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Appropriate Use of Cardiac Imaging: A Multidisciplinary Mandate

  • Robert C. Hendel
    Correspondence
    Requests for reprints should be addressed to Robert C. Hendel, MD, 1430 Tulane Avenue, Suite 7550 New Orleans, LA, 70112.
    Affiliations
    Sidney W. and Marilyn S. Lassen Chair in Cardiovascular Medicine Professor of Medicine and Radiology, School of Medicine, Tulane University, New Orleans, La
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      To the Editor:
      I read the recent review article regarding imaging for the evaluation of chest pain by Dr Bader et al
      • Bader AS
      • Rubinowitz AN
      • Gange CP
      • et al.
      Imaging in the evaluation of chest pain in the primary care setting, part one: cardiovascular etiologies.
      with great interest. As an imaging cardiologist, I firmly believe that our specialty (cardiology) can also provide important information and ideas related to cardiac imaging. However, the focus of this article was exclusively from the perspective of a radiologist.
      The authors failed to acknowledge the development of appropriate use criteria (AUC) developed by the American College of Cardiology (ACC). The methodology behind the ACC's version of AUC is more intricate and literature-based than that from the American College of Radiology (ACR), based on my experience of having served on rating panels for both organizations.
      • Hendel RC
      • Lindsay BD
      • Allen JM
      • et al.
      ACC appropriate use criteria methodology: 2018 update: a report of the American College of Cardiology Appropriate Use Criteria Task Force.
      It is also worth noting that there has been a joint effort between the ACR and ACC that resulted in defining AUC for acute chest pain.
      • Rybicki FJ
      • Udelson JE
      • Peacock WF
      • et al.
      2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force.
      One of the key differences between these different sets of criteria is that the ACC's version does not seek to determine the “best noninvasive imaging test,” which is stated to be a chest x-ray in the ACR appropriateness criteria.
      • Earls JP
      • White RD
      • Woodard PK
      • et al.
      ACR Appropriateness Criteria® chronic chest pain-high probability of coronary artery disease.
      The ACC instead focused on describing which tests would be categorized as “reasonable,” allowing for individual patient factors, as well as local availability and expertise.
      • Hendel RC
      • Lindsay BD
      • Allen JM
      • et al.
      ACC appropriate use criteria methodology: 2018 update: a report of the American College of Cardiology Appropriate Use Criteria Task Force.
      However, the ACR's focus on noncardiac etiologies for chest pain is worthwhile and well-stated in the Bader publication. I also appreciated the summary of recent evidence regarding the use of computed tomography (CT) coronary angiography.
      The appropriate use of cardiovascular imaging is critical to the optimization of patient care and preservation of access to technology. However, it also emphasizes the need for a consciousness of cost, which is part of our responsibility in providing cost-effective care. Patients, as well as the imaging community, are best served by collaboration among medical specialties, as opposed to competition. Qualified individuals from either radiology or cardiology may offer excellent patient care and permit further expansion of the field of cardiovascular imaging. This is especially important with regard to research initiatives. Additionally, efforts to provide reasonable reimbursement and the reduction of administrative burdens are most effective when the cardiology and radiology communities may speak with a single voice.

      References

        • Bader AS
        • Rubinowitz AN
        • Gange CP
        • et al.
        Imaging in the evaluation of chest pain in the primary care setting, part one: cardiovascular etiologies.
        Am J Med. 2020; 133: 1033-1038
        • Hendel RC
        • Lindsay BD
        • Allen JM
        • et al.
        ACC appropriate use criteria methodology: 2018 update: a report of the American College of Cardiology Appropriate Use Criteria Task Force.
        J Am Coll Cardiol. 2018; 71: 935-948
        • Rybicki FJ
        • Udelson JE
        • Peacock WF
        • et al.
        2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force.
        J Am Coll Cardiol. 2016; 67: 853-879
        • Earls JP
        • White RD
        • Woodard PK
        • et al.
        ACR Appropriateness Criteria® chronic chest pain-high probability of coronary artery disease.
        J Am Coll Radiol. 2011; 8: 679-686