ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 …

1 appropriate USE CRITERIAACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SC MR/SOPE2014 appropriate Use criteria forInitial Transthoracic Echocardiographyin Outpatient Pediatric CardiologyA Report of the American College of Cardiology appropriate Use criteria Task Force,American Academy of Pediatrics, American Heart Association, American Society ofEchocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography andInterventions, Society of Cardiovascular Computed Tomography, Society for CardiovascularMagnetic Resonance, and Society of Pediatric EchocardiographyQ1 Writing Group forEchocardiographyin OutpatientPediatricCardiologyRobert M. Campbell, MD, FACC, FAHA, FAAP, FHRS,ChairPamela S. Douglas, MD, MACC, FAHA, FASEB enjamin W. Eidem, MD, FACC, FASEW yman W. Lai, MD, MPH, FACC, FASELeo Lopez, MD, FACC, FAAP, FASERitu Sachdeva, MD, FACC, FAAP, FASER ating PanelRobert M. Campbell, MD, FACC, FAHA, FAAP, FHRS,Chair*Pamela S.

2 Douglas, MD, MACC, FAHA, FASE,Moderator*Louis I. Bezold, MD, FACC, FAAP, FASEyWilliam B. Blanchard, MD, FACC, FAHA, FAAP*Jeffrey R. Boris, MD, FACC*Bryan Cannon, MDzGregory J. Ensing, MD, FACC, FASExCraig E. Fleishman, MD, FACC, FASEjjMark A. Fogel, MD, FACC, FAHA, FAAP{B. Kelly Han, MD, FACC#Shabnam Jain, MD, MPH, FAAP*Mark B. Lewin, MDjjRichard Lockwood, MD**G. Paul Matherne, MD, MBA, FACC, FAHAyyDavid Nykanen, MD, FACCzzCatherine L. Webb, MD, FACC, FAHA, FASEyyRobert Wiskind, MD, FAAP**American College of Cardiology Academy ofPediatrics Rhythm Society Society of Echocardiography ofPediatric Echocardiography representative.{Society for CardiovascularMagnetic Resonance representative. #Society of Cardiovascular ComputedTomography representative. **Health Plan Association for CardiovascularAngiography and Interventions document was approved by the American College of Cardiology Board of Trustees in June American College of Cardiology requests that this document be cited as follows:Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R.}}

3 ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteriafor initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology appropriate Use CriteriaTask Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society forCardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, andSociety of Pediatric Echocardiography. J Am Coll Cardiol 2014; document is copublished in theJournal of the American Society of : This document is available on the World Wide Web site of the American College of Cardiology ( ). For copies of this document,please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, Modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of theAmerican College of OF THE AMERICAN COLLEGE OF , ,2014 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATIONISSN 0735-1097/$ BY ELSEVIER JAC20491_proof 12 September 2014 3:25 pm ce12345678910111213141516171819202122232 4252627282930313233343536373839404142434 4454647484950515253545556575859606162636 4656667686970717273747576777879808182838 4858687888990919293949596979899100101102 103104105106107108 AppropriateUse CriteriaTask ForceManesh R.

4 Patel, MD, FACC,ChairChristopher M. Kramer, MD, FACC, FAHA,Co-ChairSteven R. Bailey, MD, FACC, FAHA, FSCAIAlan S. Brown, MD, FACCJohn U. Doherty, MD, FACC, FAHAP amela S. Douglas, MD, MACC, FAHA, FASER obert C. Hendel, MD, FACC, FAHA, FASNCB ruce D. Lindsay, MD, FACCL eslee J. Shaw, PhD, FACC, FASNC, FAHAL. Samuel Wann, MD, MACCJ oseph M. Allen, MATABLE OF 1. AUC Development GENERAL 2. Factors Influencing Outcomesof an Imaging TRANSTHORACIC ECHOCARDIOGRAPHY INOUTPATIENT PEDIATRIC CARDIOLOGY: appropriate USE criteria (BY INDICATION)..XXTable 1. Palpitations and 2. 3. Chest 4. 5. Other Symptoms and 6. Prior Test 7. Systemic 8. Family History of Cardiovascular Disease inPatients Without Signs or Symptoms and WithoutConfirmed Cardiac 9. Outpatient Neonates Without Post-NatalCardiology FLOW DIAGRAMS FOR COMMONPATIENT 3. Chest 4. 5. Palpitaions and 6. and and with the Adult Cardiology of AUC to Improve AAppropriate Use criteria for Initial TransthoracicEchocardiography in Outpatient Pediatric BRelationships With Industry (RWI) andOther American College of Cardiology (ACC) participated ina joint project with the American Society of Echocardi-ography, the Society of Pediatric Echocardiography, andseveral other subspecialty societies and organizations toestablish and evaluate appropriate Use criteria (AUC) forthe initial use of outpatient pediatric for the AUC were identified, including thefact that all indications assumed afirst-time transthoracicechocardiographic study in an outpatient setting for pa-tients without previously known heart disease.

5 The defi-nitions for frequently used terminology in outpatientpediatric cardiology were established using publishedguidelines and standards and expert opinion. These AUCserve as a guide to help clinicians in the care of childrenwith possible heart disease, specifically in terms of whena transthoracic echocardiogram is warranted as an initialdiagnostic modality in the outpatient setting. They , ,2014 AUC for Pediatric Echocardiography-,2014:- JAC20491_proof 12 September 2014 3:25 pm ce10911011111211311411511611711811912012 1122123124125126127128129130131132133134 1351361371381391401411421431441451461471 4814915015115215315415515615715815916016 1162163164165166167168169170171172173174 1751761771781791801811821831841851861871 8818919019119219319419519619719819920020 1202203204205206207208209210211212213214 215216infrastructure for future quality improvement initiativesas well as research in healthcare delivery, outcomes, andresource complete the AUC process, the writing group iden-tified 113 indications based on common clinical scenariosand/or published clinical practice guidelines, and eachindication was classified into 1 of 9 categories of commonclinical presentations, including palpitations, syncope,chest pain, and murmur.

6 A separate, independent ratingpanel evaluated each indication using a scoring scale of 1to 9, thereby designating each indication as appropriate (median score 7 to 9), May Be appropriate (medianscore 4 to 6), or Rarely appropriate (median score 1 to3). Fifty-three indications were identified as appropriate ,28 as May Be appropriate , and 32 as Rarely an effort to respond to the need for the rational use ofservices in the delivery of high quality care, the ACC hasundertaken a process to determine the appropriate use ofcardiovascular imaging and procedures for selected pa-tient publications reflect an ongoing effort by the ACCto critically and systematically create, review, and cate-gorize clinical situations where diagnostic tests and pro-cedures are utilized by physicians caring for patients withknown or suspected cardiovascular diseases. The processis based on current understanding of the technical capa-bilities of the imaging modalities and procedures exam-ined.

7 Although not intended to be entirely comprehensivedue to the wide diversity of clinical disease, the in-dications are meant to identify common scenariosencountered by the majority of contemporary the breadth of information they convey, the in-dications do not directly correspond to the InternationalClassification of Diseases (ICD) ACC believes that careful blending of a broad rangeof clinical experiences and available evidence-based infor-mation will help guide a more efficient and equitable allo-cation of health care resources in cardiovascular ultimate objective of AUC is to improve patient careand health outcomes in a cost-effective manner, but theyare not intended to ignore ambiguity and nuance intrinsicto clinical decision-making. Local parameters, such as theavailability or quality of equipment or personnel, may in-fluence the selection of certain tests or procedures. AUCthus should not be considered substitutes for sound clinicaljudgment and practice INTRODUCTIONI mprovements in cardiovascular imaging technologiesand their application, particularly with increasing thera-peutic options for cardiovascular disease, have led to anincrease in the utilization of such technologies.

8 As theseimaging technologies and clinical applications continue toadvance, the healthcare community needs to understandhow best to incorporate these options into daily clinicalcare and how to choose between new and long-standing,established imaging technologies. In an effort to res-pond to this need and to ensure the effective use ofadvanced diagnostic imaging tools and procedures, theAUC project was initiated. The AUC in this document havebeen developed in order to promote effective patientcare, better clinical outcomes, and improved resourceutilization. This set of AUC should be useful not only forpediatric cardiologists, but also for general pediatriciansand family practitioners, who are frequently thefirst cli-nicians to consider the need for this AUC have been established for echocardiog-raphy in adult patients(1 3), a similar document for pe-diatric patients has not yet been published. This is partlybecause the scope of such a document would require animpossibly extensive list, if criteria were developed foreach congenital cardiac malformation and its variantsbefore and after intervention.

9 Guidelines and standardsfor performing a pediatric echocardiogram, as well asrecommendations for quantification methods, havealready been published(4,5). However, the questionsoften raised by AUC of when to do and how often todo a pediatric echocardiogram still address these concerns, the American College ofCardiology initiated an AUC document on pediatricechocardiography in the outpatient setting, since outpa-tient care is an important component of clinical pediatriccardiology. Children with heart disease represent a widelyvaried group of patients, frequently characterized bycomplex anatomic malformations requiring lifelongfollow-up. While echocardiography is the primary diag-nostic modality for children with established congenitaland acquired heart disease, the scope of the currentdocument has been limited tofirst-time outpatienttransthoracic echocardiographic studies in patientswithout previously known cardiac abnormalities.

10 Thisnarrower set of clinical presentations has been chosenbecause of the high volume of such testing within pedi-atric cardiology. In addition, this initiative has establishedthe infrastructure to develop additional AUC for pediatricand congenital echocardiography in other METHODSThis document covers a wide array of potential signsand symptoms associated with cardiovascular disease inpediatric patients. A standardized approach was used tocreate different categories ofindications with the goal ofcapturing actual clinical scenarios, without making the listof indications excessively long. Indications were createdJACC , , ,2014:- -AUC for Pediatric JAC20491_proof 12 September 2014 3:25 pm ce21721821922022122222322422522622722822 9230231232233234235236237238239240241242 2432442452462472482492502512522532542552 5625725825926026126226326426526626726826 9270271272273274275276277278279280281282 2832842852862872882892902912922932942952 9629729829930030130230330430530630730830 9310311312313314315316317318319320321322 323324to represent most of the possible uses of echocardiographyin the outpatient pediatric setting rather than limiting theAUC to indications for which evidence was identify and categorize the indications, a writinggroup of pediatric echocardiography experts was formedof representatives from a variety of organizations andsocieties.