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ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization

A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Thoracic Surgeons

      Abstract

      The American College of Cardiology Foundation, in collaboration with the Society for Cardiovascular Angiography and Interventions and key specialty and subspecialty societies, conducted a review of common clinical scenarios where diagnostic catheterization is frequently considered.
      The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of noninvasive imaging appropriate use criteria. The 166 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median 7 to 9), uncertain use (median 4 to 6), and inappropriate use (median 1 to 3).
      Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease with other procedure components (eg, hemodynamic measurements, ventriculography) at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the use of coronary angiography at the discretion of the operator. Seventy-five indications were rated as appropriate, 49 were rated as uncertain, and 42 were rated as inappropriate.
      The appropriate use criteria for diagnostic catheterization have the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

      Preface

      In an effort to respond to the need for the rational use of cardiovascular services, including imaging and invasive procedures in the delivery of high-quality care, the American College of Cardiology Foundation (ACCF) in collaboration with other professional organizations has undertaken a process to determine the appropriate use of cardiovascular procedures for selected patient indications.
      Appropriate use criteria (AUC) publications reflect an ongoing effort to critically and systematically create, review, and categorize clinical situations where diagnostic tests and therapeutic procedures are utilized by physicians caring for patients with cardiovascular disease. The process is based on understanding the technical capabilities of the procedures examined. The diversity of clinical disease present makes it difficult to be comprehensive, but the indications presented hopefully identify common scenarios encompassing the majority of situations encountered in contemporary practice. Given the breadth of information conveyed, the indications do not directly correspond to the Ninth Revision of the International Classification of Diseases system as these codes do not include clinical information, such as symptom status.
      The ACCF and the Society for Cardiovascular Angiography and Interventions (SCAI) believe that careful blending of a broad range of clinical experiences and available evidence-based information will help guide a more efficient and equitable allocation of healthcare resources in cardiovascular care and invasive catheterization. The ultimate objective of the AUC is to improve patient care and health outcomes in a cost-effective manner while recognizing that some ambiguity and nuance is intrinsic to clinical decision making. Therefore, the AUC should not be considered substitutes for sound clinical judgment and practice experience. However, when the clinical judgment and practice patterns routinely conflict with AUC ratings, further evaluation of the specific clinical circumstances should be considered.
      The AUC development process itself is also evolving. Given the iterative nature of the process and incorporation of new information about the role for diagnostic and therapeutic interventions, readers are counseled that comparison of individual appropriate use ratings developed at different times over the past several years may not reflect the comparative utility of different modalities for a given indication, as the ratings may vary over time. Cardiac catheterization plays a central role in the care of patients with cardiovascular disease, and guidance around the rationale and evidence based use of the procedure is the goal of the current document.
      We are grateful to the technical panel and its moderator, Pamela S. Douglas, MD, MACC, FAHA, FASE, a professional group with a wide range of skills and insights, for their thoughtful and thorough deliberation of the merits of diagnostic catheterization for various indications. We would also like to thank the 28 individuals who provided a careful review of the draft of indications, the parent AUC Task Force, and the ACCF staff, specifically Joseph M. Allen and Lea Binder for their exceptionally skilled support in the generation of this document.
      Manesh R. Patel, MD, FACC
      Co-Chair, Diagnostic Catheterization Writing Group
      Steven R. Bailey, MD, FACC, FSCAI, FAHA
      Co-Chair, Diagnostic Catheterization Writing Group
      Michael J. Wolk, MD, MACC
      Chair, Appropriate Use Criteria Task Force

      1. Introduction

      The ACCF, in collaboration with SCAI and several other professional organizations, developed common clinical scenarios where diagnostic cardiac catheterization is frequently considered. The indications, as presented in these clinical scenarios, were derived from common presentations or anticipated uses, as well as from current clinical practice guidelines. The 166 indications in this document were developed by a writing group with diverse clinical expertise and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (median scores 7 to 9), uncertain use (median scores 4 to 6), and inappropriate use (median scores 1 to 3).
      The AUC for diagnostic catheterization has the potential to impact physician decision making, healthcare delivery, and reimbursement policy. Furthermore, it is hoped that recognition of uncertain clinical scenarios facilitates identification of areas that could benefit from future research.
      This report addresses the appropriate use of diagnostic catheterization. Improvements in cardiovascular imaging technology and an expanding array of noninvasive diagnostic tools and therapeutic options for patients with cardiovascular disease have led to many more choices than in the past. As the field advances, the healthcare community needs to understand how to best incorporate this technology into daily clinical care. ACCF and SCAI are dedicated to this effort.

      2. Methods

      The indications included in this publication cover a variety of cardiovascular signs and symptoms as well as clinical judgments as to the likelihood of cardiovascular findings. Within each main disease category, a standardized approach was used to capture a significant number of clinical scenarios without making the list of indications excessive. The term “indication” is used interchangeably with “clinical scenario” in the document for brevity and does not imply that imaging should necessarily be done. Diagnostic catheterization may include several different procedure components. The indications developed focused primarily on 2 aspects of diagnostic catheterization. Many indications focused on the performance of coronary angiography for the detection of coronary artery disease (CAD), with other procedure components (eg, hemodynamic measurements, ventriculography) performed at the discretion of the operator. The majority of the remaining indications focused on hemodynamic measurements to evaluate valvular heart disease, pulmonary hypertension, cardiomyopathy, and other conditions, with the addition of coronary angiography at the discretion of the operator.
      The spectrum of cardiovascular disease was addressed as it would apply to the standard adult catheterization laboratory. The writing group did not consider invasive evaluations of complex adult congenital heart disease in this document, with the belief that such complex cases would be best performed by individuals with considerable specialized expertise and at institutions with sufficient patient volume. Recommendations in this area are addressed in separate subspecialty publications. Additionally, invasive procedures such as endomyocardial biopsy, pericardiocentesis, or right heart catheterization not performed in the catheterization laboratory are not covered in this document.
      The indications were constructed by a varied group of experts in both invasive and noninvasive diagnostic cardiac imaging. Subsequent modifications in the indications were made based on discussions with the task force and feedback from independent reviewers. Wherever possible, indications were mapped to relevant clinical guidelines and key publications/references (see Online Appendix available at http://content.onlinejacc.org/j.jacc.2012.03.003/DC2).
      A detailed description of the methods used for rating the selected clinical indications is found in a previous publication, “ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging.”
      • Patel M.R.
      • Spertus J.A.
      • Brindis R.G.
      • et al.
      ACCF proposed method for evaluating the appropriateness of cardiovascular imaging.
      Briefly, this process combines evidence-based medicine and practice experience by engaging a technical panel in a modified Delphi exercise. The technical panel first rated the indications independently, after which the results were summarized and the panel convened for a face-to-face meeting to discuss each indication. At this meeting, panel members were provided with their scores and a blinded summary of their peers’ scores. After the meeting, panel members once again independently rated each indication to determine the final scores.
      Although panel members were not provided explicit cost information to help determine their ratings, they were asked to implicitly consider costs as an additional factor in their evaluation of appropriate use. In rating these criteria, the technical panel was asked to assess whether the use of the test for each indication is appropriate, uncertain, or inappropriate, and was provided with the following definition of appropriate use:
      An appropriate diagnostic cardiac catheterization (left heart, right heart, ventriculography, and/or coronary angiography) is one in which the expected incremental information combined with clinical judgment exceeds the negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication.
      Each member of the technical panel assigned a score to each indication, and the scores of the technical panel were tabulated for the final ratings and assigned an appropriateness rating as follows:
      Median Score 7 to 9
      Appropriate test for specific indication (test is generally acceptable and is a reasonable approach for the indication).
      Median Score 4 to 6
      Uncertain for specific indication (test may be generally acceptable and may be a reasonable approach for the indication). Uncertainty also implies that more research and/or patient information is needed to classify the indication definitively.
      Median Score 1 to 3
      Inappropriate test for that indication (test is not generally acceptable and is not a reasonable approach for the indication).
      The division of these scores into 3 levels of appropriateness should be viewed as a continuum. It is important to emphasize that the category of “uncertain” is a distinct category and must not be considered either “appropriate” or “inappropriate” or lumped together with the other categories when characterizing appropriateness ratings. A rating of uncertain will exist if: (1) there is considerable diversity in the ratings among individual members of the technical panel indicating a wide range of opinions; (2) there is insufficient clinical information provided in the clinical scenario for the raters to reach a firm conclusion about appropriateness; or (3) there is a lack of specific information in the medical literature to make a firm recommendation regarding appropriateness. The uncertain category designation should encourage investigators to perform definitive research whenever possible. A designation of “uncertain” does not imply that the test should not be used in a specific clinical scenario. Many other factors known by the clinician and difficult to characterize within the structure of the AUC could affect a decision to perform or not perform a procedure in a specific patient. It is anticipated that the AUC reports will continue to be revised as further data are generated and information from the implementation of the criteria is accumulated. The writing group recognizes that a large portion of routine medical care would be rated as uncertain when held to the standards of the AUC and therefore hope this rating is correctly interpreted and can be placed in proper context.
      To prevent bias in the scoring process, the technical panel was deliberately comprised of a minority of specialists in cardiac catheterization. Specialists, although offering important clinical and technical insights, might have a natural tendency to rate the indications within their specialty as more appropriate than nonspecialists. In addition, care was taken in providing objective, nonbiased information, including guidelines and key references, to the technical panel.
      The level of agreement among panelists as defined by RAND
      • Fitch K.
      • Bernstein S.J.
      • Aguilar M.D.
      • et al.
      The RAND/UCLA Appropriateness Method User’s Manual.
      was analyzed based on the BIOMED rule for a panel of 14 to 16 members. As such, agreement is defined as an indication where 4 or fewer panelists’ ratings fell outside the 3-point region containing the median score.
      Disagreement was defined as where at least 5 panelists’ ratings fell in both the appropriate and the inappropriate categories. Any indication having disagreement was categorized as uncertain regardless of the final median score.

      3. Assumptions

      To limit inconsistencies in interpretation, specific assumptions were used by the writing group in drafting indications and by the technical panel when rating the clinical indications for the appropriate use of diagnostic catheterization.
      • 1.
        The clinical scenarios were rated based on published literature and clinical practice guidelines regarding the risks and benefits of diagnostic catheterization, if available. In general, there are few randomized trials specifically examining diagnostic catheterization as a procedure. However, diagnostic catheterization was used within the study design of many randomized trials in which specific therapies were tested. Specific patient groups not well represented in the literature are not presented in the current clinical scenarios. However, the writing group recognizes that decisions about diagnostic catheterization in such patients are frequently required. Examples of such patients include those with end-stage renal disease, advanced age, or malignancy.
      • 2.
        All patients are attempting to achieve optimal care, including guideline-based risk factor modification for primary or secondary prevention in cardiovascular patients unless specifically noted.
        • Pearson T.A.
        • Blair S.N.
        • Daniels S.R.
        • et al.
        American Heart Association Science Advisory and Coordinating Committee
        AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases.
        • Buse J.B.
        • Ginsberg H.N.
        • Bakris G.L.
        • et al.
        Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association.
        • Chobanian A.V.
        • Bakris G.L.
        • Black H.R.
        • et al.
        Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
        • Adult Treatment Panel I.I.I.
        Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report.
        • Smith Jr., S.C.
        • Benjamin E.J.
        • Bonow R.O.
        • et al.
        AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation.
      • 3.
        Despite the best efforts of the clinician, all patients may not achieve target goals for risk factor modification. However, a plan of care to address risk factors is assumed to be occurring in patients represented in the indications. For patients with chronic stable angina, the writing group recognizes that there is a wide variance in the medical therapy for angina.
      • 4.
        Operators performing diagnostic catheterization have appropriate clinical training and experience and have satisfactory outcomes as assessed by quality assurance monitoring.
        • King III, S.B.
        • Aversano T.
        • Ballard W.L.
        • et al.
        ACCF/AHA/SCAI 2007 update of the clinical competence statement on cardiac interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures).

        Bashore TM, Balter S, Barac A, et al. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. June 5, 2012 [E-pub ahead of print], doi:10.1016/j.jacc.2012.02.010.

      • 5.
        Diagnostic catheterization (left heart, right heart, and/or coronary angiography) is performed in a manner consistent with established standards of care.
        • King III, S.B.
        • Aversano T.
        • Ballard W.L.
        • et al.
        ACCF/AHA/SCAI 2007 update of the clinical competence statement on cardiac interventional procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Update the 1998 Clinical Competence Statement on Recommendations for the Assessment and Maintenance of Proficiency in Coronary Interventional Procedures).

        Bashore TM, Balter S, Barac A, et al. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. June 5, 2012 [E-pub ahead of print], doi:10.1016/j.jacc.2012.02.010.

      • 6.
        All indications for diagnostic catheterization were considered with the following important assumptions:
        • a.
          All indications were first evaluated on the basis of the available medical literature.
        • b.
          In many cases, studies published in the medical literature provide minimal information about the role of the test in clinical decision making.
        • c.
          Appropriate use criteria development requires a risk/benefit trade-off as determined by individual patient indications. Radiation exposure should be considered in risk estimates.
        • d.
          No circumstances exist that would preclude cardiac catheterization (eg, severe coagulopathy, patient refusal).
      • 7.
        A complete clinical history and physical exam has been completed by a qualified clinician such that the clinical status of the patient can be assumed to be valid as stated in the indication (eg, asymptomatic patient is truly asymptomatic for the condition in question and that sufficient questioning of the patient has been undertaken).
      • 8.
        Cost was be considered implicitly in the appropriate use determination.
      • 9.
        For each indication, the rating reflected whether diagnostic catheterization is reasonable for the patient and not whether it is preferred over another modality.
      • 10.
        The category of “uncertain” was used when insufficient clinical data are available for a definitive categorization or there is substantial disagreement regarding the appropriateness of that indication. Those scenarios designated as uncertain reflect variations in clinical practice patterns. The designation of “uncertain” should not be used as grounds for denial of reimbursement.
      • 11.
        All procedures presented are to be considered for clinical indications and not part of a research protocol.
      • 12.
        All prior noninvasive testing was adequately completed.

      4. Definitions

      Definitions of terms used throughout the indication set are listed here. These definitions were provided to and discussed with the technical panel prior to rating of indications.
      Stress Testing and Risk of Findings on Noninvasive Testing: Stress testing is commonly used for both diagnosis (possible/presumed) and risk stratification of patients with established CAD. Using criteria defined for traditional exercise stress tests
      • Gibbons R.J.
      • Abrams J.
      • Chatterjee K.
      • et al.
      ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina).
      • Fraker Jr., T.D.
      • Fihn S.D.
      • Gibbons R.J.
      • et al.
      2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina.
      :
      • Low-risk stress test findings: associated with a cardiac mortality of <1% per year
      • Intermediate-risk stress test findings: associated with a 1% to 3% per year cardiac mortality
      • High-risk stress test findings: associated with a >3% per year cardiac mortality
      Symptomatic/Ischemic Equivalent: Chest Pain Syndrome, Anginal Equivalent, or Ischemic Electrocardiogram (ECG) Abnormalities: Any constellation of clinical findings that the physician believes is consistent with CAD manifestations. Examples of such findings include, but are not limited to, chest pain, chest tightness, chest burning, shoulder pain, left arm pain, jaw pain, new ECG abnormalities, or other symptoms/findings suggestive of CAD. Clinical presentations in the absence of chest pain (eg, dyspnea with exertion or reduced/worsening effort tolerance) that are thought to be consistent with CAD may also be considered to be an ischemic equivalent.
      Clinical Classification of Chest Pain:
      • Typical Angina (Definite): defined as (1) substernal chest pain or discomfort that is (2) provoked by exertion or emotional stress and (3) relieved by rest and/or nitroglycerin.
        • Diamond G.A.
        A clinically relevant classification of chest discomfort.
      • Atypical Angina (Probable): chest pain or discomfort that lacks 1 of the characteristics of definite or typical angina.
      • Nonanginal Chest Pain: chest pain or discomfort that meets 1 or none of the typical angina characteristics.
      Grading of Angina Pectoris by the Canadian Cardiovascular Society Classification System
      • Campeau L.
      Letter: grading of angina pectoris.
      :
      • Class I: ordinary physical activity does not cause angina, such as walking, climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.
      • Class II: slight limitation of ordinary activity. Angina occurs on walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and in normal condition.
      • Class III: marked limitations of ordinary physical activity. Angina occurs on walking 1 or 2 blocks on the level and climbing 1 flight of stairs in normal conditions and at a normal pace.
      • Class IV: inability to carry on any physical activity without discomfort—anginal symptoms may be present at rest.
      Pretest Probability of Coronary Artery Disease: Symptomatic (Ischemic Equivalent) Patients: Once the physician determines that symptoms are present that may represent CAD, the pretest probability of CAD should be assessed. There are a number of risk algorithms
      • Pryor D.B.
      • Shaw L.
      • McCants C.B.
      • et al.
      Value of the history and physical in identifying patients at increased risk for coronary artery disease.
      • Morise A.P.
      • Haddad W.J.
      • Beckner D.
      Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease.
      available that can be used to calculate this probability. Clinicians should be familiar with those algorithms that pertain to the populations they encounter most often. In rating the appropriateness of cardiac catheterization for specific indications, the following probabilities, as calculated from any of the various available validated algorithms, should be applied
      • Gibbons R.J.
      • Abrams J.
      • Chatterjee K.
      • et al.
      ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina).
      :
      • Very low pretest probability: <5% pretest probability of CAD
      • Low pretest probability: between 5% and 10% pretest probability of CAD
      • Intermediate pretest probability: between 10% and 90% pretest probability of CAD
      • High pretest probability: >90% pretest probability of CAD
      The method recommended by the ACCF/AHA guidelines for chronic stable angina
      • Gibbons R.J.
      • Abrams J.
      • Chatterjee K.
      • et al.
      ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina).
      is provided as one example of a method used to calculate pretest probability and is a modification of a previously published literature review.
      • Diamond G.A.
      • Forrester J.S.
      Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease.
      Please refer to Table A and the clinical classification of chest pain definition angina characteristics. It is important to note that other historical factors or ECG findings (eg, prior infarction) can affect pretest probability, although these factors are not accounted for in Table A. Similarly, while not incorporated into the algorithm, other CAD risk factors may also affect pretest likelihood of CAD. Detailed nomograms are available that incorporate the effects of a history of prior infarction, ECG Q waves and ST- and T-wave changes, diabetes, smoking, and hypercholesterolemia.
      • Pryor D.B.
      • Harrell Jr., F.E.
      • Lee K.L.
      • Califf R.M.
      • Rosati R.A.
      Estimating the likelihood of significant coronary artery disease.
      Table APretest probability of CAD by age, gender, and symptoms
      Modified from the ACC/AHA Exercise Testing Guidelines to reflect all age ranges.18
      Age (y)GenderTypical/definite angina pectorisAtypical/probable angina pectorisNonanginal chest painAsymptomatic
      <39MenIntermediateIntermediateLowVery low
      WomenIntermediateVery lowVery lowVery low
      40-49MenHighIntermediateIntermediateLow
      WomenIntermediateLowVery lowVery low
      50-59MenHighIntermediateIntermediateLow
      WomenIntermediateIntermediateLowVery low
      >60MenHighIntermediateIntermediateLow
      WomenHighIntermediateIntermediateLow
      High: >90% pretest probability. Intermediate: between 10% and 90% pretest probability. Low: between 5% and 10% pretest probability. Very low: <5% pretest probability.
      CAD, Coronary artery disease.
      Modified from the ACC/AHA Exercise Testing Guidelines to reflect all age ranges.
      • Gibbons R.J.
      • Balady G.J.
      • Bricker J.T.
      • et al.
      ACC/AHA 2002 guideline update for exercise testing: summary article A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines).
      Global CAD Risk: It is assumed that clinicians will use current standard methods of global risk assessment such as those presented in the National Heart, Lung, and Blood Institute report on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III])
      Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
      Executive summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).
      or similar national guidelines.
      Absolute risk is defined as the probability of developing CAD over a given time period. The ATP III report estimates the absolute risk for CAD over the next 10 years. CAD risk refers to 10-year risk for any hard cardiac event (eg, myocardial infarction or CAD death). However, acknowledging that global absolute risk scores may have not been evaluated in certain populations (eg, women, younger men, minority populations), clinical judgment must be applied in assigning categorical risk thresholds in such subpopulations.
      • Low global CAD risk
        • Defined by the age-specific risk level that is below average. In general, low risk will correlate with a 10-year absolute CAD risk <10%. However, in women and younger men, low risk may correlate with 10-year absolute CAD risk <6%.
      • Intermediate global CAD risk
        • Defined by the age-specific risk level that is average. In general, moderate risk will correlate with a 10-year absolute CAD risk range of 10% to 20%. Among women and younger men, an expanded intermediate risk range of 6% to 20% may be appropriate.
      • High global CAD risk
        • Defined by the age-specific risk level that is above average. In general, high risk will correlate with a 10-year absolute CAD risk of >20%. CAD equivalents (eg, diabetes mellitus, peripheral arterial disease) can also define high risk.
      Duke Treadmill Score
      • Shaw L.J.
      • Peterson E.D.
      • Shaw L.K.
      • et al.
      Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups.
      : The equation for calculating the Duke treadmill score (DTS) is DTS = exercise time in minutes − (5 × ST-segment deviation) − (4 × exercise angina), with 0 = none, 1 = nonlimiting, and 2 = exercise-limiting.
      The score typically ranges from −25 to +15. These values correspond to low-risk (with a score of ≥+5), moderate-risk (with scores ranging from −10 to +4), and high-risk (with a score of ≤−11) categories.
      ECG—Uninterpretable: Refers to ECGs with resting ST-segment depression (≥0.10 mV), left bundle branch block (LBBB), pre-excitation (Wolff-Parkinson-White Syndrome), or paced rhythm.
      Adjunct Invasive Diagnostic Testing:
      • Fractional flow reserve (FFR)
        • An invasive diagnostic tool used to provide physiological measurements as an adjunct to coronary angiography for the determination of lesion severity and to assist in decisions about revascularization. FFR is calculated using the ratio of the mean arterial pressure distal to a stenosis to the mean aortic pressure during maximal hyperemia. FFR measurements <0.75 are associated with ischemia on exercise testing and adjunct imaging (echo or nuclear) with high sensitivity (88%), specificity (100%), and overall accuracy (93%). FFR measurements >0.80 are associated with negative ischemic results with a predictive accuracy of 95%. Routine measurement of FFR in patients with multivessel coronary artery disease who are undergoing PCI with drug-eluting stents with deferral of lesions with FFR >0.80 has been shown to significantly reduce the rate of the composite endpoint of death, nonfatal myocardial infarction, and repeat revascularization at 1 year.
          • Tonino P.A.
          • De Bruyne B.
          • Pijls N.H.
          • et al.
          Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.
      • Intravascular ultrasound
        • An invasive diagnostic test performed as an adjunct to diagnostic catheterization to provide an ultrasound-based anatomic assessment that extends beyond conventional angiography. This technique is used to identify lesion and vessel characteristics and obtain basic measurements for diagnostic and interventional application (minimal and maximal luminal diameters, cross-sectional area, and plaque area).
      Evaluating Perioperative Risk for Noncardiac Surgery: See Figure A, “Stepwise Approach to Perioperative Cardiac Assessment,” from the ACCF/AHA 2009 perioperative guidelines.
      • Fleisher L.A.
      • Beckman J.A.
      • Brown K.A.
      • et al.
      2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.
      According to the algorithm, once it is determined that the patient does not require urgent surgery, the clinician should determine the patient’s active cardiac conditions (see Table B) and/or perioperative risk predictors (see Table C). If any active cardiac conditions and/or major risk predictors are present, Figure A suggests consideration of guideline-based care that may include coronary angiography and postponing or canceling noncardiac surgery. Once perioperative risk predictors are assessed, the surgical risk and the patient’s functional status should be used to establish the need for noninvasive testing.
      Figure thumbnail gr8
      Figure AStepwise approach to perioperative cardiac assessment. Cardiac evaluation and care algorithm for noncardiac surgery based on active clinical conditions, known cardiovascular disease, or cardiac risk factors for patients ≥50 years of age. HR, Heart rate; LOE, level of evidence; MET, metabolic equivalent.
      Modified from Fleisher et al.
      • Fleisher L.A.
      • Beckman J.A.
      • Brown K.A.
      • et al.
      2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.
      Table BActive cardiac conditions for which the patient should undergo evaluation and treatment before noncardiac surgery (class I, level of evidence: B)
      ConditionExamples
      Unstable coronary syndromesUnstable or severe angina
      According to Campeau13;
      (CCS class III or IV)
      may include “stable” angina in patients who are unusually sedentary;
      Recent MI
      the American College of Cardiology National Database Library defines recent MI as >7 days but ≤1 month (within 30 days).
      Decompensated HF (NYHA functional class IV; worsening or new-onset HF)
      Significant arrhythmiasHigh-grade atrioventricular block
      Mobitz II atrioventricular block
      Third-degree atrioventricular heart block
      Symptomatic ventricular arrhythmias
      Supraventricular arrhythmias (including atrial fibrillation) with uncontrolled ventricular rate (HR >100 beats/min at rest)
      Symptomatic bradycardia
      Newly recognized ventricular tachycardia
      Severe valvular diseaseSevere aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm2, or symptomatic)
      Symptomatic mitral stenosis (progressive dyspnea on exertion, extertional presyncope, or HF)
      Reprinted from Fleisher et al.
      • Fleisher L.A.
      • Beckman J.A.
      • Brown K.A.
      • et al.
      2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.
      CCS, Canadian Cardiovascular Society; HF, heart failure; HR, heart rate; MI, myocardial infarction; NYHA, New York Heart Association.
      According to Campeau
      • Campeau L.
      Letter: grading of angina pectoris.
      ;
      may include “stable” angina in patients who are unusually sedentary;
      the American College of Cardiology National Database Library defines recent MI as >7 days but ≤1 month (within 30 days).
      Table CPerioperative clinical risk factors
      As defined by the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.22 Note that these are not standard coronary artery disease risk factors.
      • History of ischemic heart disease
      • History of compensated or prior heart failure
      • History of cerebrovascular disease
      • Diabetes mellitus (requiring insulin)
      • Renal insufficiency (creatinine >2.0)
      ACCF, American College of Cardiology Foundation; AHA, American Heart Association.
      As defined by the ACCF/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.
      • Fleisher L.A.
      • Beckman J.A.
      • Brown K.A.
      • et al.
      2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.
      Note that these are not standard coronary artery disease risk factors.

      5. Abbreviations

      ACS = acute coronary syndrome
      AV = atrioventricular
      CABG = coronary artery bypass grafting surgery
      CAD = coronary artery disease
      ECG = electrocardiogram
      FFR = fractional flow reserve
      LBBB = left bundle branch block
      LV = left ventricular

      6. Results of Ratings

      The final ratings for diagnostic catheterization are listed by indication in Table 1.1, Table 1.2, Table 1.3, Table 1.4, Table 1.5, Table 1.6, Table 1.7, Table 2.1, Table 2.2, Table 2.3, Table 3.1. The final score reflects the median score of the 17 technical panel members and has been labeled according to the 3 appropriate use categories of appropriate (median 7 to 9), uncertain (median 4 to 6), and inappropriate (median 1 to 3). Table 4, Table 5, Table 6 present the same indications by the appropriate use categories.
      Table 1.1Suspected or known ACS
      A, Appropriate; ACS, acute coronary syndrome; GRACE, Global Registry of Acute Coronary Events; LV, left ventricular; STEMI, ST-elevation myocardial infarction; TIMI, Thrombolysis In Myocardial Infarction; UA/NSTEMI, unstable angina non–ST-elevation myocardial infarction.
      Table 1.2Suspected CAD: No prior noninvasive stress imaging (no prior PCI, CABG, or angiogram showing ≥50% angiographic stenosis)
      A, Appropriate; CABG, coronary bypass grafting surgery; CAD, coronary artery disease; I, inappropriate; PCI, percutaneous coronary intervention; U, uncertain.
      Table 1.3Suspected CAD: Prior noninvasive testing (no prior PCI, CABG, or angiogram showing ≥50% angiographic stenosis)
      A, Appropriate; CABG, coronary bypass grafting surgery; CAD, coronary artery disease; CMR, cardiovascular magnetic resonance; CTA, computed tomography angiography; ECG, electrocardiogram; I, inappropriate; LV, left ventricular; LVEF, left ventricular ejection fraction; PET, positron emission tomography; SPECT MPI, single-photon emission computed tomography myocardial perfusion imaging; TID, transient ischemic dilation; TTE, transthoracic echocardiography; U, uncertain; VSD, ventricular septal defect.
      ∗Coronary calcium score only rated for asymptomatic patients as these patients are the population in which it is used.
      Table 1.4Adjunctive invasive diagnostic testing in patients undergoing appropriate diagnostic coronary angiography
      A, Appropriate; FFR, fractional flow reserve; I, inappropriate; IVUS, intravascular ultrasound; U, uncertain.
      ∗Concordance refers to noninvasive imaging studies that demonstrate evidence of abnormal myocardial perfusion that is in the same distribution as a coronary artery stenosis, or degree of valvular disease that is similar to clinical impression.
      Table 1.5Patients with known obstructive CAD (eg, prior MI, prior PCI, prior CABG, or obstructive disease on invasive angiography)
      A, Appropriate; CABG, coronary bypass grafting surgery; CAD, coronary artery disease; I, inappropriate; MI, myocardial infarction; PCI, percutaneous coronary intervention; U, uncertain.
      Table 1.6Arrhythmias
      A, Appropriate; AV, atrioventricular; CHD, coronary heart disease; I, inappropriate; LBBB, left bundle branch block; LV, left ventricular; U, uncertain; VF, ventricular fibrillation; VT, ventricular tachycardia.
      Table 1.7Preoperative coronary evaluation for noncardiac surgery in stable patients
      Cr, Creatinine; I, inappropriate; METS, metabolic equivalents; U, uncertain.
      Table 2.1Valvular disease
      A, Appropriate; I, inappropriate; U, uncertain.
      Table 2.2Pericardial diseases
      A, Appropriate.
      Table 2.3Cardiomyopathies
      A, Appropriate; U, uncertain.
      Table 3.1Pulmonary hypertension or intracardiac shunt evaluation
      A, Appropriate.
      Table 4Appropriate indications (median score 7–9)
      A, Appropriate; ACS, acute coronary syndrome; CABG, coronary bypass grafting surgery; CAD, coronary artery disease; CMR, cardiovascular magnetic resonance; CTA, computed tomography angiography; ECG, electrocardiogram; FFR, fractional flow reserve; GRACE, Global Registry of Acute Coronary Events; IVUS, intravascular ultrasound; LV, left ventricular; LVEF, left ventricular ejection fraction; MI, myocardial infarction; PET, positron emission tomography; PCI, percutaneous coronary intervention; SPECT MPI, single-photon emission computed tomography myocardial perfusion imaging; STEMI, ST-elevation myocardial infarction; TID, transient ischemic dilation; TIMI, Thrombolysis In Myocardial Infarction; TTE, transthoracic echocardiography; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; VF, ventricular fibrillation; VSD, ventricular septal defect; VT, ventricular tachycardia.

      7. Diagnostic Catheterization Appropriate Use Criteria (By Indication)

      • A.
        CAD Assessment
        • 1.
          Coronary Angiography With or Without Left Heart Catheterization and Left Ventriculography
          Coronary angiography is widely used to evaluate patients with known or suspected CAD. Depending on the clinical circumstances and prior testing, coronary angiography may be coupled with the measurement of left ventricular (LV) pressures (left heart catheterization) and/or the evaluation of LV systolic function and wall motion (left ventriculography).
          The indications developed in Section A relate to appropriateness of coronary angiography. A decision about the performance of left heart catheterization and left ventriculography is left to the discretion of the operator and the patient’s primary physician.
      • B.
        Assessment for Conditions Other Than Coronary Artery Disease
        • 2.
          Right and Left Heart Catheterization or Right Heart Catheterization Alone With or Without Left Ventriculography and Coronary Angiography
          Right and left heart catheterization (including the measurement of cardiac output and intracardiac oxygen saturations) is used to evaluate a variety of conditions. The syndrome of heart failure may or may not be present in these clinical scenarios. Depending on the clinical circumstances and prior testing, coronary angiography, left or right ventriculography, and additional angiography such as supravalvular aortography may be coupled with hemodynamic measurements. A decision about the need for coronary angiography in addition to the hemodynamic study should be at the discretion of the operator and the patient’s primary physician.
        • 2.1.
          Valvular Disease
          Patients with valvular heart disease can be challenging to evaluate, and these challenges are even greater in the setting of multivalve involvement. Failure to intervene with appropriate therapies at the correct time can result in the permanent impairment of heart function and a poor prognosis. The evaluation of valvular disease should start with a careful history and physical examination and is then augmented by noninvasive imaging, most frequently echocardiography. One of the challenges faced by clinicians occurs when the clinical impression of valve lesion severity based on the history and physical exam differs from that derived from an imaging test. The presence of concordant or conflicting impressions may affect the decision to perform an invasive evaluation and this is tested in the table below. For patients in whom valve surgery is planned, the indication for cardiac catheterization is covered in Indication 70.
          Table 2.1 only considers isolated lesions of left-sided valves and does not consider mixed disease of a valve (eg, aortic stenosis and regurgitation) or multivalve disease. Invasive evaluation may be necessary in these settings but often requires the assessment of several other variables such as LV function and should be at the discretion of the clinician. Scenarios were not developed for isolated or mixed disease of the tricuspid or pulmonic valve because they are relatively uncommon in adults and, when present, are often associated with left-sided valve lesions.
        • 2.2.
          Cardiomyopathies
          A variety of conditions present with signs and/or symptoms of heart failure. Right heart catheterization alone or combined right and left heart catheterization (including the measurement of cardiac and pulmonary pressures, cardiac output, vascular resistance, and intracardiac oxygen saturations) is used to evaluate many of these conditions. Depending on the clinical circumstances and prior testing, coronary angiography, left or right ventriculography, and additional angiography may be coupled with these hemodynamic measurements. The indications developed below relate to appropriateness of the right and left heart catheterization. A decision about the performance of coronary angiography should be at the discretion of the operator and the patient’s primary physician.
        • 3.
          Right Heart Catheterization
          In several clinical situations, the performance of right heart catheterization (hemodynamics and cardiac output) alone is used. This can be performed in the cardiac catheterization laboratory.

      8. Diagnostic Catheterization Appropriate Use Criteria (By Appropriate Use Rating)

      Table 5Uncertain indications (median score 4–6)
      AV, Atrioventricular; CABG, coronary bypass grafting surgery; CAD, coronary artery disease; CHD, coronary heart disease; CMR, cardiovascular magnetic resonance; Cr, creatinine; CTA, computed tomography angiography; ECG, electrocardiogram; FFR, fractional flow reserve; IVUS, intravascular ultrasound; LBBB, left bundle branch block; LV, left ventricular; LVEF, left ventricular ejection fraction; METS, metabolic equivalents; MI, myocardial infarction; PCI, percutaneous coronary intervention; PET, positron emission tomography; SPECT MPI, single-photon emission computed tomography myocardial perfusion imaging; TTE, transthoracic echocardiography; U, uncertain; VT, ventricular tachycardia.
      Table 6Inappropriate indications (median score 1–3)
      AV, atrioventricular; CABG, coronary bypass grafting surgery; CAD, coronary artery disease; CHD, coronary heart disease; CMR, cardiovascular magnetic resonance; Cr, creatinine; CTA, computed tomography angiography; ECG, electrocardiogram; FFR, fractional flow reserve; I, inappropriate; IVUS, intravascular ultrasound; METS, metabolic equivalents; MI, myocardial infarction; PCI, percutaneous coronary intervention; PET, positron emission tomography; SPECT MPI, single-photon emission computed tomography myocardial perfusion imaging.

      9. Figures

      Figure thumbnail gr1
      Figure 1Suspected CAD: No prior noninvasive stress imaging. A, Appropriate; CAD, coronary artery disease; I, inappropriate; U, uncertain.
      Figure thumbnail gr2
      Figure 2Suspected CAD: Prior noninvasive stress testing. Indications 22 to 27 not covered in figure. CAD, Coronary artery disease; ECG, electrocardiography.
      Figure thumbnail gr3
      Figure 3Suspected CAD: Prior noninvasive cardiac CT (calcium score and CTA). ∗Coronary calcium score only rated for asymptomatic patients as these patients are the population in which it is used. CT, Computed tomography; CTA, computed tomography angiography.
      Figure thumbnail gr4
      Figure 4Patients with known obstructive CAD. CAD, Coronary artery disease; PCI, percutaneous coronary intervention.
      Figure thumbnail gr5
      Figure 5Evaluation of arrhythmias. Indication 63 for newly diagnosed LBBB is not represented in this figure and was rated as “uncertain.” CHD, Coronary heart disease; LBBB, left bundle branch block; LV, left ventricular; NI, noninvasive; VF, ventricular fibrillation; VT, ventricular tachycardia.
      Figure thumbnail gr6
      Figure 6Preoperative coronary evaluation: Patients with no prior noninvasive stress testing. METS, Metabolic equivalents.
      Figure thumbnail gr7
      Figure 7Evaluation of valvular disease. Preoperative assessment before valvular surgery is not represented in this figure and is rated “appropriate.” ∗Indication 90 for acute moderate or severe mitral or aortic regurgitation is not represented in this figure. Rating for concordant imaging is “uncertain” and conflicting imaging is “appropriate.” NI, Noninvasive.

      10. Discussion

      Diagnostic cardiac catheterization incorporates both imaging and hemodynamic procedures aimed at providing information to document specific cardiovascular disease states as well as help care for and improve the health of patients with known or suspected heart disease. The AUC are meant to provide guidance concerning the rational and timely use of diagnostic cardiac catheterization and coronary angiography. The current document provides an evaluation of many of the indications commonly considered in clinical practice. The writing group felt that review of the recommendations by general procedures and indications would be of the highest utility to clinical practice.

      10.1 Assessment for CAD

      Several sets of indications were rated regarding the use of invasive coronary angiography for the evaluation of CAD. The writing group felt that the decision to include left heart catheterization, left ventriculography, and perhaps other invasive procedures with coronary angiography should be at the discretion of the operator, depending on the clinical situation, the presence or absence of noninvasive assessments of LV function and pulmonary pressures, and the perceived accuracy of these noninvasive results.
      In general, these indications were grouped by the clinical suspicion for acute coronary syndromes, suspected or known obstructive CAD, use of adjunctive invasive diagnostic technologies, evaluation of arrhythmias, and preoperative evaluation. Although these scenarios represented many common clinical indications for the evaluation of CAD, the writing group acknowledges that this is not comprehensive and thus there are likely clinical scenarios encountered in practice that are not rated in this document. Nevertheless, review of these scenarios should provide clinicians guidance on the use of coronary angiography.
      Overall, patients with definite or suspected acute coronary syndromes were rated as appropriate for coronary angiography. These ratings reflect the current management and risk stratification of patients with acute coronary syndrome (ACS), which usually involves defining the presence, location, and degree of coronary stenosis and is based on abundant clinical studies on the management of ACS patients that used coronary angiography. Alternatively, in patients without known CAD, referral directly for coronary angiography for the suspicion of obstructive disease was felt to be appropriate only in symptomatic patients with a high pretest probability. The remaining patients (asymptomatic patients and symptomatic patients with low or intermediate pretest probability) were felt to be uncertain or inappropriate for a management strategy that used coronary angiography as the initial diagnostic test.
      In patients with prior noninvasive testing, coronary angiography was rated inappropriate for asymptomatic patients with low-risk findings. Symptomatic patients with intermediate- or high-risk findings or equivocal/discordant noninvasive findings were rated appropriate for coronary angiography. Coronary calcium scores, regardless of severity, were rated as inappropriate indications for invasive coronary angiography in asymptomatic patients. The technical panel was not asked to rate calcium scores in symptomatic patients as this test is usually only performed in asymptomatic patients to assess risk. For patients with known CAD, asymptomatic patients following revascularization and medically managed patients with stable symptoms and low-risk noninvasive test findings were rated inappropriate in general for coronary angiography, whereas patients with high-risk noninvasive findings or those with limiting or worsening symptoms were rated as appropriate.
      Several clinical scenarios related to the use of coronary angiography in the evaluation of certain cardiac arrhythmias were developed. Coronary angiography was rated as appropriate for patients resuscitated after cardiac arrest (assuming return of reasonable neurologic function) and for those with sustained VT regardless of symptoms. The other scenarios developed related to syncope, new onset atrial fibrillation/flutter, high-degree atrioventricular block, or new LBBB and were generally inappropriate for patients with a low coronary heart disease (CHD) risk and uncertain with a high CHD risk.
      Scenarios for patients scheduled for noncardiac surgical procedures were also rated. In the preoperative setting for noncardiac surgery, direct catheterization and angiography was not generally considered appropriate unless the patient had significant risk factors or was undergoing transplantation of a solid organ or vascular surgery.

      10.2 Assessment for Conditions Other Than CAD

      Assessment of intracardiac and pulmonary pressures and other testing such as measurement of cardiac output were evaluated primarily in the setting of valvular heart disease, cardiomyopathies, and pulmonary hypertension. In the section on CAD assessment, the scenarios developed considered the use of coronary angiography and considered other procedures during the invasive evaluation (eg, left heart catheterization, left ventriculography) as secondary to the primary purpose of the evaluation and at the discretion of the operator. In a similar format, the scenarios developed in this section rated the use of the hemodynamic evaluations and considered coronary angiography as secondary to the primary purpose of the evaluation and at the discretion of the operator.
      It should be noted that, in general, for patients with planned valvular surgery, preoperative catheterization for coronary anatomy was rated as appropriate. Additionally, in patients with symptomatic and severe valvular heart disease with discordant clinical and noninvasive imaging findings, hemodynamic assessment was rated as appropriate. Specific groups such as those with low transvalvular gradient, depressed LV function or decreased cardiac output were rated as appropriate for further evaluation using hemodynamic studies.
      Patients without symptoms, with mild to moderate stenosis or concordant clinical and noninvasive findings were generally rated as inappropriate for diagnostic catheterization procedures with hemodynamic assessment. Those without symptoms but with severe disease were rated as uncertain. Asymptomatic patients with valvular heart disease were rated based on the noninvasive findings alone since discordance between a clinical impression and noninvasive findings in these patients would not be easily determined. Patients with pulmonary hypertension, either clinically suspected or documented and requiring evaluation for pharmacological therapy, were identified as appropriate for invasive hemodynamic assessment at rest as well as with provocative maneuvers (exercise or pharmacological challenge).
      Specific groups such as those suspected of pericardial disease, intracardiac shunts, tamponade, suspected cardiomyopathy or patients who have received cardiac transplant were rated as appropriate for hemodynamic studies and endomyocardial biopsy.

      10.3 Application of the Criteria

      In their work developing and rating these clinical scenarios, the writing group and technical panel focused on the multiple goals of diagnostic cardiac catheterization and coronary angiography and common clinical scenarios seen in clinical practice. Clinical scenarios and ultimately the ratings of the technical panel were focused on obtaining information from the procedure that should help in the management of patients with suspected or known heart disease including providing needed reassurance about the clinical status of the patient. Additionally, the diagnostic catheterization AUC was written with recognition that these indications would be linked with the coronary revascularization AUC. In fact, the hope of the writing group was to develop a system that would inform patients and clinicians to increase the right patients undergoing appropriate invasive catheterization procedures before discussions and considerations around revascularization.
      With these goals in mind, there are many potential applications for the AUC in this document. Decision support and educational tools should be developed. Ideally, these would translate these ratings into clinical tools used at the point of care to aid clinicians and patients in the decision to perform or undergo an invasive procedure. Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7 are meant to provide some initial algorithms for the overall ratings.
      Facilities and payers may choose to use these criteria, either prospectively in the design of protocols or review procedures, or retrospectively for quality reports. It is hoped that payers would use these criteria to ensure that their members receive necessary, beneficial, and cost-effective cardiovascular care, rather than for other purposes. It is expected that services performed for appropriate and/or uncertain indications will receive reimbursement. In contrast, services performed for inappropriate indications may require additional documentation to justify payment because of the unique circumstances or the clinical profile that may exist in such a patient. This additional documentation should not be required for uncertain indications. It is critical to emphasize that the writing group, technical panel, AUC Task Force, and clinical community do not believe an uncertain rating justifies denial of reimbursement for these invasive procedures. Rather, uncertain ratings are those in which the available data vary and many other factors exist that may affect the decision to perform or not perform cardiac catheterization and coronary angiography. The opinions of the technical panel often varied for these indications, reflecting that additional research is needed. Indications with high clinical volume that are rated as uncertain identify important areas for further research. The writing group and technical panel favor the collaborative interaction between patients, referring clinicians, and cardiologists in determining the need for these invasive procedures.
      When evaluating physician or facility performance, AUC should be used in conjunction with efforts that lead to quality improvement. Prospective preauthorization procedures, if put in place, are most effective once a retrospective review has identified a pattern of potential inappropriate use. Because these criteria are based on current scientific evidence and the deliberations of the technical panel, they should be used prospectively to generate future discussions about reimbursement, but should not be applied retrospectively to cases completed before issuance of this report or documentation of centers/providers performing an unexpectedly high proportion of inappropriate cases as compared with their peers.
      The writing group recognizes that these criteria will be evaluated during routine clinical care. To that end, specific data fields such as symptom status, presence or absence of acute coronary syndrome, history of CAD or revascularization, and type of noninvasive testing and findings will be required to determine individual appropriate use ratings. It is recognized that the characterization of symptoms is inherently subjective, and there is variability in the interpretation of many noninvasive tests. Fundamental to the application of the AUC is the understanding that the characterization of symptoms or interpretation of noninvasive tests is performed in a manner such that independent qualified reviewers would reach the same conclusions or support the conclusions of the individual physician about symptoms or noninvasive test results.
      The primary objective of this report is to provide guidance regarding the use of diagnostic catheterization including coronary angiography, left heart catheterization and left ventriculography, and right heart catheterization for a diverse set of clinical scenarios. As with previous AUC documents, consensus among the raters was desirable, but an attempt to achieve complete agreement within this diverse panel would have been artificial and was not the goal of the process. Two rounds of ratings with substantial discussion among the technical panel members between the ratings did lead to some consensus among panelists. However, further attempts to drive consensus would have diluted true differences in opinion among panelists and, therefore, was not undertaken.
      Future research analyzing patient outcomes for indications rated as appropriate and inappropriate will help ensure the equitable and efficient allocation of resources for cardiac catheterization. Further exploration of the indications rated as “uncertain” will help generate the information required to further define the appropriate use of cardiac catheterization procedures. Additionally, the criteria will need to be updated with the publication of ongoing trials in imaging and revascularization occurs.
      In conclusion, this document represents the current understanding of the clinical utility of diagnostic cardiac catheterization. It is intended to provide a practical guide to clinicians and patients when these procedures.

      Appendix A. Additional Diagnostic Catheterization Definitions

      TIMI Risk Score—For Patients With Suspected ACS

      TIMI Risk Score. Available at: http://www.timi.org. Accessed March 15, 2011.

      :
      Variables (1 point each)
      • Age ≥65 years
      • ≥3 risk factors (hypertension, diabetes mellitus, family history, lipids, smoking)
      • Known CAD (stenosis ≥50%)
      • Aspirin use in past 7 days
      • Severe angina (≥2 episodes within 24 hours)
      • ST-segment deviation ≥0.5 mm
      • Elevated cardiac markers
      Risk of death or ischemic event through 14 days
      • Low: 0 to 2 (<8.3% event rate)
      • Intermediate: 3 to 4 (<19.3% event rate)
      • High: 5 to 7 (41% event rate)
      GRACE ACS Risk Model

      Center for Outcomes Research, University of Massachusetts Medical School. GRACE ACS Risk Model. 2011. Available at: http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html. Accessed May 17, 2011.

      :
      At admission (in-hospital/to 6 months)
      • Age
      • Heart rate
      • Systolic blood pressure mm Hg
      • Creatinine
      • Congestive heart failure Killip class
      • Cardiac arrest at admission
      • ST-segment deviation
      • Elevated cardiac enzymes/markers
      At discharge (to 6 months)
      • Age
      • Heart rate
      • Systolic blood pressure mm Hg
      • Creatinine
      • Congestive heart failure
      • In-hospital PCI
      • In-hospital CABG
      • Past history of myocardial infarction
      • ST-segment depression
      • Elevated cardiac enzymes/markers

      Appendix B. Additional Methods

      Relationships With Industry and Other Entities

      The American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions and its partnering organizations rigorously avoid any actual, perceived, or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the technical panel. Specifically, all panelists were asked to provide disclosure statements of all relationships that might be perceived as real or potential conflicts of interest. These statements were reviewed by the Appropriate Use Criteria Task Force, discussed with all members of the technical panel at the face-to-face meeting, and updated and reviewed as necessary. A table of disclosures by all participants, listed in Appendix C, in the Appropriate Use Criteria for Diagnostic Catheterization can be found in Appendix D. In addition, to ensure complete transparency, complete disclosure information (available online at: http://content.onlinejacc.org/j.jacc.2012.03.003/DC1)—including relationships not pertinent to this document—is available online as a document supplement.

      Literature Review

      The technical panel members were asked to refer to the relevant guidelines for a summary of the relevant literature, guideline recommendation tables, and reference lists provided for each indication table when completing their ratings (Online Appendix available at: http://content.onlinejacc.org/j.jacc.2012.03.003/DC2).

      Appendix C. ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate Use Criteria For Diagnostic Catheterization Participants

      Diagnostic Catheterization Writing Group

      Manesh R. Patel, MD, FACC—Co-Chair, Appropriate Use Criteria for Diagnostic Catheterization Writing Group—Assistant Professor of Medicine, Division of Cardiology, Assistant Director, Cardiac Catheterization Lab, Duke University Medical Center, Durham, NC
      Steven R. Bailey, MD, FACC, FSCAI, FAHA—Co-Chair, Appropriate Use Criteria for Diagnostic Catheterization Writing Group—Chair, Division of Cardiology, Professor of Medicine and Radiology, Janey Briscoe Distinguished Chair, University of Texas Health Sciences Center, San Antonio, Tex
      Robert O. Bonow, MD, MACC, MACP, FAHA—Goldberg Distinguished Professor, Director, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Ill
      Charles E. Chambers, MD, FACC, FSCAI—Professor of Medicine and Radiology, Pennsylvania State University; Director, Cardiac Catheterization Laboratories, Milton S. Hershey Medical Center, Hershey, Pa
      Paul S. Chan, MD, MSc—Assistant Professor of Internal Medicine, Saint Luke’s Mid America Heart Institute, Kansas City, Mo
      Gregory J. Dehmer, MD, FACC, FSCAI, FACP, FAHA—Past President, Society for Cardiovascular Angiography and Interventions, Professor of Medicine, Texas A&M School of Medicine; and Director, Cardiology Division, Scott & White Clinic, Temple, Tex
      Ajay J. Kirtane, MD, SM, FACC, FSCAI—Assistant Professor of Clinical Medicine, Chief Academic Officer, Director, Interventional Cardiology Fellowship Program, Center for Interventional Vascular Therapy, Columbia University Medical Center/New York–Presbyterian Hospital, New York, NY
      L. Samuel Wann, MD, MACC—Clinical Professor of Medicine, University of Wisconsin, Madison and Medical College of Wisconsin Milwaukee, Wauwatosa, Wis
      R. Parker Ward, MD, FACC, FASE, FASNC—Associate Professor of Medicine, Director of Cardiovascular Fellowship Program, University of Chicago Medical Center, Chicago, Ill

      Diagnostic Catheterization Technical Panel

      Pamela S. Douglas, MD, MACC, FAHA, FASE—Moderator for the Technical Panel—Past President, American College of Cardiology Foundation; Past President American Society of Echocardiography; and Ursula Geller Professor of Research in Cardiovascular Diseases, Duke University Medical Center, Durham, NC
      Manesh R. Patel, MD, FACC—Writing Group Liaison for the Technical Panel—Chair, Appropriate Use Criteria for Coronary Revascularization Writing Group—Assistant Professor of Medicine, Division of Cardiology, Assistant Director, Cardiac Catheterization Lab, Duke University Medical Center, Durham, NC
      Steven R. Bailey, MD, FACC, FSCAI, FAHA—Writing Group Liaison for the Technical Panel—Chair, Division of Cardiology, Professor of Medicine and Radiology, Janey Briscoe Distinguished Chair, University of Texas Health Sciences Center, San Antonio, Tex
      Philip Altus, MD, MACP—Professor Emeritus, Department of Internal Medicine, University of South Florida, Tampa, Fla
      Denise D. Barnard, MD, FACC—Clinical Professor of Medicine, Division of Cardiology, Advanced Heart Failure Treatment Program, Heart Transplant and Mechanical Circulatory Assist Device Program, University of California, San Diego School of Medicine, Staff Physician, VA Medical Center, San Diego, Calif
      James C. Blankenship, MD, MACC, FSCAI—Director of Cardiology and Cardiac Catheterization Laboratories, Geisinger Medical Center, Danville, Pa
      Donald E. Casey, Jr., MD, MPH, MBA, FACP, FAHA—Vice President of Quality and Chief Medical Officer, Atlantic Health System, Morristown, NJ
      Larry S. Dean, MD, FACC, FAHA, FSCAI—Professor of Medicine and Surgery, University of Washington School of Medicine, Director, UW Medicine Regional Heart Center, Seattle, Wash
      Reza Fazel, MD, MSc, FACC—Assistant Professor of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Ga
      Ian C. Gilchrist, MD, FACC, FSCAI, FCCM—Professor of Medicine, Heart & Vascular Institute, The Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pa
      Clifford J. Kavinsky, MD, PhD, FACC, FSCAI—Professor of Medicine and Pediatrics, Director, Cardiovascular Medicine Fellowship Training Program, Associate Director, Cardiac Critical Care Unit, Section of Cardiology, Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, Ill
      Susan G. Lakoski, MD, MS—Assistant Professor, University of Texas Southwestern, Department of Cardiology, Dallas, Tex
      D. Elizabeth Le, MD, FACC, FASE—Assistant Professor of Medicine, Oregon Health and Science University, Staff Physician, Portland VA Medical Center, Portland, Ore
      John R. Lesser, MD, FACC, FSCAI, FSCCT—Director of Cardiovascular MRI and CT, Minneapolis Heart Institute, Adjunct Associate Professor of Medicine, University of Minnesota, Minneapolis, Minn
      Glenn N. Levine, MD, FACC, FAHA—Professor of Medicine, Baylor College of Medicine, Director, Cardiac Care Unit, Michael E. DeBakey Medical Center, Pearland, Tex
      Roxana Mehran, MD, FACC, FACP, FCCP, FESC, FAHA, FSCAI—Professor of Medicine and Health Policy, Director of Interventional Cardiovascular Research and Clinical Trials at the Zena and Michael A. Weiner Cardiovascular Institute at Mount Sinai School of Medicine, New York, NY
      Andrea M. Russo, MD, FACC, FHRS—Director, Cardiac Electrophysiology and Arrhythmia Services, Cooper University Hospital, Professor of Medicine, University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School/Cooper Medical School of Rowan University, Camden, NJ
      Matthew J. Sorrentino, MD, FACC—Professor of Medicine, University of Chicago Pritzer School of Medicine, Chicago, Ill
      Mathew R. Williams, MD, FACC—Assistant Professor of Surgery (in Medicine), Columbia University College of Physicians and Surgeons, Surgical Director, Cardiovascular Transcatheter Therapies, New York–Presbyterian Hospital, Columbia University Medical Center, New York, NY
      John B. Wong, MD, FACP—Professor of Medicine, Chief, Division of Clinical Decision Making, Informatics, and Telemedicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Mass

      External Reviewers of the Appropriate Use Criteria Indications

      Stephan Achenbach, MD—Professor of Medicine, Department of Cardiology, University of Giessen, Germany
      Suhail Q. Allaqaband, MD, FACC, FCCP, FSCAI—Clinical Associate Professor of Medicine, University of Wisconsin School of Medicine and Public Health, Director, Clinical Cardiovascular Research, Aurora Health Care, Department of Cardiology, Milwaukee, Wis
      Jeffrey L. Anderson, MD, FACC—Associate Chief of Cardiology, Intermountain Medical Center, Professor of Medicine, University of Utah, Murray, Utah
      Joshua N. Baker, MD—Surgeon, Massachusetts General Hospital, Boston, Mass
      Victor Y. Cheng, MD, FACC—Staff Cardiologist, Cedars-Sinai Heart Institute; Assistant Clinical Professor, University of California, Los Angeles, Calif
      Mauricio G. Cohen, MD, FACC, FSCAI—Associate Professor of Medicine, University of Miami Miller School of Medicine, Director, Cardiac Catheterization Laboratory, University of Miami Hospital, Miami, Fla
      Michael J. Davidson, MD—Assistant Professor of Surgery, Brigham & Women’s Hospital, Division of Cardiology, Boston, Mass
      Joseph J. DeRose, Jr, MD—Chief, Adult Cardiac Surgery, Einstein-Weiler Division Director, Minimally Invasive and Robotic Cardiac Surgery, Montefiore Medical Center, Associate Professor of Cardiothoracic Surgery Albert Einstein College of Medicine, Bronx, NY
      Rory Hachamovitch, MD, MSc, FACC—Staff Cardiologist, Cleveland Clinic, Cleveland, Ohio
      Clifford J. Kavinsky, MD, PhD, FACC—Professor of Medicine and Pediatrics, Director, Cardiovascular Medicine Fellowship Training Program, Associate Director, Cardiac Critical Care Unit, Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, Ill
      Kevin P. Landolfo, MD, MSc—Professor of Surgery, Chair Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Fla
      Richard A. Lange, MD, MBA, FACC—Professor and Executive Vice Chairman, Department of Medicine, Director, Office of Educational Programs, University of Texas Health Science Center at San Antonio, San Antonio, Tex
      D. Elizabeth Le, MD, FACC, FASE—Assistant Professor of Medicine, Oregon Health and Science University, Staff Physician, Portland VA Medical Center, Portland, Ore
      John R. Lesser, MD, FACC, FAHA, FSCAI, FSCMR, FSCCT—Director of Cardiovascular MRI and CT, Minneapolis Heart Institute, Adjunct Associate Professor of Medicine, University of Minnesota, Minneapolis, Minn
      Sheldon E. Litwin, MD, FACC—Professor and Chief, Cardiology Division, Medical College of Georgia, Georgia Health Sciences University, Augusta, Ga
      John J. Mahmarian, MD, FACC—Medical Director, Nuclear Cardiology and CT Laboratories, Methodist DeBakey Heart and Vascular Center, Houston, Tex
      Rick A. Nishimura, MD, FACC—Judd and Mary Morris Leighton Professor of Medicine, Mayo Clinic, Consultant, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn
      Amit R. Patel, MD, FACC—Assistant Professor of Medicine and Radiology, Co-Director, Cardiac Magnetic Resonance, Co-Director, Cardiac Computed Tomography, University of Chicago Medical Center, Chicago, Ill
      Harry R. Phillips, MD, FACC, FSCAI—Professor of Medicine, Duke University Medical Center, Durham, NC
      Eric E. Roselli, MD—Staff Surgeon, Cleveland Clinic Department of Thoracic and Cardiovascular Surgery, Cleveland, Ohio
      Amit J. Shanker, MD, FACC, FHRS—Director, Center for Advanced Arrhythmia Medicine, Bassett Healthcare Network, Assistant Professor of Medicine, Columbia University College of Physicians and Surgeons, Cooperstown, NY
      Sidney C. Smith, Jr., MD, FACC, FAHA—Professor of Medicine, Director, Center for Cardiovascular Science and Medicine, Chapel Hill, NC
      Jonathan S. Steinberg, MD—Chief, Division of Cardiology, Endowed Director, Al-Sabah Arrhythmia Institute, Professor of Medicine, Columbia University, New York, NY
      Vinod H. Thourani, MD—Associate Professor of Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, Ga
      Thomas M. Tu, MD, FSCAI—Director, Catheterization Laboratory, Baptist Medical Associates, Louisville, Ky
      Jonathan W. Weinsaft, MD, FACC—Associate Professor of Medicine, Greenberg Division of Cardiology, Weill Cornell Medical College, Cardiac MR/CT Imaging Program, New York, NY
      Joseph N. Wight, Jr., MD, FACC—Clinical Assistant Professor, Department of Medicine, Tufts University School of Medicine, Director of Heart Failure, Maine Medical Center, Maine Medical Partners, MaineHealth Cardiology, Portland, Me
      Marco A. Zenati, MD, FETCS—Professor of Surgery, Harvard Medical School, Chief of Cardiac Surgery, VA Boston Health Care System, Associate Surgeon, Brigham & Women’s Hospital, Boston, Mass

      Appropriate Use Criteria Task Force

      Michael J. Wolk, MD, MACC—Chair, Task Force, Past President, American College of Cardiology Foundation and Clinical Professor of Medicine, Weill-Cornell Medical School, New York, NY
      Steven R. Bailey, MD, FACC, FSCAI, FAHA—Chair, Division of Cardiology, Professor of Medicine and Radiology, Janey Briscoe Distinguished Chair, University of Texas Health Sciences Center, San Antonio, Tex
      Pamela S. Douglas, MD, MACC, FAHA, FASE—Past President, American College of Cardiology Foundation; Past President American Society of Echocardiography; and Ursula Geller Professor of Research in Cardiovascular Diseases, Duke University Medical Center, Durham, NC
      Robert C. Hendel, MD, FACC, FAHA, FASNC—Chair, Appropriate Use Criteria for Radionuclide Imaging Writing Group—Director of Cardiac Imaging and Outpatient Services, Division of Cardiology, Miami University School of Medicine, Miami, Fla
      Christopher M. Kramer, MD, FACC, FAHA—Professor of Medicine and Radiology, Director, Cardiovascular Imaging Center, University of Virginia Health System, Charlottesville, Va
      James K. Min, MD, FACC—Director of Cardiac Imaging Research and Co-Director of Cardiac Imaging, Cedars-Sinai Heart Institute, Los Angeles, Calif
      Manesh R. Patel, MD, FACC—Assistant Professor of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC
      Leslee Shaw, PhD, FACC, FASNC—Professor of Medicine, Emory University School of Medicine, Atlanta, Ga
      Raymond F. Stainback, MD, FACC, FASE—Medical Director of Noninvasive Cardiac Imaging, Texas Heart Institute at St. Luke’s Episcopal Hospital; Clinical Associate Professor of Medicine, Baylor College of Medicine, Houston, Tex
      Joseph M. Allen, MA—Director, TRIP (Translating Research Into Practice), American College of Cardiology Foundation, Washington, DC

      Staff

      • American College of Cardiology Foundation
      • William J. Oetgen, MD, MBA, FACC, Senior Vice President, Science and Quality
      • Joseph M. Allen, MA, Director, TRIP (Translating Research Into Practice)
      • Lea Binder, MA, Senior Research Specialist, Appropriate Use Criteria
      • Erin A. Barrett, MPS, Senior Specialist, Science and Clinical Policy

      Appendix D. ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 Appropriate use criteria for diagnostic catheterization writing group, technical panel, indication reviewers, and task force—relationships with industry and other entities (in alphabetical order)

      Tabled 1
      ParticipantConsultantSpeaker’s bureauOwnership/ partnership/ principalResearchInstitutional, organizational, or other financial benefitExpert witness
      Diagnostic Catheterization Appropriate Use Criteria Writing Group
      Manesh R. PatelNoneNoneNoneNoneNoneNone
      Steven R. BaileyNoneNoneNone
      • Palmaz Scientific
      NoneNone
      Robert O. Bonow
      • Edwards Lifesciences
      NoneNoneNoneNoneNone
      Charles E. ChambersNoneNoneNoneNoneNoneNone
      Paul S. ChanNoneNoneNoneNoneNoneNone
      Gregory J. DehmerNoneNoneNoneNoneNoneNone
      Ajay J. KirtaneNoneNoneNoneNoneNoneNone
      L. Samuel WannNoneNoneNoneNoneNoneNone
      R. Parker WardNoneNoneNoneNoneNoneNone
      Diagnostic Catheterization Appropriate Use Criteria Technical Panel
      Pamela S. DouglasNoneNoneNoneNoneNoneNone
      Manesh R. PatelNoneNoneNoneNoneNoneNone
      Steven R. BaileyNoneNoneNone
      • Palmaz Scientific
      NoneNone
      Philip AltusNoneNoneNoneNoneNoneNone
      Denise D. BarnardNoneNoneNoneNoneNoneNone
      James C. BlankenshipNoneNoneNone
      • Boston Scientific
      • Conor Medsystems
      NoneNone
      Donald E. Casey, JrNoneNoneNoneNoneNoneNone
      Larry S. Dean
      • Emageon
      • Philips Medical
      NoneNone
      • Edwards Lifesciences
      NoneNone
      Reza FazelNoneNoneNoneNoneNoneNone
      Ian C. GilchristNone
      • Terumo Medical
      NoneNoneNoneNone
      Clifford J. KavinskyNoneNoneNoneNoneNoneNone
      Susan G. LakoskiNoneNoneNoneNoneNoneNone
      D. Elizabeth LeNoneNoneNoneNoneNoneNone
      John R. LesserNoneNoneNoneNoneNoneNone
      Glenn N. LevineNoneNoneNoneNoneNoneNone
      Roxana Mehran
      • Johnson & Johnson
      NoneNoneNoneNoneNone
      Andrea M. RussoNone
      • Boston Scientific
      NoneNoneNoneNone
      Matthew J. SorrentinoNoneNoneNoneNoneNoneNone
      Mathew R. Williams
      • Abbott
      • Edwards Lifesciences
      • Medtronic
      NoneNoneNoneNoneNone
      John B. WongNoneNoneNoneNoneNoneNone
      Diagnostic Catheterization Appropriate Use Criteria Indication Reviewers
      Stephan Achenbach
      • Siemens
      NoneNone
      • Siemens∗
      NoneNone
      Suhail Q. AllaqabandNoneNoneNoneNoneNoneNone
      Jeffrey L. AndersonNoneNoneNone
      • Toshiba
      NoneNone
      Joshua N. BakerNoneNoneNoneNoneNoneNone
      Victor Y. ChengNoneNoneNoneNoneNoneNone
      Mauricio G. Cohen
      • Medtronic
      • Terumo Medical
      NoneNoneNoneNone
      Michael J. DavidsonNoneNoneNoneNoneNoneNone
      Joseph J. DeRose, JrNoneNoneNoneNoneNoneNone
      Rory HachamovitchNoneNoneNoneNoneNoneNone
      Clifford J. KavinskyNoneNoneNoneNoneNoneNone
      Kevin P. LandolfoNoneNoneNoneNoneNoneNone
      Richard A. LangeNoneNoneNoneNoneNoneNone
      D. Elizabeth LeNoneNoneNoneNoneNoneNone
      John R. LesserNoneNoneNoneNoneNoneNone
      Sheldon E. LitwinNoneNoneNoneNoneNoneNone
      John J. Mahmarian
      • GE Healthcare
      NoneNoneNoneNoneNone
      Rick A. NishimuraNoneNoneNoneNoneNoneNone
      Amit R. PatelNoneNoneNoneNoneNoneNone
      Harry R. Phillips
      • Abbott Vascular∗
      NoneNoneNoneNoneNone
      Eric E. RoselliNoneNoneNoneNoneNoneNone
      Amit J. ShankerNoneNoneNoneNoneNoneNone
      Sidney C. Smith, JrNoneNoneNoneNoneNoneNone
      Jonathan S. SteinbergNoneNoneNoneNoneNoneNone
      Vinod H. Thourani
      • Edwards Lifesciences
      • Medtronic
      • Sorin
      • St. Jude Medical
      NoneNoneNoneNoneNone
      Thomas TuNoneNone
      • Abbott Vascular
      • Cordis
      NoneNoneNone
      Jonathan W. WeinsaftNoneNoneNoneNoneNoneNone
      Joseph N. Wight, Jr.NoneNoneNoneNoneNoneNone
      Marco ZenatiNoneNoneNoneNoneNoneNone
      Appropriate Use Criteria Task Force
      Michael J. WolkNoneNoneNoneNoneNoneNone
      Steven R. BaileyNoneNoneNone
      • Palmaz Scientific
      NoneNone
      Pamela S. DouglasNoneNoneNoneNoneNoneNone
      Robert C. HendelNoneNoneNoneNoneNoneNone
      Christopher M. Kramer
      • St. Jude Medical
      NoneNone
      • Siemens∗
      NoneNone
      James K. MinNone
      • GE Healthcare
      NoneNoneNoneNone
      Manesh R. PatelNoneNoneNoneNoneNoneNone
      Leslee ShawNoneNoneNoneNoneNoneNone
      Raymond F. StainbackNoneNoneNoneNoneNoneNone
      Joseph M. AllenNoneNoneNoneNoneNoneNone
      This table represents the relevant relationships with industry and other entities that were disclosed by participants at the time of participation. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review. Participation does not imply endorsement of this document. ∗Significant relationship.

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