According to the ACCF, AHA, and others, Multimodality AUC are not intended to be used as a substitute for sound clinical judgment and practice experience, as the selection of appropriate imaging procedures may be influenced by local parameters. The ultimate objective of the Multimodality AUC is to improve patient care and health outcomes in a cost-effective manner.7

7 Modalities Included in the Multimodality AUC

1

Exercise electrocardiogram (ECG)7

2

Stress radionuclide imaging (SPECT; PET)7

Part of the Medicare AUC program9
SPECT = single-photon emission computed tomography.

SPECT images on left courtesy of Kim Allan Williams, MD; PET images on right courtesy of W. A. Jaber, MD.

3

Stress echocardiography (echo)7

Image courtesy of H. C. Lewin, MD.

4

Stress cardiovascular magnetic resonance (CMR) imaging7

Part of the Medicare AUC program9

Image courtesy of D. H. Kwon, MD.

5

Coronary artery calcium (CAC) scoring7

Image courtesy of H. C. Lewin, MD.

6

Coronary computed tomography angiography (CCTA)7

Part of the Medicare AUC program9

Image courtesy of H. C. Lewin, MD.

7

Invasive coronary angiography7

Image courtesy of D. Wolinsky, MD.

Multimodality AUC Appropriateness Ratings

The Multimodality AUC rate each imaging test by appropriateness for each indication based on technical capabilities, evidence, and clinical experience. When you use AUC, you'll get 1 of 3 ratings: appropriate, may be appropriate, or rarely appropriate.7

Appropriate
  • Benefits generally outweigh risks
  • Generally an effective option
  • Dependent on physician judgment and patient-specific preferences
May Be
Appropriate
  • Variable evidence regarding the risk-benefit ratio
  • Potentially an effective option
  • Dependent on clinical variables, physician judgment, and patient preferences
Rarely
Appropriate
  • Lack of evidence that benefits clearly outweigh risks
  • Rarely an effective option
  • Exceptions should have documentation of clinical reasons

Applying the Multimodality AUC

Let's look at how the Multimodality AUC might be used. Each example below highlights the applicable row from the Multimodality AUC tables. (Highlighting is for illustrative purposes only; it does not appear in the original.)

Hypothetical Patient #1 Indication:

The patient presented with exertional chest pain. The ECG was not interpretable, and after evaluation, it was determined that the patient had an intermediate pretest probability of CAD. What do you do?

Table 1.1. Symptomatic
Table 1.1

Appropriate Use Key: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate. CAD = coronary artery disease; CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; Echo = echocardiography; RNI = radionuclide imaging.

Hypothetical Patient #2 Indication:

The patient has a strong family history of heart disease but does not present with symptoms herself. Upon evaluation, it is determined she has an intermediate pretest probability of CAD, but she had a hip replacement 3 weeks ago. What do you do?

Table 1.2. Asymptomatic (Without Symptoms or Ischemic Equivalent)
Table 1.2

Appropriate Use Key: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate. CAD = coronary artery disease; CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; Echo = echocardiography; RNI = radionuclide imaging.

Hypothetical Patient #3 Indication:

The patient showed normal results with an exercise ECG a year ago. However, now he complains of feeling winded after walking up the 2 flights of stairs to his apartment. What do you do?

Table 2.3. Follow-up Testing: New or Worsening Symptoms
Table 2.3

Appropriate Use Key: A = Appropriate; M = May Be Appropriate; R = Rarely Appropriate. CAD = coronary artery disease; CCTA = coronary computed tomography angiography; CMR = cardiac magnetic resonance; ECG = electrocardiogram; Echo = echocardiography; RNI = radionuclide imaging.

For patients who may have more than 1 clinical indication, there is a flowchart that places indications into a hierarchy to help stratify test appropriateness.7

View a printable PDF of this flowchart to view the hierarchy of indications for ordering appropriate tests.

Download

"An appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequencesa by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication."7
From the ACCF/AHA Multimodality AUC.

aNegative consequences of cardiovascular imaging include the risks of the procedure (ie, radiation or contrast exposure) and the downstream impact of poor test performance, such as delay in diagnosis (false negatives) or inappropriate diagnosis (false positives).

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