Myocardial Perfusion Scans

Kusai S. Aziz

Indications for Myocardial Perfusion Scans

There has been tremendous growth in the use of myocardial perfusion scans over the years, mainly because of their noninvasive nature, good sensitivity and specificity, and prognostic value. However, in many cases there has been overuse of this technology, leading to unnecessary further testing including invasive procedures, and increasing the cost of health care in general. In 2005, a joint task force of the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) published the appropriateness criteria for ordering single photon emission computed tomography (SPECT) myocardial perfusion scans (Tables 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 2.10, 2.11, 2.12).1 Following the publication of the appropriateness criteria, the ACCF published a statement of the inappropriate use of SPECT myocardial perfusion imaging (MPI) (Table 2.13). The editors of this book believe that adhering to these criteria leads to the most cost-effective and evidence-based use of this important modality based on the available scientific evidence.

TABLE 2.1 Detection of CAD: Symptomatic

Indication		Appropriateness Criteria (Median Score)
Evaluation of Chest Pain Syndrome
1.	• Low pre-test probability of CAD • ECG interpretable AND able to exercise	I (2.0)
2.	• Low pre-test probability of CAD • ECG uninterpretable OR unable to exercise	U^a (6.5)
3.	• Intermediate pre-test probability of CAD • ECG interpretable AND able to exercise	A (7.0)
4.	• Intermediate pre-test probability of CAD • ECG uninterpretable OR unable to exercise	A (9.0)
5.	• High pre-test probability of CAD • ECG interpretable AND able to exercise	A (8.0)
6.	• High pre-test probability of CAD • ECG uninterpretable OR unable to exercise	A (9.0)
Acute Chest Pain (in Reference to Rest Perfusion Imaging)
7.	• Intermediate pre-test probability of CAD • ECG–no ST elevation AND initial cardiac enzymes negative	A (9.0)
8.	• High pre-test probability of CAD • ECG–ST elevation	I (1.0)
New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome
9.	• Intermediate pre-test probability of CAD	A (8.0)
^aMedian scores of 3.5 and 6.5 are rounded to the middle (Uncertain).
A, (Appropriate); CAD, coronary artery disease; ECG, electrocardiogram; I, (Inappropriate); U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.2 Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)

Indication		Appropriateness Criteria (Median Score)
Asymptomatic
10.	• Low CHD risk (Framingham risk criteria)	I (1.0)
11.	• Moderate CHD risk (Framingham)	U (5.5)
New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction Without Chest Pain Syndrome
12.	• Moderate CHD risk (Framingham) • No prior CAD evaluation AND no planned cardiac catheterization	A (7.5)
Valvular Heart Disease Without Chest Pain Syndrome
13.	• Moderate CHD risk (Framingham) • To help guide decision for invasive studies	U (5.5)
New-Onset Atrial Fibrillation
14.	• Low CHD risk (Framingham) • Part of the evaluation	U^a (3.5)
15.	• High CHD risk (Framingham) • Part of the evaluation	A (8.0)
Ventricular Tachycardia
16.	• Moderate to high CHD risk (Framingham)	A (9.0)
^aMedian score of 3.5 and 6.5 are rounded to the middle (Uncertain).
A, (Appropriate); CAD, coronary artery disease; CHD, coronary heart disease; I, (Inappropriate); U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.3 Risk Assessment: General and Specific Patient Populations

Indication		Appropriateness Criteria (Median Score)
Asymptomatic
17.	• Low CHD risk (Framingham)	I (1.0)
18.	• Moderate CHD risk (Framingham)	U (4.0)
19.	• Moderate to high CHD risk (Framingham) • High-risk occupation (e.g., airline pilot)	A (8.0)
20.	• High CHD risk (Framingham)	A (7.5)
A, (Appropriate); CHD, coronary heart disease; I, (Inappropriate); U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.4 Risk Assessment With Prior Test Results

Indication		Appropriateness Criteria (Median Score)
Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study
21.	• Normal initial RNI study • High CHD risk (Framingham) • Annual SPECT MPI study	I (3.0)
22.	• Normal initial RNI study • High CHD risk (Framingham) • Repeat SPECT MPI study after 2 years or greater	A (7.0)
Asymptomatic OR Stable Symptoms Abnormal Catheterization OR Prior SPECT MPI Study
23.	• Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure • Asymptomatic OR stable symptoms • Less than 1 year to evaluate worsening disease	I (2.5)
24.	• Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure • Greater than or equal to 2 years to evaluate worsening disease	A (7.5)
Worsening Symptoms Abnormal Catheterization OR Prior SPECT MPI Study
25.	• Known CAD on catheterization OR prior SPECT MPI study	A (9.0)
Asymptomatic CT Coronary Angiography
26.	• Stenosis of unclear significance	U^a (6.5)
Asymptomatic Prior Coronary Calcium Agatston Score
27.	• Agatston score greater than or equal to 400	A (7.5)
28.	• Agatston score less than 100	I (1.5)
UA/NSTEMI, STEMI, or Chest Pain Syndrome Coronary Angiogram
29.	• Stenosis of unclear significance	A (9.0)
Duke Treadmill Score
30.	• Intermediate Duke treadmill score • Intermediate CHD risk (Framingham)	A (9.0)
^aMedian score of 3.5 and 6.5 are rounded to the middle (Uncertain).
A, (Appropriate); CAD, coronary artery disease; CHD, coronary heart disease; I, (Inappropriate); RNI, radionuclide imaging;SPECT MPI, single photon emission computed tomography myocardial perfusion imaging; U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.5 Risk Assessment: Preoperative Evaluation for Noncardiac Surgery

Indication		Appropriateness Criteria (Median Score)
Low–Risk Surgery
31.	• Preoperative evaluation for noncardiac surgery risk assessment	I (1.0)
Intermediate–Risk Surgery
32.	• Minor to intermediate perioperative risk predictor • Normal exercise tolerance (greater than or equal to 4 METS)	I (3.0)
33.	• Intermediate perioperative risk predictor OR • Poor exercise tolerance (less than 4 METS)	A (8.0)
High-Risk Surgery
34.	• Minor perioperative risk predictor • Normal exercise tolerance (greater than or equal to 4 METS)	U (4.0)
35.	• Minor Perioperative risk predictor • Poor exercise tolerance (less than 4 METS)	A (8.0)
36.	• Asymptomatic up to 1 year post normal catheterization, noninvasive test, or previous revascularization	I (3.0)
A, (Appropriate); I, (Inappropriate); METS, metabolic equivalents; U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.6 Risk Assessment: Following Acute Coronary Syndrome

Indication		Appropriateness Criteria (Median Score)
STEMI—Hemodynamically Stable
37.	• Thrombolytic therapy administered • Not planning to undergo catheterization	A (8.0)
STEMI—Hemodynamically Unstable, Signs of Cardiogenic Shock, or Mechanical Complications
38.	• Thrombolytic therapy administered	I (1.0)
UA/NSTEMI—No Recurrent Ischemia or No Signs of HF
39.	• Not planning to undergo early catheterization	A (8.5)
ACS—Asymptomatic Post Revascularization (PCI or CABG)
40.	• Routine evaluation prior to hospital discharge	I (1.0)
A, (Appropriate); ACS, acute coronary syndrome; CABG, coronary artery bypass graft; HF, heart failure; I, (Inappropriate);
PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; U, (Uncertain); UA/NSTEMI, unstable angina/non–ST-elevation myocardial infraction
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.7 Risk Assessment-Post-Revascularization (PCI or CABG)

Indication		Appropriateness Criteria (Median Score)
Symptomatic
41.	• Evaluation of chest pain syndrome	A (8.0)
Asymptomatic
42.	• Asymptomatic prior to previous revascularization • Less than 5 years after CABG	U (6.0)
43.	• Symptomatic prior to previous revascularization • Less than 5 years after CABG	U (4.5)
44.	• Asymptomatic prior to previous revascularization • Greater than or equal to 5 years after CABG	A (7.5)
45.	• Symptomatic prior to previous revascularization • Greater than or equal to 5 years after CABG	A (7.5)
46.	• Asymptomatic prior to previous revascularization • Less than 1 year after PCI	U (6.5)
47.	• Symptomatic prior to previous revascularization • Less than 1 year after PCI	1 (3.0)
48.	• Asymptomatic prior to previous revascularization • Greater than or equal to 2 years after PCI	U^a (6.5)
49.	• Symptomatic prior to previous revascularization • Greater than or equal to 2 years after PCI	U (5.5)
^aMedian scores of 3.5 and 6.5 are rounded to the middle (Uncertain).
A, (Appropriate); CABG, coronary artery bypass graft; I, (Inappropriate); PCI, percutaneous coronary intervention; U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.8 Assessment of Viability/Ischemia

Indication		Appropriateness Criteria (Median Score)
Ischemic Cardiomyopathy Assessment of Viability/Ischemia (Includes SPECT Imaging for Wall Motion and Ventricular Function)
50.	• Known CAD on catheterization • Patient eligible for revascularization	A (8.5)
A, (Appropriate); CAD, coronary artery disease; I, (Inappropriate); SPECT, single photon emission computed tomography; U, (Uncertain)Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.9 Evaluation of Ventricular Function

Indication		Appropriateness Criteria (Median Score)
Evaluation of Left Ventricular Function
51.	• Non diagnostic echocardiogram	A (9.0)
Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)
52.	• Baseline and serial measurements	A (9.0)
A, (Appropriate); I, (Inappropriate); U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.10 Inappropriate Indications (Median Rating of 1 to 3)

Indication		Appropriateness Criteria (Median Score)
Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome
1.	• Low pre-test probability of CAD • ECG: interpretable AND able to exercise	I (2.0)
Detection of CAD Symptomatic—Acute Chest Pain (in Reference to Rest Perfusion Imaging)
8.	• High pre-test probability of CAD • ECG: ST elevation	I (1.0)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)
10.	• Low CHD risk (Framingham risk criteria)	I (1.0)
Risk Assessment: General and Specific Patient Populations—Asymptomatic
17.	• Low CHD risk (Framingham)	I (1.0)
Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Normal Prior SPECT MPI Study
21.	• Normal initial RNI study • High CHD risk (Framingham) • Annual SPECT MPI study	I (3.0)
Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Abnormal Catheterization OR Prior SPECT MPI Study
23.	• Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure • Asymptomatic OR stable symptoms • Less than 1 year to evaluate worsening disease	I (2.5)
Risk Assessment With Prior Test Results: Asymptomatic—Prior Coronary Calcium Agatston Score
28.	• Agatston score less than 100	I (1.5)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—Low-Risk Surgery
31.	• Preoperative evaluation for noncardiac surgery risk assessment	I (1.0)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery— Intermediate-Risk Surgery
32.	• Minor to intermediate perioperative risk predictor • Normal exercise tolerance (greater than or equal to 4 METS)	I (3.0)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery—High Risk Surgery
36.	• Asymptomatic up to 1 year post normal catheterization, noninvasive test, or previous revascularization	I (3.0)
Risk Assessment: Following Acute Coronary Syndrome STEMI—Hemodynamically Unstable, Signs of Cardiogenic Shock, or Mechanical Complications
38.	• Thrombolytic therapy administered	I (1.0)
Risk Assessment: Following Acute Coronary Syndrome— Asymptomatic Post-Revascularization (PCI or CABG)
40.	• Routine evaluation prior to hospital discharge	I (1.0)
Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic
47.	• Symptomatic prior to previous revascularization • Less than 1 year after PCI	I (3.0)
A, (Appropriate); CABG, coronary artery bypass graft; CAD, coronary artery disease; CHD, coronary heart disease; ECG, electrocardiogram; I, (Inappropriate); METS, metabolic equivalents; PCI, percutaneous coronary intervention; RNI, radionuclide imaging; SPECT MPI, single photon emission computed tomography myocardial perfusion imaging; STEMI, ST-elevation myocardial infarction; U, (Uncertain)Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.11 Appropriate Indications (Median Rating of 7 to 9)

Indication		Appropriateness Criteria (Median Score)
Detection of CAD): Symptomatic— Evaluation’ of Chest Pain Syndrome
3.	• Intermediate pre-test probability of CAD • ECG interpretable AND able to exercise	A (7.0)
4.	• Intermediate pre-test probability of CAD • ECG uninterpretable OR unable to exercise	A (9.0)
5.	• High pre-test probability of CAD • ECG interpretable AND able to exercise	A (8.0)
6.	• High pre-test probability of CAD • ECG uninterpretable OR unable to exercise	A (9.0)
Detection of CAD: Symptomatic— Acute Chest Pain (in Reference to Rest Perfusion Imaging)
7.	• Intermediate pre-test probability of CAD • ECG: no ST elevation AND initial cardiac enzymes negative	A (9.0)
Detection of CAD: Symptomatic— New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome
9.	• Intermediate pre-test probability of CAD	A (8.0)
Detection of CAD: Asymptomatic— New-Onset or Diagnosed Heart Failure of LV Systolic Dysfunction Without Chest Pain Syndrome
12.	• Moderate CHD risk (Framingham) • No prior CAD evaluation AND no planned cardiac catheterization	A (7.5)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— New-Onset Atrial Fibrillation
15.	• High CHD Risk (Framingham) • Part of the evaluation	A (8.0)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— Ventricular Tachycardia
16.	• Moderate to high CHD risk (Framingham)	A (9.0)
Risk Assessment: General and Specific Patient Populations— Asymptomatic
19.	• Moderate to high CHD risk (Framingham) • High-risk occupation (e.g., airline pilot)	A (8.0)
20.	• High CHD risk (Framingham)	A (7.5)
Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Normal Prior SPECT MPI Study
22.	• Normal initial RNI study • High CHD risk (Framingham) • Repeat SPECT MPI study after 2 years or greater	A (7.0)
Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Abnormal Catheterization or Prior SPECT MPI Study
24.	• Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure • Greater than or equal to 2 years to evaluate worsening disease	A (7.5)
Risk Assessment With Prior Test Results: Worsening Symptoms— Abnormal Catheterization OR Prior SPECT MPI Study
25.	• Known CAD on catheterization OR prior SPECT MPI study	A (9.0)
Risk Assessment With Prior Test Results: Asymptomatic— Prior Coronary Calcium Agatston Score
27.	• Agatston score greater that or equal to 400	A (7.5)
Risk Assessment With Prior Test Results: UA/NSTEMI, STEMI, or Chest Pain Syndrome—Coronary Angiogram
29.	• Stenosis of unclear significance	A (9.0)
Risk Assessment With Prior Test Results— Duke Treadmill Score
30.	• Intermediate Duke treadmill score • Intermediate CHD risk (Framingham)	A (9.0)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery— Intermediate-Risk Surgery
33.	• Intermediate perioperative risk predictor OR • Poor exercise tolerance (less than 4 METS)	A (8.0)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery— High-Risk Surgery
35.	• Minor perioperative risk predictor AND • Poor exercise tolerance (less than 4 METS)	A (8.0)
Risk Assessment: Following Acute Coronary Syndrome— STEMI-Hemodynamically Stable
37.	• Thrombolytic therapy administered • Not planning to undergo catheterization	A(8.0)
Risk Assessment: Following Acute Coronary Syndrome— UA/NSTEMI—No Recurrent Ischemia OR No Signs of HF
39.	• Not planning to undergo early catheterization	A(8.5)
Risk Assessment: Post-Revascularization (PCI or CABG)— Symptomatic
41.	• Evaluation of chest pain syndrome	A(8.0)
Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic
44.	• Asymptomatic prior to previous revascularization • Greater than or equal to 5 years after CABG	A(7.5)
45.	• Symptomatic prior to previous revascularization • Greater than or equal to 5 years after CABG	A(7.5)
Assessment of Viability/Ischemia: Ischemic Cardiomyopathy (Includes SPECT Imaging for Wall Motion and Ventricular Function)
50.	• Known CAD on catheterization • Patient eligible for revascularization	A(8.5)
Evaluation of Left Ventricular Function
51.	• Non-diagnostic echocardiogram	A (9.0)
Evaluation of Ventricular Function: Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)
52.	• Baseline and serial measurement	A (9.0)
A, (Appropriate); CAD, coronary artery disease; CHD, coronary heart disease; ECG, electrocardiogram; I, (Inappropriate); LV, left ventricular; METS, metabolic equivalents; PCI, percutaneous coronary intervention; RNI, radionuclide imaging; STEMI, ST-elevation myocardial infarction; U, (Uncertain); UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.12 Uncertain Indications (Median Rating of 4 to 6) (Possibly Appropriate Indications That Should Be Reimbursed, but Additional Research and/or Patient Information Is Required During Updates of the Criteria in Order to Rate Them Definitively as Being Appropriate)

Indication		Appropriateness Criteria (Median Score)
Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome
2.	• Low pre-test probability of CAD • ECG uninterpretable OR unable to exercise	U^a (6.5)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)
11.	• Moderate CHD risk (Framingham)	U(5.5)
Detection of CAD: Asymptomatic— Valvular Heart Disease Without Chest Pain Syndrome
13.	• Moderate CHD risk (Framingham) • To help guide decision for invasive studies	U(5.5)
Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— New -Onset Atrial Fibrillation
14.	• Low CHD risk (Framingham) • Part of the evaluation	U^a (3.5)
Risk Assessment: General and Specific Patient Populations— Asymptomatic
18.	• Moderate CHD risk (Framingham)	U (4.0)
Risk Assessment With Prior Test Results: Asymptomatic— CT Coronary Angiography
26.	• Stenosis of unclear significance	U^a (6.5)
Risk Assessment: Preoperative Evaluation for Noncardiac Surgery— High-Risk Surgery
34.	• Minor periopetative risk predictor • Normal exercise tolerance (greater than or equal to 4 METS)	U (4.0)
Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic
42.	• Asymptomatic prior to previous revascularization • Less than 5 years after CABG	U (6.0)
43.	• Symptomatic prior to previous revascularization • Less than 5 years after CABG	U (4.5)
Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic
46.	• Asymptomatic prior to previous revascularization • Less than 1 year after PCI	U^a (6.5)
48.	• Asymptomatic prior to previous revascularization • Greater than or equal to 2 years after PCI	U^a (6.5)
49.	• Symptomatic prior to previous revascularization • Greater than or equal to 2 years after PCI	U (5.5)
^aMedian scores of 3.5 and 6.5 are rounded to the middle (Uncertain).
A, (Appropriate) CABG, coronary artery bypass graft; CAD, coronary artery disease; CHD, coronary heart disease; ECG, electrocardiogram; I, (Inappropriate); PCI, percutaneous coronary intervention; U, (Uncertain)
Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

TABLE 2.13 Inappropriate Use of SPECT MPI (Prepare to Justify Your Order for These Indications)

Today’s sophisticated imaging technologies present new possibilities for the cardiovascular patient—and new challenges for the cardiovascular physician, who must decide how best to use them.

The American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) are leading the way to meet those challenges. The recent publication of the ACCF ASNC Appropriateness Criteria for Single Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) meets a critical need for appropriateness criteria in nuclear cardiovascular imaging. Appropriateness criteria cannot take the place of a physician’s best judgment. But they are a critical tool for cardiologists and referring physicians as we strive to avoid overuse of imaging procedures and to practice cost-effective medicine.

A Technical Panel of 12 experts rated the use of SPECT MPI for 52 indications, weighing the risks and benefits of the test in each. Twenty-seven indications were rated appropriate, and 12 were rated possibly appropriate (uncertain). The ACCF and ASNC recommend reimbursement for these 39 indications.

The panel does not recommend reimbursement for the 13 indications rated inappropriate for performing SPECT MPI. When ordering an SPECT MPI for one of the following indications, be aware that payers will likely require additional documentation. Be prepared to justify your order mitigating clinical parameters and patient circumstances.

• Detection of CAD: Evaluation of Chest Pain Syndrome
   Low pretest probability of CAD, ECG interpretable and able to exercise
• Detection of CAD: Symptomatic Acute Chest Pain (in Reference to Rest Perfusion Imaging)
   High pretest probability of CAD and ECG: ST elevation
• Detection of CAD: Asymptomatic (without Chest Pain Syndrome)
   Low CHD Risk based on Framingham Risk Criteria
• Risk Assessment: General and Specific Patient Populations—Asymptomatic
   Low CHD risk based on Framingham Risk Criteria
• Risk Assessment with Prior Test Results: Asymptomatic or Stable Symptoms—Normal Prior SPECT
   MPI Study
   Normal initial RNI study, high CHD risk and annual SPECT MPI study
• Risk Assessment with Prior Test Results: Asymptomatic or Stable Symptoms—Abnormal
   Catheterization of Prior SPECT MPI Study
   Known CAD on catheterization or prior SPECT MPI study in patients who have not had revascularization
   procedure, asymptomatic or stable symptoms, and less than one year to evaluate worsening disease
• Risk Assessment with Prior Test Results: Asymptomatic
   Prior coronary calcium agatston score less than 100
• Risk Assessment: Preoperative Evaluation for Low-Risk, Noncardiac Surgery Preoperative evaluation for
   noncardiac surgery risk assessment
• Risk Assessment: Preoperative Evaluation for Intermediate Risk. Noncardiac Surgery
   Minor to intermediate perioperative risk predictor and normal exercise tolerance (greater than or equal
   to 4 METS)
• Risk Assessment: Preoperative Evaluation for High Risk, Noncardiac Surgery Asymptomatic up to one year
   post normal catheterization, noninvasive test, or previous revascularization
• Risk Assessment: Following Acute Coronary Syndrome (STEMI—Hemodynamically Unstable, Signs of
   Cardiogenic Shock, or Mechanical Complications)
   Thrombolytic therapy administered
• Risk Assessment: Following Acute Coronary Syndrome—Asymptomatic Post Revascularization
   (PCI or CABG)
   Routine evaluation prior to hospital discharge
• Risk Assessment: Post-Revascularization, Asymptomatic
   Symptomatic prior to previous revascularization and less than two years after PCI—pending approval from
   Technical Panel

BNI, radionuclide imaging; CAD, coronary artery disease; CHD, coronary heart disease; ECG, electrocardiogram; METS, metabolic equivalents The Appropriateness Criteria for SPECT MPI appear in the Oct 18, 2005, issue of the Journal of the American College of Cardiology. 46: 1587–1605. The report is also available at www.acc.org/clinical/pdfs/SPECTMPIACPubFile.pdf.

For additional hard copies. call(800) 253–4636, ext. 8603.

Reprinted from Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005; 46:1587–1605, with permission from Elsevier.

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