging is included in patient decision-making and is often referenced in guidelines and other data standards. However, differing definitions abound, leading to misunderstanding and confusion. Furthermore, structured reporting is becoming commonplace and imaging data fields are increasingly being used within registries and clinical databases. The ACC has led a multisocietal effort that culminated in the development of a document that recommends the use of structured reporting for cardiovascular imaging as an essential component of improved cardiovascular health care (1); that article is being published simultaneously with these data standards. These two writing efforts were coordinated with each other and underscore the importance for capturing and reporting clear, consistent and complete information for patients undergoing cardiovascular imaging./.../

Noninvasive Coronary Artery Imaging. Magnetic Resonance Angiography and Multidetector Computed Tomography Angiography. A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention of the Council on Cardio

Noninvasive Coronary Artery Imaging. Magnetic Resonance Angiography and Multidetector Computed Tomography Angiography. A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention of the Council on Cardio

Magnetic Resonance Angiography and Multidetector Computed Tomography Angiography A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and ntervention of the Council on Cardiovascular Radiology and Intervention, and the Councils on Clinical Cardiology and Cardiovascular Disease in the Young David A. Bluemke, MD, PhD, FAHA, Chair; Stephan Achenbach, MD; Matthew Budoff, MD, FAHA; Thomas C. Gerber, MD, FAHA; Bernard Gersh, DPhil, MD, FAHA; L. David Hillis, MD; W. Gregory Hundley, MD, FAHA; Warren J. Manning, MD, FAHA; Beth Feller Printz, MD, PhD; Matthias Stuber, PhD; Pamela K. Woodard, MD, FAHA
Since the early 1960s, selective x-ray coronary angiography has provided the only means of visualizing the coronary arterial system in vivo. However, it has several disadvantages. First, the incidence, albeit relatively low, of so-called major adverse events (death, myocardial infarction, or stroke) during or within 24 hours of selective coronary angiography is reported to be 0.2% to 0.3%, and the incidence of so-called minor complications (most of which are related to problems with the peripheral vessels through which catheters are inserted) is roughly 1% to 2%.1–3 Second, x-ray coronary angiography is accompanied by a modest amount of discomfort, because the placement of catheters is invasive.
Third, it is expensive: the required equipment is costly, and the performance of the procedure necessitates considerable time and skill of highly trained physicians and support personnel. Last, the information obtained via catheter-based coronary angiography pertains to the coronary arterial lumen alone. As a result, alternative methods of visualizing the coronary arterial system that would allow one to avoid these disadvantages are desirable./.../

Safety of Magnetic Resonance Imaging in Patients With Cardiovascular Devices

Safety of Magnetic Resonance Imaging in Patients With Cardiovascular Devices
An American Heart Association Scientific Statement From the Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Council on Cardiovascular Radiology and Intervention: Endorsed by the American College of Cardiology Foundation, the North American Society for Cardiac Imaging, and the Society for Cardiovascular Magnetic Resonance Glenn N. Levine, MD, FAHA; Antoinette S. Gomes, MD, FAHA; Andrew E. Arai, MD, FAHA; David A. Bluemke, MD, FAHA; Scott D. Flamm, MD; Emanuel Kanal, MD; Warren J. Manning, MD, FAHA; Edward T. Martin, MD, FAHA; J. Michael Smith, MD; Norbert Wilke, MD; Frank S. Shellock, PhD
Advances in magnetic resonance (MR) imaging over the past 2 decades have led to MR becoming an increasingly attractive imaging modality. With the growing number of patients treated with permanent implanted or temporary cardiovascular devices, it is becoming ever more important to clarify safety issues in regard to the performance of MR examinations in patients with these devices. Extensive, although not complete, ex vivo, animal, and clinical data are available from which to generate recommendations regarding the safe performance of MR examination in patients with cardiovascular devices, as well as to ascertain caveats and contraindications regarding MR examination for such patients. Safe MR imaging involves a careful initial patient screening, accurate determination of the permanent implanted or temporary cardiovascular device and its properties, a thoughtful analysis of the risks and benefits of performing the examination at that time, and, when indicated, appropriate physician management and supervision. This scientific statement is intended to summarize and clarify issues regarding the safety of MR imaging in patients with cardiovascular devices.