NEWS & VIEWS CORONARY ARTERY DISEASE
Appropriate testing for stable ischaemic heart disease Sameer Bansilal and Zahi A. Fayad
Currently, numerous tests are available for the assessment and triage of patients with stable ischaemic heart disease. National societies in the USA have collaborated to develop appropriate use criteria to give guidance to clinicians about the evidence-based use of these tests. Bansilal, S. & Fayad, Z. A. Nat. Rev. Cardiol. 11, 137–138 (2014); published online 4 February 2014; doi:10.1038/nrcardio.2014.5
Ischaemic heart disease caused approximately one-sixth of deaths in the USA in 2009.1 A coronary event occurs every 34 s in the USA, and is the cause of one death every minute. 1 The cost of medical care associated with heart disease is expected to rise from an estimated US$273 billion in 2010 to US$818 billion in 2030. 2 The assessment and triage of patients with stable ischaemic heart disease using non invasive and invasive testing form the core of cardiovascular practice. In 2014, these tests include exercise or pharmacological stress testing with electroc ardiography, echocardiography, radionuclide or magnetic resonance imaging, coronary CT scanning for calcium scoring or angiograms, and invasive catheter-based angiography (Figure 1). The ACC and other professional societies self-regulate the practice of cardiovascular medicine by defining ‘appropriate use criteria’ for the optimal use of various tests and procedures. Wolk and colleagues now present a consensus do cument from the ACC Foundation, AHA, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Inter ventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons on the appropriate use of multimodality imaging for the detection and risk assessment of stable ischaemic heart disease, 3 which updates previous appropriate use criteria.4 This document is marked out as unique and a major step forward by the provision of side-by-side ratings of tests for particular
indications. At the same time, the ratings are not comparative and do not provide a recommendation for the ‘best test’ among those rated. Therefore, the intention is to provide guidance to clinicians for making an evidence-based choice that is appropriate to their chosen clinical strategy. Physician judgement using Bayesian principles with an emphasis on pretest likelihood of disease (which is known to influence the interpret ation of results and, therefore, treatment decisions) is heavily endorsed in the guidelines. The authors clarify that even if a test is rated, it does not necessarily need to be performed. They also highlight that, when deciding which test to perform, potential Coronary artery calcium scoring
Coronary CT angiography
Stress radionucleotide imaging
■ Patients with signs, symptoms, or various levels of risk of coronary disease ■ Patients with a previous test or revascularization procedure for follow-up testing
Stress echocardiography
clinical benefit must be prioritized over cost. In the document, appropriate use criteria are outlined using as many as 80 nonurgent scenarios. Broadly, these scenarios can be divided into four categories of patients with stable ischaemic heart disease (Figure 1). The algorithm in most scenarios endorses the clinical assessment of the background cardiovascular risk of a patient (performed using simple scores, such as the Framingham or PROCAM risk scores), or assessment of functional capacity or the Revised Cardiac Risk Index for preoperative patients. Most clinicians will agree with the classification of those tests and scenarios listed as ‘appropriate’ or ‘maybe appropriate’. Exercise electrocardiography is the only test listed as being appropriate for patients with a low pretest probability of obstructive coronary disease or who are at low cardiovascular risk, and for those requiring clearance for an exercise or rehabilitation programme. Most tests are considered appropriate for patients who are symptomatic and being assessed for an ischaemic syndrome, newonset heart failure, arrhythmia, or syncope; repeat testing of patients within 90 days of an abnormal or inconclusive test or if they develop new or worsening symptoms; and preoperative testing in patients with a poor
Stress MRI
Invasive coronary angiography
■ Preoperative assessment for noncardiac surgery ■ Patients scheduled to undergo an exercise programme or cardiac rehabilitation Stress electrocardiography
Figure 1 | Imaging modalities for stable ischaemic heart disease. The new consensus document gives recommendations on the appropriate use of multimodality imaging to assess coronary artery disease.
NATURE REVIEWS | CARDIOLOGY
VOLUME 11 | MARCH 2014 © 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS functional capacity and undergoing highrisk vascular surgery, organ transplantation, or intermediate risk surgery if the individual has an elevated cardiac risk profile. Similarly, many of the ‘rarely appropriate’ listings— testing low-risk, asymptomatic patients; routine follow-up testing within 2 years of percutaneous coronary intervention or 5 years of CABG surgery in patients without new symptoms; preoperative testing of patients with adequate functional capacity and normal results from stress testing or who are undergoing low-risk surgery; and complicated forms of imaging-based stress tests before exercise or rehabilitation programmes—will find broad acceptance. Some classifications that might generate discussion are exercise electrocardio graphy being listed as ‘maybe appropriate’ for patients with previous obstructive coronary artery disease diagnosed using invasive coronary angiography within the past 90 days—a recommendation that seems far too conservative—and invasive
MARCH 2014 | VOLUME 11
angiography being listed as ‘maybe appropriate’ for symptomatic patients with a normal electrocardiogram—one that seems far too aggressive. All-in-all, the authors should be commended for creating a consensus document with little in their recommendations to cause debate. The ‘at-a-glance’ rating of the various clinical tests is a profoundly useful tool for practising clinicians. The logical next step would be to provide comparative ratings and for the guidelines to provide recommendations by weighing the evidence. The good news is that adequately powered studies of comparative effectiveness, such as the PROMISE trial,5 are scheduled to be completed in 2014. These data will further refine the art of cardiovascular diagnostics and provide clinicians with a rigorous scientific base for making decisions. Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029‑6574, USA (S.B., Z.A.F.).
Correspondence to: S.B. [email protected] Competing interests The authors declare no competing interests. 1.
2.
3.
4.
5.
Go, A. S. et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation http://dx.doi.org/10.1161/ 01.cir.0000441139.02102.80. Heidenreich, P. A. et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 123, 933–944 (2011). Wolk, M. J. et al. ACCF/AHA/ASE/ASNC/ HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J. Am. Coll. Cardiol. http://dx.doi.org/10.1016/ j.jacc.2013.11.009. Hendel, R. C. et al. Appropriate use of cardiovascular technology: 2013 ACCF appropriate use criteria methodology update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J. Am. Coll. Cardiol. 61, 1305–1317 (2013). US National Library of Medicine. ClinicalTrials.gov [online], http://clinicaltrials.gov/show/ NCT01174550 (2013).
www.nature.com/nrcardio © 2014 Macmillan Publishers Limited. All rights reserved
Appropriate testing for stable ischaemic heart disease Sameer Bansilal and Zahi A. Fayad
Currently, numerous tests are available for the assessment and triage of patients with stable ischaemic heart disease. National societies in the USA have collaborated to develop appropriate use criteria to give guidance to clinicians about the evidence-based use of these tests. Bansilal, S. & Fayad, Z. A. Nat. Rev. Cardiol. 11, 137–138 (2014); published online 4 February 2014; doi:10.1038/nrcardio.2014.5
Ischaemic heart disease caused approximately one-sixth of deaths in the USA in 2009.1 A coronary event occurs every 34 s in the USA, and is the cause of one death every minute. 1 The cost of medical care associated with heart disease is expected to rise from an estimated US$273 billion in 2010 to US$818 billion in 2030. 2 The assessment and triage of patients with stable ischaemic heart disease using non invasive and invasive testing form the core of cardiovascular practice. In 2014, these tests include exercise or pharmacological stress testing with electroc ardiography, echocardiography, radionuclide or magnetic resonance imaging, coronary CT scanning for calcium scoring or angiograms, and invasive catheter-based angiography (Figure 1). The ACC and other professional societies self-regulate the practice of cardiovascular medicine by defining ‘appropriate use criteria’ for the optimal use of various tests and procedures. Wolk and colleagues now present a consensus do cument from the ACC Foundation, AHA, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Inter ventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons on the appropriate use of multimodality imaging for the detection and risk assessment of stable ischaemic heart disease, 3 which updates previous appropriate use criteria.4 This document is marked out as unique and a major step forward by the provision of side-by-side ratings of tests for particular
indications. At the same time, the ratings are not comparative and do not provide a recommendation for the ‘best test’ among those rated. Therefore, the intention is to provide guidance to clinicians for making an evidence-based choice that is appropriate to their chosen clinical strategy. Physician judgement using Bayesian principles with an emphasis on pretest likelihood of disease (which is known to influence the interpret ation of results and, therefore, treatment decisions) is heavily endorsed in the guidelines. The authors clarify that even if a test is rated, it does not necessarily need to be performed. They also highlight that, when deciding which test to perform, potential Coronary artery calcium scoring
Coronary CT angiography
Stress radionucleotide imaging
■ Patients with signs, symptoms, or various levels of risk of coronary disease ■ Patients with a previous test or revascularization procedure for follow-up testing
Stress echocardiography
clinical benefit must be prioritized over cost. In the document, appropriate use criteria are outlined using as many as 80 nonurgent scenarios. Broadly, these scenarios can be divided into four categories of patients with stable ischaemic heart disease (Figure 1). The algorithm in most scenarios endorses the clinical assessment of the background cardiovascular risk of a patient (performed using simple scores, such as the Framingham or PROCAM risk scores), or assessment of functional capacity or the Revised Cardiac Risk Index for preoperative patients. Most clinicians will agree with the classification of those tests and scenarios listed as ‘appropriate’ or ‘maybe appropriate’. Exercise electrocardiography is the only test listed as being appropriate for patients with a low pretest probability of obstructive coronary disease or who are at low cardiovascular risk, and for those requiring clearance for an exercise or rehabilitation programme. Most tests are considered appropriate for patients who are symptomatic and being assessed for an ischaemic syndrome, newonset heart failure, arrhythmia, or syncope; repeat testing of patients within 90 days of an abnormal or inconclusive test or if they develop new or worsening symptoms; and preoperative testing in patients with a poor
Stress MRI
Invasive coronary angiography
■ Preoperative assessment for noncardiac surgery ■ Patients scheduled to undergo an exercise programme or cardiac rehabilitation Stress electrocardiography
Figure 1 | Imaging modalities for stable ischaemic heart disease. The new consensus document gives recommendations on the appropriate use of multimodality imaging to assess coronary artery disease.
NATURE REVIEWS | CARDIOLOGY
VOLUME 11 | MARCH 2014 © 2014 Macmillan Publishers Limited. All rights reserved
NEWS & VIEWS functional capacity and undergoing highrisk vascular surgery, organ transplantation, or intermediate risk surgery if the individual has an elevated cardiac risk profile. Similarly, many of the ‘rarely appropriate’ listings— testing low-risk, asymptomatic patients; routine follow-up testing within 2 years of percutaneous coronary intervention or 5 years of CABG surgery in patients without new symptoms; preoperative testing of patients with adequate functional capacity and normal results from stress testing or who are undergoing low-risk surgery; and complicated forms of imaging-based stress tests before exercise or rehabilitation programmes—will find broad acceptance. Some classifications that might generate discussion are exercise electrocardio graphy being listed as ‘maybe appropriate’ for patients with previous obstructive coronary artery disease diagnosed using invasive coronary angiography within the past 90 days—a recommendation that seems far too conservative—and invasive
MARCH 2014 | VOLUME 11
angiography being listed as ‘maybe appropriate’ for symptomatic patients with a normal electrocardiogram—one that seems far too aggressive. All-in-all, the authors should be commended for creating a consensus document with little in their recommendations to cause debate. The ‘at-a-glance’ rating of the various clinical tests is a profoundly useful tool for practising clinicians. The logical next step would be to provide comparative ratings and for the guidelines to provide recommendations by weighing the evidence. The good news is that adequately powered studies of comparative effectiveness, such as the PROMISE trial,5 are scheduled to be completed in 2014. These data will further refine the art of cardiovascular diagnostics and provide clinicians with a rigorous scientific base for making decisions. Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029‑6574, USA (S.B., Z.A.F.).
Correspondence to: S.B. [email protected] Competing interests The authors declare no competing interests. 1.
2.
3.
4.
5.
Go, A. S. et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation http://dx.doi.org/10.1161/ 01.cir.0000441139.02102.80. Heidenreich, P. A. et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 123, 933–944 (2011). Wolk, M. J. et al. ACCF/AHA/ASE/ASNC/ HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J. Am. Coll. Cardiol. http://dx.doi.org/10.1016/ j.jacc.2013.11.009. Hendel, R. C. et al. Appropriate use of cardiovascular technology: 2013 ACCF appropriate use criteria methodology update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J. Am. Coll. Cardiol. 61, 1305–1317 (2013). US National Library of Medicine. ClinicalTrials.gov [online], http://clinicaltrials.gov/show/ NCT01174550 (2013).
www.nature.com/nrcardio © 2014 Macmillan Publishers Limited. All rights reserved
