ASCI 2010 appropriateness criteria for cardiac computed tomography: A report of the Asian Society of Cardiovascular Imaging cardiac computed

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1 ASCI 2010 appropriateness criteria for cardiac computed tomography: A report of the Asian Society of Cardiovascular Imaging cardiac computed tomography and cardiac magnetic resonance imaging guideline Working Group ASCI CCT & CMR Guideline Working Group I-Chen Tsai, MD 1, Moderator of CCT appropriateness criteria Byoung Wook Choi, MD 2, Director of ASCI CCT & CMR guideline Working Group Carmen Chan, MD 3 Masahiro Jinzaki, MD 4 Kakuya Kitagawa, MD 5 Hwan Seok Yong, MD 6 Wei Yu, MD 7 1. Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan. 2. Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University Health System, Seoul, Korea. 3. Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong, China. 4. Department of Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan. 5. Department of Diagnostic Radiology, Mie University School of Medicine, Mie, Japan. 6. Department of Radiology, Korea University Guro Hospital, Seoul, Korea. 7. Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China. Technical Panel Members of ASCI 2010 Cardiac CT Shyh-Jye Chen, MD, PhD (Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan), Stephen Chi Wai Cheung, MBBS, MRCP, FRCR (Department of Radiology, Queen Mary Hospital, Hong Kong, China), Pow-Li Chia, MBBS, MRCP, MMed (Department of Cardiology, Tan Tock Seng Hospital, Singapore), Hyun Woo Goo, MD, PhD (Department of 1

2 Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea), John Hoe, MD (Department of Radiology, Mount Elizabeth Hospital, Singapore), Xihong Hu, MD, PhD (Department of Radiology, Children s Hospital, Fudan University, Shanghai, China), Gham Hur, MD, PhD (Departments of Diagnostic Radiology, Inje University Ilsanpaik Hospital, Korea), Sutipong Jongjirasiri, MD (Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand), Young Jin Kim, MD, PhD (Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University Health System, Seoul, Korea), Fumiko Kimura, MD (Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Saitama, Japan), Sung Min Ko, MD (Department of Radiology, Konkuk University Hospital School of Medicine, Seoul, Korea), Wen-Jeng Lee, MD (Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan), Wen-Lieng Lee, MD, PhD (Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan), Gladys Goh Lo, MD, DABR, FHKAM(Rad), FHKCR (Department of Diagnostic & Interventional Radiology, Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong, China), Hoang Minh Loi, MD, PhD (Department of Radiology, Hue Central Hospital, Hue Medical University, Hue, Vietnam), Oraporn See, MD, FACC,FSGC, FASE (Cardiology Division, Ramathibodi Hospital, Mahidol University and Heart Institute, Samitivej Sukumvit Hospital, Bangkok, Thailand), Kui-Hian Sim, MBBS, FRACP (Department of Cardiology, Sarawak General Hospital. Kuching, Malaysia), Wei-Lin Tsai, MD (Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan), Nguyen Khoi Viet, MD (Radiology Department, Bach Mai Hospital, Hanoi, Vietnam), Chi-Ming Wong, MB., FRCP., FHKAM, FACC, FSCAI (Department of Cardiology, Sir Run Run Shaw Heart Centre, St. Teresa's Hospital, Hong Kong, China), Ming-Ting Wu, MD (Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan), Zhi-Gang Yang, MD, PhD (Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China), Kunihiro Yoshioka, MD, PhD (Department of Radiology, Iwate Medical University, Iwate, Japan) 2

3 ASCI 2010 appropriateness criteria for cardiac computed tomography: A report of the Asian Society of Cardiovascular Imaging cardiac computed tomography and cardiac magnetic resonance imaging guideline Working Group Running Title: ASCI 2010 cardiac CT appropriateness criteria 3

4 ABSTRACT In Asia, the healthcare system, populations and patterns of disease differ from Western countries. The current reports on the criteria for cardiac CT scans, provided by Western professional societies, are not appropriate for Asian cultures. The Asian Society of Cardiovascular Imaging, the only society dedicated to cardiovascular imaging in Asia, formed a Working Group and invited 23 Technical Panel members representing a variety of Asian countries to rate the 51 s for cardiac CT in clinical practice in Asia. The s were rated as appropriate (7-9), uncertain (4-6), or inappropriate (1-3) on a scale of 1 to 9. The median score was used for the final result if there was no disagreement. The final ratings for s were 33 appropriate, 14 uncertain and 4 inappropriate. And 20 of them are highly agreed (19 appropriate and 1 inappropriate). Specifically, the Asian representatives considered cardiac CT as an appropriate modality for Kawasaki disease and congenital heart diseases in follow up and in symptomatic patients. In addition, except for some specified conditions, cardiac CT was considered to be an appropriate modality for one-stop shop ischemic heart disease evaluation due to its general appropriateness in coronary, structure and function evaluation. This report is expected to have a significant impact on the clinical practice, research and reimbursement policy in Asia. KEYWORDS appropriateness criteria; cardiac computed tomography; CT coronary angiography; guideline; Asia 4

5 INTRODUCTION In recent years, the technical advances of multi-detector row computed tomography (MDCT) [1] and magnetic resonance imaging (MRI) [2] have enriched the field of non-invasive cardiovascular imaging. Even though new generation scanners with updated technology are available almost all over the world, the geographic, ethnic [3], socioeconomic [4], medical care system [5], and disease prevalence [6-8] variations result in different clinical applications, acceptabilities, techniques and appropriateness [9, 10]. Since the gross domestic product per capita [4], medical expenses, healthcare systems [5], body habitus, disease risk factors and prevalence [3] in Asian countries are all different from Western countries, the guidelines developed in the United States and Europe usually are not appropriate for Asian countries. For example, the current cardiac CT (CCT) appropriateness criteria provided by Western experts [11, 12] don t have recommendations on Kawasaki disease [6-8], which is a prevalent disease in Japan, Korea, Taiwan and China. In addition, the busy clinical working environment and relatively limited resources in Asia result in Asian radiologists developing special techniques and workflow using the MDCT for congenital heart diseases to answer important clinical questions [13-18]. Although Asian investigators have significantly contributed to this field of investigation, the specific Asian characteristics have not been adequately addressed in the existing reports; this has limited the applicability of these well prepared Western reports [11, 12] to Asian patients. The Asian Society of Cardiovascular Imaging (ASCI) [19] is the only society in Asia dedicated solely to cardiovascular imaging, and as such, the ASCI is responsible for taking a leadership role in quality improvement. After the establishment of ASCI, we hold annual meetings with scientific presentations, refresher courses, and technology advances in Korea, Singapore, Japan and Taiwan sequentially [19]. The ASCI reviews and endorses many teaching courses [20] to provide a hand-on learning environment for cardiologists, radiologists and technologists throughout Asia. With this approach, we hope to improve the quality of care of Asian patients with cardiovascular disease. As a 5

6 part of the goal to improve quality, in March 2009, the ASCI nominated 7 representatives from different Asian countries to form a Working Group. The task of this Working Group was to provide summaries and recommendations for cardiac CT and cardiac MRI. Cardiac CT appropriateness criteria is the first step of this project. This first step includes the summaries of leading cardiac CT practitioners with their opinions on the current status, characteristics and considerations based on their extensive clinical experience and the existing scientific evidence. The purpose of this report is to serve as a reference for guidelines applied in clinical practice by cardiologists and radiologists. It is anticipated that this report will have a significant impact on clinical decision making, the direction of future research and reimbursement policies in Asia. 6

7 METHODS Modified Delphi method After a literature search and Working Group discussion, a modified Delphi method was considered the best method currently available for evaluating the s for a rapidly advancing field such as cardiovascular imaging [21]. In addition, the cardiac CT appropriateness criteria published in 2006 [11] by American College of Cardiology Foundation (ACCF) was used as an important reference in this field. Thus, ASCI Working Group decided to use this method [11, 21, 22] for this report. However, during the rating process, to maintain the independence of the experts and to arrive at results that could be widely applied, not only for issues with consensus but also for differences, we used the modified method that was used in an international update report published on 2009 [12], and collected data by a one-round questionnaire. Selection of Technical Panel Members The number of Technical Panel members from each country was decided by the Working Group according to the participation in the ASCI executive committee [23], ASCI annual meetings, the use of the cardiac CT in each country, and the academic credentials of the investigators in the field. The Technical Panel members were nominated by the ASCI office and each of the Working Group members, and approved by the Working Group by consensus. Thirty four panelists were nominated (Korea 6, Japan 6, Taiwan 5, China 3, Hong Kong (China) 3, Singapore 3, Vietnam 3, Philippines 2, Thailand 2, Malaysia 1). No compensation, other than being listed as a Technical Panel member, was promised or provided to participants in return for their thoughtful completion of the survey. Development of s 7

8 After Working Group review, the 39 s provided by the ACCF 2006 appropriateness criteria [11] were used as the framework of this survey. The s for common Asian diseases were added [6-8, 24], and the top five proposed s from the 2009 appropriateness criteria international update published in the Journal of Cardiovascular Computed Tomography (JCCT) [12] were also added. The important clinical applications proposed by Asian investigators were also included, such as congenital heart diseases [13-18], structural heart diseases [25, 26], valvular heart diseases [27], and the detection of myocardial infarction [28-30]. After integration of the results, there were 51 s approved by the Working Group. Using this method we could determine the Asian characteristics and real clinical situations, and compare the results with the existing medical literature. The questionnaire (in MS-WORD.doc format) was then ed to the 34 Technical Panel members. After completion, the questionnaires were collected by the ASCI office. The data collection was done within the period from August 26 to September 7, Please refer to the online supplement for the complete questionnaire (Online Supplement 1). Cardiac CT definition Since currently cardiac CT is still a developing field [1], the definition and techniques used might differ among investigators and scanners. Some practitioners consider a cardiac CT to be CT coronary angiography, while others think a cardiac CT should include motion and viability assessment [28-31]. Also, there is debate with regard to the scanning mode (sequential vs. spiral), ECG-gating technique (full dose, ECG-pulsing, or prospective [13, 27, 29-32]) and post-processing technique [33]. Since these issues continue to be debated, the Working Group leaves the definition to the judgment of the Technical Panel members. The variations in the definition might be an important reflection of the current perspectives of the leading Asian cardiac CT practitioners. Thus, in the questionnaire, the cardiac CT protocol may include the calcium score, CT coronary angiography (either prospective or retrospective gating), as well as motion and viability (delayed 8

9 phase) evaluation. Rating system The rating system used in this Asian survey is the same as previously used in other appropriateness criteria reports [11, 12]. The panelists were asked to assess whether the use of cardiac CT for various s was appropriate, uncertain or inappropriate. In rating each, the panel was provided the following definition of appropriateness: An appropriate imaging study is one in which the expected incremental information combined with clinical judgment, exceeds the expected negative consequences (ie, the risk of procedure, radiation and contrast exposure, potential effect of poor test performance and inappropriate diagnosis) by a sufficiently wide margin for a specific that the procedure is generally considered acceptable care and a reasonable approach for the. [11, 12] The Technical Panel scored each as follows: Score 7 to 9: Appropriate test for the specific. Test is generally acceptable and a reasonable approach for the listed. Score 4 to 6: Uncertain for specific. Test may be generally acceptable and may be a reasonable approach for the. Uncertainty also implies that more research or patient information or both are needed to classify the definitively. Score 1 to 3: Inappropriate test for specific. Test is not generally acceptable and is not a reasonable approach for the. In a panel with 23 to 25 members, highly agreed was defined as 7 or fewer panelists rating outside the three-point region containing the median [21, 22]. Disagreement was defined as at 9

10 least 8 panelists rating in each extreme (1 to 3 and 7 to 9) [21, 22]. Median values for each served as the final scoring if no disagreement occurred among Technical Panelists [11, 12, 21, 22]. If there was with disagreement, the final appropriateness score was set as uncertain regardless of the median. 10

11 RESULTS At August 26, 2009, 34 s with questionnaires attached were send to the Technical Panel members. Twenty three (67.6%) completed questionnaires were returned before September 7. These 23 Technical Panelists include well-known investigators, doctors with extensive clinical experiences and leading experts in their own countries. There were 17 radiologists and 6 cardiologists involved. The years of experience in the cardiovascular field ranged from 4 to 29 years. The number of cardiac CT scans interpreted ranged from 300 to 20,000 cases. For the cardiologists, percutaneous coronary intervention procedures performed ranged from 1000 to 8000 cases. The hospitals included city hospitals, medical centers, university hospitals, public hospitals and private hospitals, with in-patient beds ranging from 200 to 4300 beds. The complete list of Technical Panel is provided in the beginning of this report. Among the s rated by Technical Panel, there was no disagreement. There were 33 appropriate, 14 uncertain and 4 inappropriate s reported. Twenty of the s were highly agreed, including 19 appropriate and 1 inappropriate s. The highly agreed inappropriate was the use of cardiac CT in asymptomatic patient with low coronary heart disease risk. The appropriateness rating results are provided as an online supplement (Online Supplement 2). Compared with the ACCF 2006 report [11], 20 s upward shifted their appropriateness, including 10 from uncertain to appropriate, 9 from inappropriate to uncertain and 1 from inappropriate to appropriate (ASCI no. 33). There were 19 s that remained in the same appropriateness category, including 13 appropriate, 2 uncertain and 4 inappropriate. Compared with the 2009 international update report [12], the results varied. Ten s 11

12 had upward shifted categories, including 8 from uncertain to appropriate and 2 inappropriate to uncertain (ASCI no. 20, 38). Four s were downward shifted categories, including 2 from appropriate to uncertain (ASCI no. 5, 26) and 2 from uncertain to inappropriate (ASCI no. 13, 25). Twenty five s remained in the same categories, including 16 appropriate, 7 uncertain and 2 inappropriate. The final ratings for the cardiac CT are listed by sequentially (Table 1-12) and by appropriateness category (Table 13-15) as follows. 12

13 ASCI CCT APPROPRIATENESS CRITERIA (BY INDICATION) Table 1 Detection of CAD: symptomatic Note Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 1 - Intermediate pre-test probability of CAD - ECG interpretable AND able to exercise - ACCF no Intermediate pre-test probability of CAD - ECG uninterpretable OR unable to exercise A (9) - Highly agreed - ACCF no High pre-test probability of CAD U (6) - ACCF no. 3 Evaluation of Intra-Cardiac Structures (Use of Cardiac CT) 4 - Evaluation of suspected coronary anomalies A (9) - Highly agreed - ACCF no. 4 Acute Chest Pain (Use of Cardiac CT) 5 - Low pre-test probability of CAD U (4) - ACCF no. 5 - No ECG changes and serial enzymes negative 6 - Intermediate pre-test probability of CAD - ACCF no. 6 - No ECG changes and serial enzymes negative 7 - High pre-test probability of CAD - ACCF no. 7 - No ECG changes and serial enzymes negative 8 - High pre-test probability of CAD I (3) - ACCF no. 8 - ECG ST-segment elevation and/or positive cardiac enzymes 9 - Triple rule out exclude obstructive CAD, aortic dissection, and pulmonary embolism - Intermediate pre-test probability for one of the above - ECG no ST-segment elevation and initial enzymes negative - ACCF no. 9 * CAD = coronary artery disease; ECG = electrocardiogram Table 2 Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) Note Asymptomatic (Use of Cardiac CT) 10 - Low CHD risk (Framingham risk criteria) I (2) - Highly agreed - ACCF no Moderate CHD risk (Framingham) U (5) - ACCF no High CHD risk (Framingham) - ACCF no. 12 * CHD = coronary heart disease 13

14 Table 3 Risk Assessment: General Population Note Asymptomatic (Use of Calcium Score) 13 - Low CHD risk (Framingham) I (3) - ACCF no Moderate CHD risk (Framingham) - ACCF no High CHD risk (Framingham) - Highly agreed - ACCF no. 15 Table 4 - Detection of CAD With Prior Test Results Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 16 - Uninterpretable or equivocal stress test (exercise, perfusion, or stress echo) A (8) Note - Highly agreed - ACCF no Evidence of moderate to severe ischemia on stress test (exercise, perfusion, or stress echo) U (6) - ACCF no. 17 Table 5 Risk Assessment With Prior Test Results Note Asymptomatic (Use of Calcium Score) 18 - Prior calcium score within previous 5 years U (5) - ACCF no. 18 Asymptomatic (Use of Cardiac CT) 19 - High CHD risk (Framingham) U (5) - ACCF no Within 2 years prior cardiac CT or invasive angiogram without significant obstructive disease 20 - High CHD risk (Framingham) - Prior calcium score greater than or equal to 400 U (6) - ACCF no

15 Table 6 CAD detection in pediatric patients with Kawasaki disease Asymptomatic (Use of Cardiac CT) 21 - No previous definitive test (invasive angiography, U (5) MRCA or CTCA) available 22 - Previous tests (invasive angiography, CMR or CCT) documented coronary aneurysm/stenosis, for follow up Symptomatic (Use of Cardiac CT) 23 - No previous definitive test (invasive angiography, MRCA or CTCA) available 24 - Previous tests (angiography, CMR or CCT) documented coronary aneurysm/stenosis, for follow up A (8) Note - Asian characteristic - Asian characteristic - Asian characteristic - Highly agreed - Asian characteristic * CCT = cardiac CT; CMR = cardiac MR; CTCA = CT coronary angiography; MRCA = MR coronary angiography Table 7 - Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery Low-Risk Surgery (Use of Cardiac CT) 25 - Intermediate perioperative risk I (3) - ACCF no. 21 Intermediate- or High-Risk Surgery (Use of Cardiac CT) 26 - Intermediate perioperative risk U (6) - ACCF no. 22 Note Table 8 Risk Assessment: Preoperative evaluation for cardiac surgery or endovascular intervention Preoperative evaluation (Use of Cardiac CT) 27 - Use of CT coronary angiography for CAD evaluation before valve surgery - JCCT 2009 proposed inication 28 - Anatomic assessment before percutaneous device closure of ASD or VSD or percutaneous aortic valve replacement A (8) - Highly agreed - JCCT 2009 proposed 29 - Evaluation of complex lesions before PCI (ie, chronic total occlusions, bifurcation lesions) A (8) - Highly agreed - JCCT 2009 proposed * ASD = atrial septal defect; PCI = percutaneous coronary intervention; VSD = ventricular septal defect Note 15

16 Table 9 - Detection of CAD: Post-Revascularization (PCI or CABG) Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 30 - Evaluation of bypass grafts and coronary anatomy A (9) - Highly agreed - ACCF no History of percutaneous revascularization with stents - ACCF no. 24 Asymptomatic (Use of Cardiac CT) 32 - Evaluation of bypass grafts and coronary anatomy U (6) - ACCF no Less than 5 years after CABG 33 - Evaluation of bypass grafts and coronary anatomy - ACCF no Greater than or equal to 5 years after CABG 34 - Evaluation for in-stent restenosis and coronary anatomy after PCI U (6) - ACCF no. 27 * CABG = coronary artery bypass graft Note Table 10 Structure and Function Morphology (Use of Cardiac CT) 35 - Assessment of complex congenital heart disease A (8) including anomalies of coronary circulation, great vessels, and cardiac chambers and valves 36 - Assessment of post-operative congenital heart disease, such as residual pulmonary stenosis, ventricular septal defect and patency check for Blalock-Taussig shunt 37 - Evaluation of coronary arteries in patients with new onset heart failure to assess etiology A (8) Note - Highly agreed - ACCF no Asian characteristic - Highly agreed - Asian characteristic - Highly agreed - ACCF no. 29 Evaluation of Ventricular and Valvular Function (Use of Cardiac CT) 38 - Evaluation of LV function following myocardial U (5) - ACCF no. 30 infarction OR in heart failure patients 39 - Evaluation of LV function following myocardial infarction OR in heart failure patients - Patients with technically limited images from echocardiogram - ACCF no Asian characteristic 40 - Characterization of native and prosthetic cardiac valves - Patients with technically limited images from echocardiogram, MRI, or TEE 41 - Assessment of RV function and morphology (in suspected ARVD and pulmonary embolism) Evaluation of Intra- and Extra-Cardiac Structures (Use of Cardiac CT) A (8) 42 - Evaluation of cardiac mass (suspected tumor or thrombus) - Patients with technically limited images from echocardiogram, MRI or TEE - Highly agreed - ACCF no Asian characteristic - JCCT 2009 proposed - Highly agreed - ACCF no

17 43 - Evaluation of pericardial conditions (pericardial mass, constrictive pericarditis, or complications of cardiac surgery) - Patients with technically limited images from echocardiogram, MRI or TEE 44 - Evaluation of pulmonary vein anatomy prior to invasive radiofrequency ablation for atrial fibrillation - Left atrial and pulmonary venous anatomy including dimensions of veins for mapping purposes 45 - Noninvasive coronary vein mapping prior to placement of biventricular pacemaker 46 - Noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization A (8) A (9) A (8) - Highly agreed - ACCF no Highly agreed - ACCF no Highly agreed - ACCF no Highly agreed - ACCF no. 37 Evaluation of Aortic and Pulmonary Disease (Use of Non-Gated Large Field-of-View CT Angiography) 47 - Evaluation of suspected aortic dissection or thoracic aortic aneurysm A (9) - Highly agreed - ACCF no Evaluation of suspected pulmonary embolism A (9) - Highly agreed - ACCF no. 39 * ARVD = arrhythmogenic right ventricular dysplasia; LV = left ventricle; RV = right ventricle; TEE = transesophageal echocardiography Table 11 Detection of Myocardial Scar and Viability Evaluation of Myocardial Scar (Use of Cardiac CT including Delayed Phase) 49 - To determine the location and extent of myocardial infarction including no-reflow regions - Post-acute myocardial infarction U (6) Note - JCCT 2009 proposed - Asian characteristic 50 - To determine viability prior to revascularization U (5) - JCCT 2009 proposed - Asian characteristic Table 12 One-Stop Shop of Ischemic Heart Disease One-Stop Shop (Use of Cardiac CT) 51 - Serving as an one-stop shop for ischemic heart disease in diagnosis, comprehensive evaluation and treatment strategy planning in difficult cases Note - Asian characteristic 17

18 ASCI CCT APPROPRIATENESS CRITERIA (BY APPROPRIATENESS CATEGORY) Table 13 Appropriate s (Median Score 7-9) Detection of CAD: symptomatic Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 1 - Intermediate pre-test probability of CAD - ECG interpretable AND able to exercise 2 - Intermediate pre-test probability of CAD A (9) - ECG uninterpretable OR unable to exercise Detection of CAD: symptomatic Evaluation of Intra-Cardiac Structures (Use of Cardiac CT) 4 - Evaluation of suspected coronary anomalies A (9) Detection of CAD: symptomatic Acute Chest Pain (Use of Cardiac CT) 6 - Intermediate pre-test probability of CAD - No ECG changes and serial enzymes negative 7 - High pre-test probability of CAD - No ECG changes and serial enzymes negative 9 - Triple rule out exclude obstructive CAD, aortic dissection, and pulmonary embolism - Intermediate pre-test probability for one of the above - ECG no ST-segment elevation and initial enzymes negative Detection of CAD Asymptomatic (Use of Cardiac CT) 12 - High CHD risk (Framingham) Risk Assessment: General Population Asymptomatic (Use of Calcium Score) 14 - Moderate CHD risk (Framingham) 15 - High CHD risk (Framingham) Detection of CAD With Prior Test Results Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 16 - Uninterpretable or equivocal stress test (exercise, perfusion, or A (8) stress echo) CAD detection in pediatric patients with Kawasaki disease Asymptomatic (Use of Cardiac CT) 22 - Previous tests (invasive angiography, CMR or CCT) documented coronary aneurysm/stenosis, for follow up CAD detection in pediatric patients with Kawasaki disease Symptomatic (Use of Cardiac CT) 23 - No previous definitive test (invasive angiography, MRCA or CTCA) available 24 - Previous tests (angiography, CMR or CCT) documented coronary aneurysm/stenosis, for follow up A (8) Risk Assessment: Preoperative evaluation for cardiac surgery or endovascular intervention Preoperative evaluation (Use of Cardiac CT) 27 - Use of CT coronary angiography for CAD evaluation before valve surgery 28 - Anatomic assessment before percutaneous device closure of ASD or VSD or percutaneous aortic valve replacement A (8) 18

19 29 - Evaluation of complex lesions before PCI (ie, chronic total occlusions, bifurcation lesions) A (8) Detection of CAD: Post-Revascularization (PCI or CABG) Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 30 - Evaluation of bypass grafts and coronary anatomy A (9) 31 - History of percutaneous revascularization with stents Detection of CAD: Post-Revascularization (PCI or CABG) Asymptomatic (Use of Cardiac CT) 33 - Evaluation of bypass grafts and coronary anatomy - Greater than or equal to 5 years after CABG Structure and Function Morphology (Use of Cardiac CT) 35 - Assessment of complex congenital heart disease including A (8) anomalies of coronary circulation, great vessels, and cardiac chambers and valves 36 - Assessment of post-operative congenital heart disease, such as A (8) residual pulmonary stenosis, ventricular septal defect and patency check for Blalock-Taussig shunt 37 - Evaluation of coronary arteries in patients with new onset heart failure to assess etiology Structure and Function Evaluation of Ventricular and Valvular Function (Use of Cardiac CT) 39 - Evaluation of LV function following myocardial infarction OR in heart failure patients - Patients with technically limited images from echocardiogram 40 - Characterization of native and prosthetic cardiac valves - Patients with technically limited images from echocardiogram, MRI, or TEE 41 - Assessment of RV function and morphology (in suspected ARVD and pulmonary embolism) Structure and Function Evaluation of Intra- and Extra-Cardiac Structures (Use of Cardiac CT) 42 - Evaluation of cardiac mass (suspected tumor or thrombus) A (8) - Patients with technically limited images from echocardiogram, MRI or TEE 43 - Evaluation of pericardial conditions (pericardial mass, A (8) constrictive pericarditis, or complications of cardiac surgery) - Patients with technically limited images from echocardiogram, MRI or TEE 44 - Evaluation of pulmonary vein anatomy prior to invasive A (9) radiofrequency ablation for atrial fibrillation - Left atrial and pulmonary venous anatomy including dimensions of veins for mapping purposes 45 - Noninvasive coronary vein mapping prior to placement of biventricular pacemaker 46 - Noninvasive coronary arterial mapping, including internal A (8) mammary artery prior to repeat cardiac surgical revascularization Structure and Function Evaluation of Aortic and Pulmonary Disease (Use of Non-Gated Large Field-of-View CT Angiography) 47 - Evaluation of suspected aortic dissection or thoracic aortic A (9) aneurysm 48 - Evaluation of suspected pulmonary embolism A (9) 19

20 One-Stop Shop of Ischemic Heart Disease One-Stop Shop (Use of Cardiac CT) 51 - Serving as an one-stop shop for ischemic heart disease in diagnosis, comprehensive evaluation and treatment strategy planning in difficult cases 20

21 Table 14 Uncertain s (Median Score 4-6) Detection of CAD: symptomatic Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 3 - High pre-test probability of CAD U (6) Detection of CAD: symptomatic Acute Chest Pain (Use of Cardiac CT) 5 - Low pre-test probability of CAD U (4) - No ECG changes and serial enzymes negative Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) Asymptomatic (Use of Cardiac CT) 11 - Moderate CHD risk (Framingham) U (5) Detection of CAD With Prior Test Results Evaluation of Chest Pain Syndrome (Use of Cardiac CT) 17 - Evidence of moderate to severe ischemia on stress test (exercise, U (6) perfusion, or stress echo) Risk Assessment With Prior Test Results Asymptomatic (Use of Calcium Score) 18 - Prior calcium score within previous 5 years U (5) Risk Assessment With Prior Test Results Asymptomatic (Use of Cardiac CT) 19 - High CHD risk (Framingham) U (5) - Within 2 years prior cardiac CT or invasive angiogram without significant obstructive disease 20 - High CHD risk (Framingham) U (6) - Prior calcium score greater than or equal to 400 CAD detection in pediatric patients with Kawasaki disease Asymptomatic (Use of Cardiac CT) 21 - No previous definitive test (invasive angiography, MRCA or U (5) CTCA) available Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery Intermediate- or High-Risk Surgery (Use of Cardiac CT) 26 - Intermediate perioperative risk U (6) Detection of CAD: Post-Revascularization (PCI or CABG) Asymptomatic (Use of Cardiac CT) 32 - Evaluation of bypass grafts and coronary anatomy U (6) - Less than 5 years after CABG 34 - Evaluation for in-stent restenosis and coronary anatomy after U (6) PCI Structure and Function Evaluation of Ventricular and Valvular Function (Use of Cardiac CT) 38 - Evaluation of LV function following myocardial infarction OR U (5) in heart failure patients Detection of Myocardial Scar and Viability Evaluation of Myocardial Scar (Use of Cardiac CT including Delayed Phase) 49 - To determine the location and extent of myocardial infarction U (6) including no-reflow regions - Post-acute myocardial infarction 50 - To determine viability prior to revascularization U (5) 21

22 Table 15 Inappropriate s (Median Score 1-3) Detection of CAD: symptomatic Acute Chest Pain (Use of Cardiac CT) 8 - High pre-test probability of CAD I (3) - ECG ST-segment elevation and/or positive cardiac enzymes Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) Asymptomatic (Use of Cardiac CT) 10 - Low CHD risk (Framingham risk criteria) I (2) Risk Assessment: General Population Asymptomatic (Use of Calcium Score) 13 - Low CHD risk (Framingham) I (3) Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery Low-Risk Surgery (Use of Cardiac CT) 25 - Intermediate perioperative risk I (3) 22

23 DISCUSSION This ASCI 2010 appropriateness criteria reflects the current status of cardiac CT in Asia, includes opinions of Asian cardiac CT leaders with regard to clinical applications, and provides a reference for the appropriate s for a cardiac CT. This report was developed to aid clinical practice in Asia, especially for centers starting a cardiac CT service, to provide guidance on the appropriate use of this technology and identify the patients that can benefit form it. There are several s worth mentioning. For screening asymptomatic low risk patient (ASCI no. 10) and evaluation of symptomatic patients with ST-segment elevation and/or positive cardiac enzymes (ASCI no. 8), the results are consistently inappropriate no matter whether a result of our survey, original 2006 ACCF appropriateness criteria [11] or the 2009 JCCT international update [12]. For those new s included in our survey, the cardiac CT is considered to be an appropriate evaluation tool for symptomatic patients and for the follow up study of patients with Kawasaki disease (ASCI no ) and congenital heart diseases (ASCI no. 35, 36). Furthermore, the panelists also considered using cardiac CT as a one-stop shop modality for ischemic heart disease (ASCI no. 51) as appropriate, since cardiac CT can also be used for structure and function evaluation (ASCI no , 39-48). However, using the delayed phase to evaluate a myocardial scar (ASCI no. 49, 50) yielded controversial results and an uncertain appropriateness score. In the future, further study on the cost-benefit and the clinical implications of delayed phase imaging should be performed to address this controversial issue. The results of this survey advance the current understanding in the field of cardiac CT in the following aspects. First, this is the first attempt to determine appropriateness criteria for cardiac CT specifically for Asian populations. Previously, two reports were published in the literature by Western experts. One is from the United States [11]. The other one claimed to be international [12], 23

24 but there are only 10 (13.9%) raters from Asia out of the 72. Most of the raters are still from North America and Europe. These two previous reports do not reflect the unique conditions of Asian populations. Second, the results of this report included many of the characteristics unique to Asia, for example, attempts at using the cardiac CT as an one-stop shop for ischemic heart disease as well as for Kawasaki disease and congenital heart diseases. Previously, these problems required evaluation by multiple modalities, include MRI, echocardiography, cardiac catheterization and even nuclear medicine, to provide sufficient information for clinical decisions. Now, these clinical problems gradually tend to adhere to an MDCT-based clinical algorithm in Asia [13, 15, 17, 24, 30]. Third, we also included the top five proposed s from the previous international update [12]. The s of using cardiac CT for preoperative evaluation such as valve surgery, a percutaneous device, and for a complex lesion before PCI (ASCI no ) and ARVD evaluation (ASCI no. 41) were rated as appropriate. Compared to the 2006 ACCF report, a general upward shift was observed [11]. However, compared to the 2009 international update [12], the results varied with upward and downward shifts as well as stable categories. However, since the Working Group, Technical Panel and timing of the rating process are all different, the potential explanations are considered to be subjective. These diverse results suggest that the s and appropriateness of imaging should be rated in the context of the culture, country, and healthcare system. This also justifies the continuing effort of the ASCI to develop Asian guidelines. This survey has several limitations. First, even though this is an Asian report, the Technical Panel didn t recruit representatives outside Eastern and Southeastern Asia [34]. The contributing countries were mostly located in Asia-Pacific region. This reflects the current academic participation in the ASCI, which was a major selection criterion for Technical Panel recruitment. Since the ASCI is a new and young society established in 2006, we plan to increase the participation of countries outside of the Asia-Pacific region to make ASCI more representative of Asia. The 24

25 second limitation, which was also suggested by many Technical Panelists, was that the clinical context should include classifications for age, renal function, scanning protocol, and radiation used. The congenital heart disease s could also be further divided into different diseases and clinical scenarios. Indeed, in clinical practice, the real situation is not as general as the 51 s listed. However, the length of the report should be limited to ensure the clinical applicability. The ASCI plans to form additional Working Groups to further explore specific topics as requested. In the future, the ASCI will continue to monitor this field and provide follow up surveys periodically. An updated Asian report will be published as needed. Since medical care is an evolving art and science, the appropriateness of s might change with technical advances. With the planned continuing effort, the goal of the ASCI is to help improve the level of clinical practice, research and education of cardiovascular imaging in Asia, together with investigators, clinicians and patients. 25

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