National Imaging Associates, Inc. Clinical guideline:

Transcription

1 Natinal Imaging Assciates, Inc. Clinical guideline: Original Date: Octber 6, 2009 CT CORONARY ANGIOGRAPHY () Page 1 f 14 CPT Cdes: Last Reviewed Date: July 2013 Guideline Number: NIA_CG_062 Last Revised Date: July 2012 Respnsible Department: Clinical Operatins Implementatin Date: January 2014 INTRODUCTION: Crnary cmputed tmgraphic angigraphy () is a nninvasive imaging study that uses intravenusly administered cntrast material and high-reslutin, rapid imaging CT equipment t btain detailed vlumetric images f bld vessels. CTA can image bld vessels thrughut the bdy. Hwever, imaging f the crnary vasculature requires shrter image acquisitin times t avid blurring frm the mtin f the beating heart. The advanced spatial and tempral reslutin features f these CT scanning systems ffer a unique methd fr imaging the crnary arteries and the heart in mtin, and fr detecting arterial calcificatin that cntributes t crnary artery disease. The table belw crrelates and matches the clinical indicatins with the Apprpriate Use Scre based n a scale f 4 t 9, where the upper range (7 t 9) implies that the test is generally acceptable and is a reasnable apprach. The mid-range (4 t 6) indicates uncertainty in the apprpriateness f the test fr the clinical scenari. In all cases, additinal factrs shuld be taken int accunt including but nt limited t cst f test, impact f the image n clinical decisin making when cmbined with clinical judgment and risks, such as radiatin expsure and cntrast adverse effects, shuld be cnsidered. Where the is the preferred test based upn the indicatin the Apprpriate Use Scre will be in the upper range such as nted with indicatin # 46, Assessment f anmalies f crnary arterial and ther thracic arterivenus vessels. Fr indicatins in which there are ne r mre alternative tests that are equally apprpriate use scre rating (apprpriate, uncertain) nted, fr example indicatin #1 Intermediate pretest prbability f CAD, ECG interpretable AND able t exercise, additinal factrs shuld be cnsidered when determining the preferred test (Stress Echcardigram if there are n cntra-indicatins) Prprietary

2 ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2010 APPROPRIATE USE SCORE CRITERIA fr : ACCF et al. (Indicatin and Apprpriate Use Scre) 1 U(5) 1 A(7) 2 A(7) 2 A(8) 2 U(4) 4 U(6) 5 U(6) 6 Lw/Int Risk* A(7) High Risk* U(4) sectin) Other imaging mdality crsswalk Stress Ech (SE) (ACCF et al. Indicatin with Apprpriate Use Scre) Detectin f CAD in Symptmatic Patients Withut Knwn Heart Disease Symptmatic Nnacute Symptms Pssibly Representing an Ischemic Equivalent Lw pretest prbability f CAD* ECG interpretable and able t exercise Intermediate pretest prbability f CAD* SE 116 A(7) ECG interpretable AND Able t exercise Lw pretest prbability f CAD* ECG uninterpretable r unable SE 115 A(7) t exercise Intermediate pretest prbability f CAD* SE 117 A(9) ECG uninterpretable r unable t exercise High pretest prbability f CAD* SE 118 A(7) ECG uninterpretable r unable t exercise Acute Symptms With Suspicin f ACS (Urgent Presentatin) Persistent ECG ST-segment elevatin fllwing exclusin f MI Acute chest pain f uncertain cause (differential diagnsis includes pulmnary emblism, artic dissectin, and ACS ["triple rule ut"]) Pretest Prbability f CAD Nn-acute symptms Pssibly Representing an Ischemic Equivalent Nrmal ECG and cardiac bimarkers (trpnin and CPK/CPK-MB) Prprietary

3 ACCF et al. (Indicatin and Apprpriate Use Scre) 7 Lw/Int Risk* A(7) High Risk* U(4) 8 Lw/Int Risk* A(7) High Risk* U(4) sectin) Other imaging mdality crsswalk Stress Ech (SE) (ACCF et al. Indicatin with Apprpriate Use Scre) Nn-acute symptms Pssibly Representing an Ischemic Equivalent ECG uninterpretable Nn-acute symptms Pssibly Representing an Ischemic Equivalent Nndiagnstic ECG r equivcal cardiac bimarkers Detectin f CAD/Risk Assessment in Asymptmatic Individuals Withut Knwn CAD Nncntrast CT fr CCS 9 A(7) Lw glbal CHD risk estimate** Family histry f premature CHD 10 Int Risk** A(7) High Risk** U(4) 11 High Risk** U(4) Risk assessment in Asymptmatic Patients N knwn CAD Crnary CTA Asymptmatic N knwn CAD SE 127 U(5) Crnary CTA Fllwing Heart Transplantatin 12 U(6) Rutine evaluatin f crnary arteries Detectin f CAD in Other Clinical Scenaris 13 Lw/Int Risk* A(7) High Risk* U(4) 14 Lw/Int Risk* U(5) High Risk* U(4) 15 Lw Risk* U(6) New-Onset r Newly Diagnsed Clinical HF and N Prir CAD Reduced left ventricular ejectin fractin (<40% EF) Nrmal left ventricular ejectin fractin SE 128 A(7) Preperative Crnary Assessment Prir t Nncrnary Cardiac Surgery Crnary evaluatin befre nncrnary cardiac surgery Prprietary

4 ACCF et al. (Indicatin and Apprpriate Use Scre) Int Risk* A(7) sectin) Other imaging mdality crsswalk Stress Ech (SE) (ACCF et al. Indicatin with Apprpriate Use Scre) Arrhythmias Etilgy Unclear After Initial Evaluatin 17 U(6) Nnsustained ventricular tachycardia 18 U(4) Syncpe Lw glbal CAD risk**- initial evaluatin includes echcardigram Intermediate and High glbal CAD risk** initial evaluatin includes echcardigram SE 130 A(7) SE 134 A(7) Elevated Trpnin f Uncertain Clinical Significance 19 U(6) Elevated trpnin withut additinal evidence f ACS r symptms suggestive f CAD 20 A(7) Nrmal ECG exercise test Cntinued symptms 21 A(7) Prir ECG exercise testing Intermediate risk*** Duke Treadmill Scre 22 A(8) Discrdant ECG exercise and imaging results 23 Prir stress imaging results: Equivcal A(8) Mild Ischemia U(6) SE 135A(7) Use f CTA in the Setting f Prir Test Results Prir ECG Exercise Testing SE 149 A(7) Sequential Testing After Stress Imaging Prcedures Prir CCS 24 U(4) Zer Crnary Calcium Scre >5 years ag 26 U(6) Diagnstic impact f crnary calcium n the decisin t perfrm cntrast CTA in symptmatic patients Crnary Calcium Scre 401 SE 153 A(8) Prprietary

5 ACCF et al. (Indicatin and Apprpriate Use Scre) sectin) >1000 Other imaging mdality crsswalk Stress Ech (SE) (ACCF et al. Indicatin with Apprpriate Use Scre) 26 A(8) Diagnstic impact f crnary calcium n the decisin t perfrm cntrast CTA in symptmatic patients Crnary Calcium Scre < Evaluatin f New r Wrsening Symptms in the Setting f Past Stress Imaging Study 29 U(6) Previus stress imaging study abnrmal SE 151 A(7) 29 A(8) Previus stress imaging study nrmal Risk Assessment Preperative Evaluatin f Nncardiac Surgery Withut Active Cardiac Cnditins 33 U(5) Functinal capacity <4 METs with 1 r mre clinical risk predictrs 37 U(6) Functinal capacity <4 METs with 1 r mre clinical risk predictrs Intermediate-Risk Surgery Vascular Surgery SE 157 U(6) SE 161 A(7) Risk Assessment Pst revascularizatin (PCI r CABG) Symptmatic (Ischemic Equivalent) 39 A(8) Evaluatin f graft patency after CABG 41 U(6) Prir crnary stent with stent diameter 3 mm Asymptmatic CABG 42 U(5) Prir crnary bypass surgery 5 y ag Asymptmatic Prir Crnary Stenting 43 A(7) Prir left main crnary stent with stent diameter 3 mm 45 U(4) Stent diameter 3 mm Greater than r equal t 2 y after PCI SE 172 U(6) Prprietary

6 ACCF et al. (Indicatin and Apprpriate Use Scre) sectin) Other imaging mdality crsswalk Stress Ech (SE) (ACCF et al. Indicatin with Apprpriate Use Scre) Evaluatin f Cardiac Structure and Functin Adult Cngenital Heart Disease 46 A(9) Assessment f anmalies f crnary arterial and ther thracic arterivenus vessels ( fr anmalies f crnary arterial vessels preferred and fr ther thracic arterivenus vessels Heart CT preferred ) Evaluatin f Intra- and Extracardiac Structures 60 A(8) Lcalizatin f crnary bypass grafts and ther retrsternal anatmy Prir t preperative chest r cardiac surgery ( fr lcalizatin f crnary bypass grafts preferred and fr ther retrsternal anatmy Heart CT preferred ) FOR CORONARY CT ANGIOGRAPHY (): may be apprpriately used when evaluating chest pain syndrmes with lw t intermediate risk CAD prfiles such as in emergency rm r bservatin unit situatins. maybe an apprpriate substitutin exam fr a left heart catheterizatin. Where Stress Echcardigraphy (SE) is nted as an apprpriate substitute fr a Crnary CT Angigraphy () indicatin (# s 1, 2, 11, 14, 17, 18, 19, 21, 23, 33, 37, and 42) then at least ne f the fllwing cntraindicatins t SE must be demnstrated: Stress echcardigraphy is nt indicated; OR Stress echcardigraphy has been perfrmed hwever findings were inadequate, there were technical difficulties with interpretatin, r results were discrdant with previus clinical data; OR is preferential t stress echcardigraphy including but nt limited t fllwing cnditins: Ventricular paced rhythm Prprietary

7 OR Evidence f ventricular tachycardia Severe artic valve dysfunctin Severe Chrnic Obstructive Pulmnary Disease, (COPD) as defined as FEV1 30% predicted r FEV1 50% predicted plus respiratry failure r clinical signs f right heart failure. (GOLD classificatin f COPD access Cngestive Heart Failure (CHF) with current Ejectin Fractin (EF), 40% Inability t get an ech windw fr imaging Prir thractmy, (CABG, ther surgery) Obesity BMI>40 Prly cntrlled hypertensin [generally abve 180 mm Hg systlic (bth physical stress and dbutamine stress may exacerbate hypertensin during stress ech)] Prly cntrlled atrial fibrillatin (Resting heart rate > 100 bpm n medicatin) Inability t exercise requiring pharmaclgical stress test Segmental wall mtin abnrmalities at rest (e.g. due t cardimypathy, recent MI, r pulmnary hypertensin) Arrhythmias with Stress Echcardigraphy - any patient n a type 1C antiarrhythmic drug (i.e. Flecainide r Prpafenne) r cnsidered fr treatment with a type 1C anti-arrhythmic drug. Fr all ther requests, the patient must meet ACCF/ASNC Apprpriateness criteria fr indicatins with Apprpriate Use Scres 4-9, as nted abve. IN ACC GUIDELINES WITH INAPPROPRIATE DESIGNATION: The patient must meet ACCF/ASNC Apprpriateness criteria fr inapprpriate indicatins (median scre 1 3) belw OR meets any ne f the fllwing: Cntra-indicatins t beta blckers used t slw heart rate during prcedure. Acute chest pain/angina (Patients with acute angina/chest pain may need t g directly t catheterizatin. Refer fr MD Review). Pre-p request fr nn-cardiac surgery Significant premature ventricular cntractins, significant frequent atrial fibrillatin, r relative cntra-indicatin t ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2010 APPROPRIATE USE SCORE CRITERIA: ACCF et al. APPROPRIATE USE SCORE (1-3); I= Inapprpriate sectin) Detectin f CAD in Symptmatic Patients Withut Knwn Heart Disease Symptmatic Nnacute Symptms Pssibly Representing an Ischemic Equivalent Prprietary

8 ACCF et al. 1 3 APPROPRIATE USE SCORE (1-3); I= Inapprpriate sectin) High pretest prbability f CAD* ECG interpretable and able t exercise Acute Symptms With Suspicin f ACS (Urgent Presentatin) Definite MI I(1) Detectin f CAD/Risk Assessment in Asymptmatic Individuals Withut Knwn CAD Nncntrast CT fr CCS 10 Lw glbal CHD risk estimate** Crnary CTA 11 Lw r Intermediate glbal CHD risk estimate** Detectin f CAD in Other Clinical Scenaris Preperative Crnary Assessment Prir t Nncrnary Cardiac Surgery 15 High pretest prbability f CAD* Crnary evaluatin befre nncrnary cardiac surgery Arrhythmias Etilgy Unclear After Initial Evaluatin 16 New-nset atrial fibrillatin (atrial fibrillatin is underlying rhythm during imaging ECG Exercise Testing Use f CTA in the Setting f Prir Test Results 21 Prir ECG exercise testing Duke Treadmill Scre*** lw risk findings 21 Prir ECG exercise testing Duke Treadmill Scre*** high risk findings Sequential Testing After Stress Imaging Prcedures 23 Stress imaging results: mderate r severe ischemia Prir CCS 25 Psitive Crnary Calcium Scre >2 y ag Peridic Repeat Testing in Asymptmatic OR Stable Symptms With Prprietary

9 ACCF et al. APPROPRIATE USE SCORE (1-3); I= Inapprpriate sectin) Prir Stress Imaging r Crnary Angigraphy 27 N knwn CAD Last study dne <2 y ag 27 N knwn CAD Last study dne 2 y ag 28 Knwn CAD Last study dne <2 y ag 28 Knwn CAD Last study dne 2 y ag Risk Assessment Preperative Evaluatin f Nncardiac Surgery Withut Active Cardiac Cnditins Lw-Risk Surgery 30 Preperative evaluatin fr nncardiac surgery risk assessment, irrespective f functinal capacity Intermediate-Risk Surgery I(1) 31 N clinical risk predictrs 32 Functinal capacity 4 METs 34 Asymptmatic <1 y fllwing a nrmal crnary angigram, stress test, r a crnary revascularizatin prcedure Vascular Surgery I(1) 35 N clinical risk predictrs 36 Functinal capacity 4 METs 38 Asymptmatic <1 y fllwing a nrmal crnary angigram, stress test, r a crnary revascularizatin prcedure Risk Assessment Pst revascularizatin (PCI r CABG) Symptmatic (Ischemic Equivalent) 40 Prir crnary stent with stent diameter <3 mm r nt knwn Asymptmatic CABG 42 Prir crnary bypass surgery <5 y ag Asymptmatic Prir Crnary Prprietary

10 ACCF et al. sectin) Stenting 44 Prir crnary stent with stent diameter <3 mm r nt knwn 45 Prir crnary stent with stent diameter 3 mm Less than 2 y after PCI APPROPRIATE USE SCORE (1-3); I= Inapprpriate Evaluatin f Cardiac Structure and Functin Evaluatin f Ventricular Mrphlgy and Systlic Functin 48 Initial evaluatin f left ventricular functin Fllwing acute MI r in HF patients Evaluatin f Intra- and Extracardiac Structures 55 Initial evaluatin f cardiac mass (suspected tumr r thrmbus) ADDITIONAL INFORMATION RELATED TO CORONARY CT ANGIOGRAPHY: Abbreviatins ACS = acute crnary syndrme CABG = crnary artery bypass grafting surgery CAD = crnary artery disease CCS = crnary calcium scre CHD = crnary heart disease CT = cmputed tmgraphy CTA = cmputed tmgraphy angigraphy ECG = electrcardigram HF = heart failure MET = estimated metablic equivalent f exercise MI = mycardial infarctin MPI = Mycardial Perfusin Imaging PCI = percutaneus crnary interventin SE = Stress Echcardigram TTE = Transthracic Echcardigraphy Chest pain - Treat symptms f angina, chest pressure r chest discmfrt as chest pain under this guideline Prprietary

11 Exercise Treadmill Testing - Exercise Treadmill Testing (ETT) is the apprpriate first line test in mst patients with suspected CAD. In apprpriately selected patients the test prvides adequate sensitivity and specificity with regard t diagnsis and prgnsticatin. There are patients in whm the test is nt the best chice, fr example thse with resting ECG abnrmalities, inability t exercise and perhaps diabetes. Als f nte frm an peratinal standpint the test des nt require pre-authrizatin. ECG Uninterpretable - Refers t ECGs with resting ST-segment depressin ( 0.10 mv), cmplete LBBB, preexcitatin (Wlff-Parkinsn-White Syndrme), r paced rhythm. *Pretest Prbability f CAD fr Symptmatic (Ischemic Equivalent) Patients: Typical Angina (Definite): Defined as 1) substernal chest pain r discmfrt that is 2) prvked by exertin r emtinal stress and 3) relieved by rest and/r nitrglycerin. Atypical Angina (Prbable): Chest pain r discmfrt that lacks 1 f the characteristics f definite r typical angina. Nnanginal Chest Pain: Chest pain r discmfrt that meets 1 r nne f the typical angina characteristics. Once the presence f symptms (Typical Angina/Atypical Angina/Nn angina chest pain/asymptmatic) is determined, the pretest prbabilities f CAD can be calculated frm the risk algrithms as fllws: Age (Years) Gender Typical/Definite Angina Pectris Atypical/Prbable Angina Pectris Nnanginal Chest Pain Asymptmatic < >60 Men Intermediate Intermediate Lw Very lw Wmen Intermediate Very lw Very lw Very lw Men High Intermediate Intermediate Lw Wmen Intermediate Lw Very lw Very lw Men High Intermediate Intermediate Lw Wmen Intermediate Intermediate Lw Very lw Men High Intermediate Intermediate Lw Wmen High Intermediate Intermediate Lw Very lw: Less than 5% pretest prbability f CAD Lw: Less than 10% pretest prbability f CAD Intermediate: Between 10% and 90% pretest prbability f CAD High: Greater than 90% pretest prbability f CAD **Glbal CAD Risk: It is assumed that clinicians will use current standard methds f glbal risk assessment such as thse presented in the Natinal Heart, Lung, and Bld Institute reprt n Detectin, Evaluatin, and Treatment f High Bld Chlesterl in Adults (Adult Treatment Panel III [ATP III]) (18) r similar natinal guidelines. CAD risk refers t 10- year risk fr any hard cardiac event (e.g., mycardial infarctin r CAD death) Prprietary

12 Lw glbal CAD risk Defined by the age-specific risk level that is belw average. In general, lw risk will crrelate with a 10-year abslute CAD risk <10%. Hwever, in wmen and yunger men, lw risk may crrelate with 10-year abslute CAD risk <6%. Intermediate glbal CAD risk Defined by the age-specific risk level that is average. In general, mderate risk will crrelate with a 10-year abslute CAD risk range f 10% t 20%. Amng wmen and yunger age men, an expanded intermediate risk range f 6% t 20% may be apprpriate. High glbal CAD risk Defined by the age-specific risk level that is abve average. In general, high risk will crrelate with a 10-year abslute CAD risk f >20%. CAD equivalents (e.g., diabetes mellitus, peripheral arterial disease) can als define high risk. ***Duke Treadmill Scre The equatin fr calculating the Duke treadmill scre (DTS) is, DTS = exercise time - (5 * ST deviatin) - (4 * exercise angina), with 0 = nne, 1 = nn limiting, and 2 = exercise-limiting. The scre typically ranges frm -25 t +15. These values crrespnd t lw-risk (with a scre f >/= +5), intermediate risk (with scres ranging frm - 10 t + 4), and high-risk (with a scre f </= -11) categries Prprietary

13 REFERENCES ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Apprpriate Use Criteria fr Cardiac Cmputed Tmgraphy: A Reprt f the American Cllege f Cardilgy Fundatin Apprpriate Use Criteria Task Frce, the Sciety f Cardivascular Cmputed Tmgraphy, the American Cllege f Radilgy, the American Heart Assciatin, the American Sciety f Echcardigraphy, the American Sciety f Nuclear Cardilgy, the Nrth American Sciety fr Cardivascular Imaging, the Sciety fr Cardivascular Angigraphy and Interventins, and the Sciety fr Cardivascular Magnetic Resnance. Jurnal f the American Cllege f Cardilgy, 56, ; di: /j.jacc Retrieved frm ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Apprpriate Use Criteria fr Echcardigraphy. A Reprt f the American Cllege f Cardilgy Fundatin Apprpriate Use Criteria Task Frce, American Sciety f Echcardigraphy, American Heart Assciatin, American Sciety f Nuclear Cardilgy, Heart Failure Sciety f America, Heart Rhythm Sciety, Sciety fr Cardivascular Angigraphy and Interventins, Sciety f Critical Care Medicine, Sciety f Cardivascular Cmputed Tmgraphy, and Sciety fr Cardivascular Magnetic Resnance. Endrsed by the American Cllege f Chest Physicians. J Am Cll Cardil. di: /j.jacc (Published nline Nvember 19, 2010) Retrieved frm Datta, J., White, C.S., Giklesn, R.C., Meyer, C.A., Kansal, S., Jani, M.L.,... Read K. (2005, June). Anmalus crnary arteries in adults: Depictin at multi-detectr rw CT angigraphy. Radilgy, 235, Retrieved frm Einstein, A. (2012). Effects f radiatin expsure frm cardiac imaging: hw gd are the data? Jurnal f the American Cllege f Cardilgy, 59(6), Retrieved frm Hendel, RC, Patel, MR, Kramer, C.M., Pn, M., Carr, J.C., Gerstad, N.A., Allen, J.M. (2006). ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Apprpriateness Criteria fr Cardiac Cmputed Tmgraphy and Cardiac Magnetic Resnance Imaging: A Reprt f the American Cllege f Cardilgy Fundatin Quality Strategic Directins Cmmittee Apprpriateness Criteria Wrking Grup, American Cllege f Radilgy, Sciety f Cardivascular Cmputed Tmgraphy, Sciety fr Cardivascular Magnetic Resnance, American Sciety f Nuclear Cardilgy, Nrth American Sciety fr Cardiac Imaging, Sciety fr Cardivascular Angigraphy and Interventins, and Sciety f Interventinal Radilgy. Jurnal f the American Cllege f Cardilgy, 48, ; di: /j.jacc Retrieved frm Prprietary

14 Hffmann, U., Trung, Q.A., Schenfeld, D.A., Chu, E.T, Wdard, P.K., Nagurney, J.T.,... Udelsn, J.E. (2012, July). Crnary CT Angigraphy versus Standard Evaluatin in Acute Chest Pain. N Engl J Med 367, Retrieved frm Nicl, E.D., Stirrup, J., Reyes, E., Rughtn, M., Padley, S.P., Rubens, M.B.,... Underwd, S.R. (2008, May). Sixty-fur-slice cmputed tmgraphy crnary angigraphy cmpared with mycardial perfusin scintigraphy fr the diagnsis f functinally significant crnary stenses in patients with a lw t intermediate likelihd f crnary artery disease. Jurnal f Nuclear Cardilgy, 15(3), Retrieved frm Sctt-Mncrieff, A., Yang, J., Levine, D., Taylr, C., Ts, D., Jhnsn, M.,... Leipsic, J. (2011). Real-wrld estimated effective radiatin dses frm cmmnly used cardiac testing and prcedural mdalities. The Canadian Jurnal f Cardilgy, 27(5), Retrieved frm timated_effective_radiatin_dses_frm_cmmnly_used_cardiac_testing_and_prcedur al_mdalities_ Thil, C., Auler, M., Zwerner, P., Cstell, P., & Schepf, U.J. (2007, Feb). Crnary CTA: Indicatins, patient selectin, and clinical implicatins. Jurnal f Thracic Imaging, 22(1), Retrieved frm Prprietary