Appropriate Use Criteria Advise on Multimodality Imaging Before Noncardiac Surgery

The American College of Cardiology (ACC), together with nine other professional societies, has released new appropriate use criteria (AUC) for a range of cardiovascular imaging modalities. The hope, their creators say, is to eliminate wasteful tests and ensure that patients receive the proper clearance before nonemergent noncardiac surgeries.

Decisions around which imaging to use—or forgo—to pass a cardiovascular examination have been largely left to physician or hospital preference.

A wide variety of clinicians encounter patients before they undergo surgery, all with the motivation to prevent complications, writing committee chair John U. Doherty, MD (Thomas Jefferson University Hospital, Philadelphia, PA), told TCTMD.

“When serious complications occur, they are often of a cardiac nature,” he said, adding that choices over which presurgical tests to perform can miss the mark. “Sometimes you have no testing done when testing should have been done in order to better determine what the risk was for that patient. And sometimes there's kind of a shotgun approach where testing is done in a situation where it may not really be of benefit.”

Because these tests can often be expensive, justification for them should be well documented and consistent, Doherty said. On top of this, he added, false positives can lead to unnecessary downstream testing.

The general bottom line was a patient that is low risk undergoing low-risk surgery almost never needs to have these things done. John U. Doherty

In the document, published online today in the Journal of the American College of Cardiology, Doherty and colleagues lay out the appropriateness of 11 imaging modalities, including transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), stress tests, MRI, CT, and invasive coronary angiography, among others. Clinical scenarios are broken down into patients with no known or suspected heart disease and those with disease broken further into those with and without prior testing.

Relatively low-risk surgeries like ophthalmologic or dermatologic procedures generally only require local anesthesia will require different evaluation than something like a kidney or liver transplant, Doherty said. But other situations might not be as obvious. Characteristics like the patient’s exercise capacity, which might denote underlying heart disease, can also affect how the patient should be evaluated.

“You might have a lower threshold to do a stress test in somebody with a diminished functional status than in that same patient if they’re able to walk a mile,” he explained.

Each clinical scenario included in the AUC received a rating from 1 to 9, with higher numbers meaning imaging should be performed. The panel broke their recommendations down into three subcategories: appropriate (7-9), maybe appropriate (4-6), and rarely appropriate (1-3).

“The general bottom line was a patient that is low risk undergoing low-risk surgery almost never needs to have these things done,” Doherty said. “Whereas [for] the patient that has underlying heart disease and/or suspicion of heart disease or has a limited functional status, or they've had previous testing that has shown that they may have some cardiac issues underlying, then there was a gradient of risk as the severity of the surgery increased.”

One of the more controversial areas covered by the document includes imaging before solid organ transplant, particularly kidney transplant where the need for routine coronary testing has previously been questioned, according to Doherty.

While he hopes clinicians will use the document in their practice, Doherty said he also would like insurers to align their reimbursement policies with it so that “hopefully we can do the right test for the right patient under the right circumstances and do so in a responsible and a cost-effective way.”

The AUC were co-sponsored by the American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. The rating panel was comprised of surgeons, anesthesiologists, general cardiologists, as well as cardiac imaging specialists.

Back in 2022, the European Society of Cardiology published guidelines in this area with a similar goal of identifying patients with unknown heart disease before they go under the knife.