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PRACTICE GUIDELINE Cardiac CT / 1 The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review and approval. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized. Revised 2011 (Resolution 38)* ACR–NASCI–SPR PRACTICE GUIDELINE FOR THE PERFORMANCE AND INTERPRETATION OF CARDIAC COMPUTED TOMOGRAPHY (CT) PREAMBLE These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from these guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective. I. INTRODUCTION This guideline was revised collaboratively by the American College of Radiology (ACR), the North American Society of Cardiovascular Imaging (NASCI), and the Society for Pediatric Radiology (SPR). Cardiac computed tomography (CT) is an evolving modality that in addition to evaluating the anatomy and pathology of the pericardium and cardiac chambers can assess the central great vessels and the function of the heart, including the cardiac valves [1-8]. CT is a proven and useful procedure for detecting and characterizing cardiac and pericardial disorders, such as masses and pericardial fluid. With the development of multidetector CT (MDCT) scanners and improving technology, CT can also assess the coronary arteries and veins and can evaluate

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  • PRACTICE GUIDELINE Cardiac CT / 1

    The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review and approval. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized.

    Revised 2011 (Resolution 38)* ACRNASCISPR PRACTICE GUIDELINE FOR THE PERFORMANCE AND INTERPRETATION OF CARDIAC COMPUTED TOMOGRAPHY (CT) PREAMBLE These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from these guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective. I. INTRODUCTION This guideline was revised collaboratively by the American College of Radiology (ACR), the North American Society of Cardiovascular Imaging (NASCI), and the Society for Pediatric Radiology (SPR). Cardiac computed tomography (CT) is an evolving modality that in addition to evaluating the anatomy and pathology of the pericardium and cardiac chambers can assess the central great vessels and the function of the heart, including the cardiac valves [1-8]. CT is a proven and useful procedure for detecting and characterizing cardiac and pericardial disorders, such as masses and pericardial fluid. With the development of multidetector CT (MDCT) scanners and improving technology, CT can also assess the coronary arteries and veins and can evaluate

  • 2 / Cardiac CT PRACTICE GUIDELINE

    cardiac function [9-23]. This guideline attempts to maximize the probability of detecting cardiac abnormalities with cardiac CT. Cardiac CT involves the exposure of patients to ionizing radiation and should only be performed under the supervision of a physician with the necessary training in radiation protection to optimize examination safety. Medical physicists and trained technical staff must be available [24]. Cardiac CT should be performed only for a valid medical indication and with the minimum radiation exposure that provides diagnostic image quality. While important abnormalities of the heart and associated structures can be detected on chest CT performed for other reasons, these guidelines are written specifically for dedicated examinations designed to detect cardiac pathology. For further information on CT imaging of other structures within the chest and of the noncardiac vasculature, the reader should see the ACRSCBT-MRSPR Practice Guideline for the Performance of Thoracic Computed Tomography (CT) [25]. II. DEFINITIONS A. Cardiac CT Cardiac CT is performed primarily for the morphologic evaluation of the cardiac chambers, valves, ventricular myocardium, coronary arteries and veins, aortic root, central pulmonary arteries and veins, and pericardium. However, noncardiac structures are included and must be evaluated and reported [26-37]. B. Unenhanced Cardiac CT Unenhanced cardiac CT is performed primarily for detecting and evaluating cardiac calcification, i.e., of the coronary arteries (coronary calcium scoring), cardiac valves, pericardium, or cardiac masses. Electrocardiogram (ECG) synchronization reduces motion artifact and is required for calcium detection, localization, and quantification [26-27,31,34]. C. Contrast-Enhanced Cardiac CT

    1. Contrast-enhanced cardiac CT is performed after intravenous (IV) administration of iodinated contrast to allow evaluation of the cardiac chambers, myocardium, valves, pericardium, and central great vessels.

    2. CT coronary arteriography is performed to characterize the origin and course of the coronary arteries and/or bypass grafts and to assess stenosis and/or atherosclerotic plaque formation.

    3. CT cardiac venography is performed to assess the cardiac or pulmonary veins. III. INDICATIONS [29,32,36-38] Unenhanced ECG-synchronized cardiac CT may be indicated for detecting and quantifying coronary artery calcium (calcium scoring). While the role of coronary artery calcium scoring is currently being refined, data support its use for risk stratification and therapeutic decision making in select patients with intermediate risk for a significant ischemic cardiac event. An additional indication is the localization of myocardial, valvular, aortic, and pericardial calcium. Indications for contrast-enhanced cardiac CT include, but are not limited to, the diagnosis, characterization, and/or surveillance of:

    1. Atherosclerotic disease. 2. Arterial dissection and intramural hematoma. 3. Arterial and venous aneurysms.

  • PRACTICE GUIDELINE Cardiac CT / 3

    4. Traumatic injuries of arteries and veins. 5. Arterial and venous thromboembolism. 6. Cardiac and vascular congenital anomalies and variants. 7. Vascular interventions (percutaneous and surgical, e.g., angioplasty, coronary stenting, coronary artery

    bypass grafts [CABGs], ablation therapy for cardiac dysrhythmia, valve surgery, aortic root replacement, pacemaker placement planning).

    8. Vascular infection, vasculitis, and collagen vascular diseases. 9. Sequelae of ischemic coronary disease (myocardial scarring, ventricular aneurysms, thrombi). 10. Primary or metastatic cardiac tumors and thrombi. 11. Pericardial diseases. 12. Cardiac functional evaluation, especially in patients who are not candidates for magnetic resonance

    imaging (e.g., if they have automatic implantable defibrillators, pacemakers, or other MRI contraindications) or for echocardiography (e.g., if there is a poor acoustic window).

    For additional indications see the Cardiac Imaging section of the ACR Appropriateness Criteria [39]. For the pregnant or potentially pregnant patient, see the ACRSPR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation [40]. IV. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL See the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT) [41] for physician qualifications to interpret general CT examinations and CTA, and for qualifications of the Qualified Medical Physicist and the Radiologic Technologist. The requirements set forth below went into effect on July 1, 2008. A. Physician

    The physician is responsible for all aspects of the study including, but not limited to, reviewing all indications for the examination, specifying the imaging sequences to be performed, specifying the methods of image reconstruction, specifying the use and dosage of contrast and pharmacologic agents, assuring the quality of the images and of the official study interpretation,1 and communicating any urgent or emergent findings. For further information see the ACR Practice Guideline for Communication of Diagnostic Imaging Findings [42].

    1. Physician with prior qualifications in general and/or thoracic CT interpretation.

    The radiologist or other physician who meets the qualifications of the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT) [41] has substantial knowledge of radiation biology, the physics of CT scanning, the principles of CT image acquisition and postprocessing including use of diagnostic workstations, and the design of CT protocols including type, amount, rate, and timing of contrast administration. The physician also will have substantial experience in CT interpretation, including CT of extracardiac thoracic structures that will be included on the cardiac CT examination, and experience with CT angiography of other regions of the body. Some of these physicians will also have substantial experience in other methods of cardiac imaging and assessment of cardiac function, and/or experience specifically in cardiac CT. These physicians are qualified to interpret coronary artery calcium scoring based on their prior experience. However, in order to achieve competency in all aspects of cardiac CT imaging, many physicians will require additional education in cardiac anatomy, physiology, pathology, and/or cardiac CT imaging.

    1The ACR Medical Legal Committee defines official interpretation as that written report (and any supplements or amendments thereto) that attach to the patients permanent record. In healthcare facilities with a privilege delineation system, such a written report is prepared only by a qualified physician who has been granted specific delineated clinical privileges for that purpose by the facilities governing body upon the recommendation of the medical staff.

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    The supervising and interpreting physician with prior qualifications in general and/or thoracic CT interpretation should also meet one of the following requirements: a. Training in cardiac CT in a training program approved by the Accreditation Council for Graduate

    Medical Education (ACGME), the Royal College of Physicians and Surgeons of Canada (RCPSC), the Collge des Mdecins du Qubec, or the American Osteopathic Association (AOA) to include: i. Education in cardiac anatomy, physiology, pathology, and cardiac CT imaging for a time

    equivalent to at least 30 hours of CME. and ii. The interpretation, reporting, and/or supervised review of at least 50 cardiac CT examinations in

    the last 36 months. Coronary artery calcium scoring does not qualify as meeting these requirements.

    or b. Completion of at least 30 hours of Category I CME in cardiac imaging, including:

    i. Cardiac CT, anatomy, physiology, and/or pathology, or documented equivalent supervised experience2 in a center actively performing cardiac CT.

    and ii. The interpretation, reporting, and/or supervised review of at least 50 cardiac CT examinations in

    the last 36 months. Coronary artery calcium scoring does not qualify as meeting these requirements.

    2. Physician who does not have prior qualifications in general and/or thoracic CT interpretation. The radiologist or other physician who does not meet the qualifications of the ACR Practice Guideline for

    Performing and Interpreting Diagnostic Computed Tomography (CT) [41] or who meets these qualifications only for a specific anatomic area outside of the thorax requires more extensive training and experience in CT scanning with an emphasis on the thorax and specific experience in cardiac CT scanning. In addition to specific training in imaging interpretation, this training must include knowledge of the principles of CT image acquisition and postprocessing, including use of diagnostic workstations, and the design of CT protocols, including rate and timing of contrast administration. The physician must also meet the same requirements, or document equivalent training, as those delineated in the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT) [41] with regard to knowledge of the physics of CT scanning and radiation biology. Some physicians will also require additional education in cardiac anatomy, physiology, and pathology.

    The supervising and interpreting physician without prior qualifications in general and/or thoracic CT

    interpretation should meet the following requirements: a. Completion of sufficient training and experience to meet the qualifications of the ACR Practice

    Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT) [41]. For a physician who assumes responsibilities for CT imaging exclusively in a specific anatomical area such as cardiac CT, this includes: i. Completion of an ACGME approved training program in the specialty practiced plus 200 hours of

    Category I CME in the performance and interpretation of CT in the subspecialty where CT reading occurs.

    and ii. Supervision, interpretation, and reporting of 500 cases, at least 100 of which must be a

    combination of thoracic CT or thoracic CT angiography during the past 36 months in a supervised situation. Coronary artery calcium scoring does not qualify as meeting these requirements.

    and b. Included in the above, completion of at least 30 hours of Category I CME in cardiac imaging,

    including

    2 Documented equivalent supervised experience is defined as supervision at a center where the proctoring physician meets these criteria to independently interpret cardiac CT.

  • PRACTICE GUIDELINE Cardiac CT / 5

    i. Cardiac CT, anatomy, physiology, and/or pathology, or documented equivalent supervised experience3 in a center actively performing cardiac CT. and

    ii. The interpretation, reporting, and/or supervised review of at least 50 cardiac CT examinations in the last 36 months. Coronary artery calcium scoring does not qualify as meeting these requirements.

    3. Administration of pharmacologic agents

    A physician knowledgeable about the administration, risks, and contraindications of the pharmacologic

    agents must be available throughout the procedure. Monitoring may be performed by a trained nurse under supervision of the physician.

    4. Maintenance of competence

    All physicians performing cardiac CT examinations should demonstrate evidence of continuing competence in the interpretation and reporting of those examinations. If competence is assured primarily on the basis of continuing experience, performance and interpretation of a minimum of 75 examinations every 3 years is recommended in order to maintain the physicians skills.

    5. Continuing medical education

    The physicians continuing medical education should be in accordance with the ACR Practice Guideline

    for Continuing Medical Education (CME) [43] of 150 hours of approved education every 3 years, and should include CME in cardiac CT as is appropriate to the physicians practice needs.

    6. Additional training recommendations Physicians supervising a cardiac CT service (creating scan protocols, administering a quality assurance

    program, and/or training of others in cardiac CT) are expected to have additional training in the performance, interpretation, and reporting of cardiac CT examinations, the pathophysiology of congenital and acquired cardiac diseases, CT technologies, and strategies for radiation dose reduction.

    B. Qualified Medical Physicist A Qualified Medical Physicist is an individual who is competent to practice independently one or more of the subfields in medical physics. The American College of Radiology considers certification, continuing education, and experience to demonstrate that an individual is competent to practice one or more of the subfields in medical physics, and to be a Qualified Medical Physicist. The ACR strongly recommends that the individual be certified in the appropriate subfield(s) by the American Board of Radiology (ABR), the Canadian College of Physics in Medicine, or by the American Board of Medical Physics (ABMP). A Qualified Medical Physicist should meet the ACR Practice Guideline for Continuing Medical Education (CME). (ACR Resolution 17, 1996 revised 2012, Resolution 42)

    The appropriate subfields of medical physics for this guideline are Therapeutic Medical Physics, Diagnostic Medical Physics, and Nuclear Medical Physics. (Previous medical physics certification categories including Radiological Physics, Therapeutic Radiological Physics, Medical Nuclear Physics, Diagnostic Radiological Physics, and Diagnostic Imaging Physics are also acceptable.)

    3Documented equivalent supervised experience is defined as supervision at a center where the proctoring physician meets these criteria to independently interpret cardiac CT.

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    C. Registered Radiologist Assistant A registered radiologist assistant is an advanced level radiographer who is certified and registered as a radiologist assistant by the American Registry of Radiologic Technologists (ARRT) after having successfully completed an advanced academic program encompassing an ACR/ASRT (American Society of Radiologic Technologists) radiologist assistant curriculum and a radiologist-directed clinical preceptorship. Under radiologist supervision, the radiologist assistant may perform patient assessment, patient management and selected examinations as delineated in the Joint Policy Statement of the ACR and the ASRT titled Radiologist Assistant: Roles and Responsibilities [24] and as allowed by state law. The radiologist assistant transmits to the supervising radiologists those observations that have a bearing on diagnosis. Performance of diagnostic interpretations remains outside the scope of practice of the radiologist assistant. (ACR Resolution 34, adopted in 2006) The radiologist assistants continuing education credits should include continuing education in cardiac CT performance as is appropriate to the radiologist assistants practice needs. Basic life support (BLS) and automatic defibrillator (AED) training is recommended. D. Radiologic Technologist The technologist should participate in assuring patient comfort and safety, in preparing and positioning the patient for the CT examination including proper positioning of the ECG leads, and in obtaining the CT data in a manner suitable for interpretation by the physician. The technologists continuing education credits should include continuing education in cardiac CT performance as is appropriate to the technologists practice needs. Basic life support (BLS) and automatic defibrillator (AED) training is recommended. V. SPECIFICATIONS OF THE CONTRAST-ENHANCED CARDIAC CT EXAMINATION The written or electronic request for cardiac CT should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination. The request for the examination must be originated by a physician or other appropriately licensed health care provider. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patients clinical problem or question and consistent with the states scope of practice requirements. (ACR Resolution 35, adopted in 2006) The supervising physician must have complete understanding of the indications, risks, and benefits of the examination, as well as alternative imaging procedures. The physician must be familiar with potential hazards associated with CT, including potential adverse reactions to contrast media [44]. The physician should be familiar with relevant ancillary studies that the patient may have undergone including echocardiography, MRI, or nuclear medicine studies. The physician performing CT interpretation must have a clear understanding and knowledge of the anatomy and congenital and acquired pathophysiology relevant to the CT examination. Standard imaging protocols may be established and varied on a case-by-case basis when necessary. These protocols should be reviewed and updated periodically. A. Patient Selection and Preparation The appropriate guidelines for patient selection for a contrast-enhanced cardiac CT examination will continue to evolve with the introduction of new scanner technology with higher temporal and spatial resolution. The availability of specific scanner technology (16 vs. 64 MDCT, for example) may affect patient selection for contrast-enhanced cardiac studies as the positive and negative predictive values will vary based on available

  • PRACTICE GUIDELINE Cardiac CT / 7

    hardware configurations. Patients scheduled for CT coronary arteriography must have adequate peripheral venous access and be able to cooperate with breath holding and the administration of medication as needed (i.e., beta blockers or nitroglycerin/nitrates). Patients referred for cardiac CT should be first evaluated by an appropriate health care provider knowledgeable of risk factors for cardiac and vascular disease. Based on the results reported in recent publications, patients selected for CT coronary arteriography may include those with [45-63]:

    1. Unexplained or atypical chest pain when an aberrant origin of the coronary artery is considered possible. 2. Unexplained or atypical chest pain with low to intermediate likelihood of atherosclerotic coronary artery

    disease based on gender, age, and risk factors. 3. Typical or atypical chest pain with normal or equivocal stress test and normal or equivocal ECG findings. 4. Unexplained severe chest pain in the acute setting without a clinical history of coronary artery disease.

    Cardiac CT may be used as a rapid triage method to evaluate for the presence of coronary artery disease, and to evaluate for other thoracic pathology causing chest pain, such as pulmonary embolism or aortic dissection.

    5. Evaluation of ischemic etiology for a newly diagnosed cardiomyopathy and/or heart failure. 6. Preoperative or preprocedural evaluation of the coronary arteries, cardiac structures, and thoracic

    anatomy. 7. Cardiac and/or coronary artery anomalies.

    Additional indications for coronary CT arteriography include patients who have previously undergone CABG and/or percutaneous coronary intervention (PCI) and:

    1. Who have new or recurrent symptoms of chest pain or chest pain equivalent to confirm graft/stent patency or detect graft/stent stenoses or other complications.

    2. Who are scheduled for additional cardiac surgery (e.g., aortic valve replacement or bypass graft revision) when preoperative definition of anatomic detail, including the bypass grafts, is critical.

    Cardiac CT should be used selectively in patients with a high pretest probability of significant coronary artery disease based on clinical or laboratory findings or other imaging studies, including stress testing. These higher risk patients are more likely to need invasive coronary catheter studies and interventions. CT should be used with caution in patients with borderline or compromised renal function since if the patient requires an invasive procedure, the contrast load will be significantly increased by performing the CT, which could result in a greater chance of renal impairment. Patients should have a liquid only diet for 3 hours and abstain from caffeine for at least 6 hours before the study. When a patient has a relative contraindication to the administration of IV iodinated contrast media, measures to reduce the possibility of contrast media reactions or nephrotoxicity should be followed as defined in the ACRSPR Practice Guideline for the Use of Intravascular Contrast Media [44] and the ACR Manual on Contrast Media [64]. A physician should also be available to treat adverse reactions to IV contrast media. An appropriate sized antecubital IV catheter (20-gauge or larger in an adult) is the preferred administration route of iodinated contrast media for CT coronary arteriography. To minimize the risk of contrast media extravasations, all catheters used for cardiac CT angiography should first be tested with a rapidly injected bolus of sterile saline to insure that the venous access is secure and effective. Trained medical personnel should monitor the injection site for signs for IV extravasation. Departmental procedures for treating IV extravasations should be documented. Because faster heart rates tend to degrade image quality [65-67], patients may need to be medicated with rate controlling drugs (beta-blockers, calcium channel blockers), unless contraindicated, prior to or during the cardiac CT arteriogram. Nitroglycerin/nitrates may also be administered in conjunction with the study. Physicians performing CT coronary arteriography should be knowledgeable of the administration, risks, and contraindications of these drugs. Blood pressure and heart rate should be monitored. Cardiac CT may be suboptimal for evaluation of atherosclerosis in patients whose body mass index (BMI) is 40 kg/m2 or greater.

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    Pediatric patients or patients suffering from anxiety or claustrophobia may require sedation or additional assistance. Administration of moderate sedation or general anesthesia may enable achievement of the examination, particularly in young children. If moderate sedation is necessary, refer to the ACRSIR Practice Guideline for Sedation/Analgesia [68]. B. Examination Technique An initial unenhanced CT acquisition may be needed to depict calcification of the arteries, valves, pericardium, and myocardium or to detect mural or extravascular hematoma/hemorrhage or to localize an anatomic structure. The section thickness may vary but should not exceed 5 mm. Because of substantial variations in the time required for an IV contrast media injection to reach the targeted vascular anatomy, an assessment of patient-specific circulation time is required in protocols that include the administration of IV contrast media. Circulation timing can be performed using two techniques:

    1. Test bolus technique. IV injection of a small bolus (e.g., 10 to 20 ml) of contrast media at the flow rate and via the IV site that will be used for the examination. Sequential stationary CT images are acquired at the anatomic level of interest during the test bolus. The timing of the contrast delivery and ensuing enhancement of the vessel lumen of interest are then plotted to create a time-density curve. The time of the peak of vascular enhancement is used to determine the scanning delay.

    2. Bolus track and trigger technique. Following the initiation of the full dose of contrast media injection, automated triggering CT software monitors the attenuation within the cardiac structure of interest. The CT is automatically started when the enhancement in the monitored vessel or structure reaches a predetermined operator selected level.

    3. For pediatric patients, in whom reduction of both contrast media and radiation dose is preferable; either an appropriate scan delay time can be determined using low dose detection techniques or an empiric delay time after the initiation of the contrast injection may be used.

    A right arm injection is preferable to avoid artifacts from undiluted contrast media in the left brachiocephalic vein as it crosses the mediastinum. A bolus of saline following the iodinated contrast media injection may reduce the volume of contrast media required to achieve adequate vascular opacification and reduce artifacts from high concentration of contrast media in the superior vena cava and right atrium. Contrast injection parameters should be modified on an individual patient basis whenever possible. The administration of iodinated contrast media for the contrast-enhanced cardiac CT should ideally be performed with a minimum flow rate of 3 ml per second in any patient weighing 50 or more kilograms. Higher flow rates of 5 ml per second or greater are frequently required for larger patients, and in general are required for shorter acquisition scan times. In children, contrast media dosing should be scaled by body weight with injection rate scaled similarly. Preferably the contrast is delivered via powered injection. The volume of contrast media should be selected in consideration of the patients weight and comorbidities that might increase the risk of nephrotoxicity. The contrast-enhanced cardiac CT acquisition should be performed with a section thickness of 1.50 mm depending on the cardiac structure to be assessed. If performed for function or cardiac morphology only, 1.25 to 1.5 mm section thickness may be adequate. Calcium scoring typically has been performed using 3 mm section thickness, but thinner sections may be used. The field of view (FOV) should span from below the tracheal carina through the apex of the heart. If the patient has had previous CABG surgery, the FOV should span from the top of the clavicular heads to the apex of the heart, to include the entire length of internal mammary grafts using breath holding and cardiac synchronization. Multisector reconstruction associated with lower pitch values may improve the effective temporal resolution of the reconstructed images, depending on the heart rate and the CT scanner. Prospective ECG triggering may be used as a radiation dose reduction method when this technology is available. Other radiation dose reduction methods, such as reduction in kVp, ECG dependent and z-axis tube current modulation, should be used when appropriate [69-72]. For CT coronary arteriography, oral and/or IV rate controlling drugs, beta-blockers, if not contraindicated, may be used during the scan, to obtain a stable heart rate of approximately 50 to 70 beats per minute. Scan data acquired with retrospective ECG-gating should be reconstructed at various phases of the cardiac cycle, and all acquisitions

  • PRACTICE GUIDELINE Cardiac CT / 9

    should be reconstructed with overlapping sections at a maximum slice increment of 50% of the effective section thickness and a FOV of approximately 25 cm. Thin section reconstruction during the most optimal temporal window is recommended to improve conspicuity of the structures of interest. Thicker section reconstructions that span the entire cardiac cycle can be performed to assess cardiac contractility. When recording to film, display settings of window width and level should be customized to clearly delineate the enhanced vascular lumen from mural calcification and myocardium. Postprocessing of the cardiac CT data should be performed by physicians, registered radiology technologists, or other experienced personnel knowledgeable of cardiovascular anatomy and pathophysiology. The data are formatted and presented using various display techniques, including multiplanar reformations (MPRs), curved planar reformations (CPRs), maximum intensity projections (MIPs), 3D volume renderings (VRs), 3D shaded surface displays, and/or 4D dynamic reconstructions. Images are to be labeled at the minimum with the following: a) patient identification, b) facility identification, c) examination date, and d) the anatomic location. Postprocessed images should be recorded and archived in a manner similar to the source CT sections. C. Interpretation Cardiac CT data should be interpreted on a computer workstation that displays axial, reformatted, and postprocessed images. Interpretation of the CT coronary arteriogram includes assessment of intraluminal plaques, to include segmental vascular location, attenuation characteristics, and degree of luminal narrowing; vascular anomalies; and abnormalities of the cardiac chambers, myocardium, and pericardium. Frequently, recon-structions from different phases of the cardiac cycle may be required to fully interpret the examination. For functional cardiac assessment, multiple phases should be examined. Interpretation of the noncardiac portion of the examination should include use of proper windowing and leveling for adequate visualization of the soft tissues, mediastinum, pulmonary, and bony portions of the chest. Comparison with previous chest CT images should be performed if available. VI. DOCUMENTATION Reporting should be in accordance with the ACR Practice Guideline for Communication of Diagnostic Imaging Findings [42]. In addition to examining the cardiac structures of interest, the CT sections should be examined for extracardiac abnormalities that may have clinical relevance. These abnormalities should also be described in the formal report of the examination. VII. EQUIPMENT SPECIFICATIONS For diagnostic quality cardiac CT, the CT scanner should meet or exceed the following specifications:

    1. Contrast-enhanced cardiac CT by MDCT, including CT coronary arteriography, a scanner capable of achieving in-plane spatial resolution 0.5 x 0.5 mm axial, z-axis spatial resolution 1 mm longitudinal, and temporal resolution 0.25 sec.

    2. Non-contrast-enhanced MDCT for coronary artery calcium scoring may be adequately performed on a scanner with a temporal resolution of 0.50 second using prospectively ECG-triggered step and shoot sequential acquisition.

    3. Tube heat capacity should be adequate. Minimum section thickness: should be 5 mm; but 3 mm for coronary calcium scoring and 1.5 mm for CT coronary arteriography.

    To maximize the CT interpretation, any CT scanner used for cardiac CT must allow display and interpretation of the full 12 bits (from -1,000 to 3,095 Hounsfield units) of attenuation information. Additionally the display FOV must be sufficient to assess the cardiovascular region of interest, and adjacent structures.

  • 10 / Cardiac CT PRACTICE GUIDELINE

    For adequate contrast-enhanced cardiac CT, including CT coronary arteriography, a power injector capable of delivering a programmed volume of a contrast agent at a steady flow rate of at least 3 cc per second for delivery of 300 mg of iodine/ml is necessary. A dual chambered power injector is preferred if a saline flush will be administered immediately after the intravenous contrast material injection. A workstation capable of creating straight or curved multiplanar reformations, maximum intensity projections, volume renderings that can be compared across multiple cardiac phases and 4D dynamic reconstructions should be available for coronary CTA and for other applications as appropriate. Appropriate emergency equipment and medications must be immediately available to treat adverse reactions, an acute coronary syndrome, and cardiac arrest. The equipment and medications should be monitored for inventory and drug expiration dates on a regular basis. The equipment, medications, and other emergency support must also be appropriate for the range of ages and sizes in the patient population. VIII. RADIATION SAFETY IN IMAGING Radiologists, medical physicists, registered radiologist assistants, radiologic technologists, and all supervising physicians have a responsibility for safety in the workplace by keeping radiation exposure to staff, and to society as a whole, as low as reasonably achievable (ALARA) and to assure that radiation doses to individual patients are appropriate, taking into account the possible risk from radiation exposure and the diagnostic image quality necessary to achieve the clinical objective. All personnel that work with ionizing radiation must understand the key principles of occupational and public radiation protection (justification, optimization of protection and application of dose limits) and the principles of proper management of radiation dose to patients (justification, optimization and the use of dose reference levels) http://www-pub.iaea.org/MTCD/Publications/PDF/p1531interim_web.pdf Nationally developed guidelines, such as the ACRs Appropriateness Criteria, should be used to help choose the most appropriate imaging procedures to prevent unwarranted radiation exposure. Facilities should have and adhere to policies and procedures that require varying ionizing radiation examination protocols (plain radiography, fluoroscopy, interventional radiology, CT) to take into account patient body habitus (such as patient dimensions, weight, or body mass index) to optimize the relationship between minimal radiation dose and adequate image quality. Automated dose reduction technologies available on imaging equipment should be used whenever appropriate. If such technology is not available, appropriate manual techniques should be used. Additional information regarding patient radiation safety in imaging is available at the Image Gently for children (www.imagegently.org) and Image Wisely for adults (www.imagewisely.org) websites. These advocacy and awareness campaigns provide free educational materials for all stakeholders involved in imaging (patients, technologists, referring providers, medical physicists, and radiologists). Radiation exposures or other dose indices should be measured and patient radiation dose estimated for representative examinations and types of patients by a Qualified Medical Physicist in accordance with the applicable ACR Technical Standards. Regular auditing of patient dose indices should be performed by comparing the facilitys dose information with national benchmarks, such as the ACR Dose Index Registry, the NCRP Report No. 172, Reference Levels and Achievable Doses in Medical and Dental Imaging: Recommendations for the United States or the Conference of Radiation Control Program Directors National Evaluation of X-ray Trends. (ACR Resolution 17 adopted in 2006 revised in 2009, 2013, Resolution 52). IX. QUALITY CONTROL AND IMPROVEMENT, SAFETY, INFECTION CONTROL, AND

    PATIENT EDUCATION Policies and procedures related to quality, patient education, infection control, and safety should be developed and implemented in accordance with the ACR Policy on Quality Control and Improvement, Safety, Infection Control, and Patient Education appearing under the heading Position Statement on QC & Improvement, Safety, Infection Control, and Patient Education on the ACR web site (http://www.acr.org/guidelines).

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    Equipment performance monitoring should be in accordance with the ACRAAPM Technical Standard for Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment. ACKNOWLEDGEMENTS This guideline was revised according to the process described under the heading The Process for Developing ACR Practice Guidelines and Technical Standards on the ACR web site (http://www.acr.org/guidelines) by the Committee on Cardiac Imaging of the ACR Commission on Body Imaging and the Guidelines and Standards Committee of the ACR Commission on Pediatric Radiology in collaboration with the NASCI and the SPR. Collaborative Committee members represent their societies in the initial and final revision of this guideline ACR NASCI Jill E. Jacobs, MD, Chair Harold I. Litt, MD, PhD Benoit Desjardins, MD, PhD Laureen M. Sena, MD S. Bruce Greenberg, MD Arthur E. Stillman, MD, PhD, FACR U. Joseph Schoepf, MD, FAHA SPR Frandcis P. Chan, MD, PhD Jeffrey C. Hellinger, MD Committee on Cardiac Imaging (ACR Committee responsible for sponsoring the draft through the process) Geoffrey D. Rubin, MD, Chair David A. Bluemke, MD, PhD, FACR Karin E. Dill, MD Andre J. Duerinckx, MD, PhD, FACR Scott D. Flamm, MD Thomas M. Grist, MD, FACR Jill E. Jacobs, MD Michael T. Lavelle, MD U. Joseph Schoepf, MD, FAHA Arthur E. Stillman, MD, PhD, FACR Pamela K. Woodard, MD, FACR Guidelines and Standards Committee Pediatric (ACR Committee responsible for sponsoring the draft through the process) Marta Hernanz-Schulman, MD, FACR, Chair Sara J. Abramson, MD, FACR Taylor Chung, MD Brian D. Coley, MD Kristin L. Crisci, MD Wendy Ellis, MD Eric N. Faerber, MD, FACR Kate A. Feinstein, MD, FACR Lynn A. Fordham, MD S. Bruce Greenberg, MD J. Herman Kan, MD Beverley Newman, MB, BCh, BSc, FACR Marguerite T. Parisi, MD Sudha P. Singh, MB, BS

  • 12 / Cardiac CT PRACTICE GUIDELINE

    Donald P. Frush, MD, FACR, Chair, Commission on Pediatric Imaging James A. Brink, MD, FACR, Chair, Commission on Body Imaging Comments Reconciliation Committee Rodney S. Owen, MD, FACR, Chair Kimberly E. Applegate, MD, MS, FACR James A. Brink, MD, FACR Frandics P. Chan, MD, PhD Benoit Desjardins, MD, PhD Howard B. Fleishon, MD, MMM, FACR Paul J. Friedman, MD, FACR Donald P. Frush, MD, FACR S. Bruce Greenberg, MD Jeffrey C. Hellinger, MD Marta Hernanz-Schulman, MD, FACR Vincent B. Ho, MD, MBA Jill E. Jacobs, MD Alan D. Kaye, MD, FACR Paul A. Larson, MD, FACR Harold I. Litt, MD, PhD Geoffrey D. Rubin, MD U. Joseph Schoepf, MD Laureen M. Sena, MD Arthur E. Stillman, MD, PhD, FACR Suzanne M. Thigpen, MD REFERENCES 1. Axel L. Assessment of pericardial disease by magnetic resonance and computed tomography. J Magn Reson

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    *Guidelines and standards are published annually with an effective date of October 1 in the year in which amended, revised or approved by the ACR Council. For guidelines and standards published before 1999, the effective date was January 1 following the year in which the guideline or standard was amended, revised, or approved by the ACR Council. Development Chronology for this Guideline 2006 (Resolution 10, 16g, 17, 34, 35, 36) Amended 2009 (Resolution 11) Revised 2011 (Resolution 38)

    SEARCHTABULAR INDEXPRACTICE GUIDELINES & TECHNICAL STANDARDSDOCUMENTATION AND REPORTINGACR Practice Guideline for Communication of Diagnostic Imaging FindingsACR Practice Guideline for Communication: Radiation OncologyACRSIR Practice Guideline for the Reporting and Archiving of Interventional Radiology Procedures

    DIAGNOSTIC RADIOLOGY: ADULT AND PEDIATRICGENERALACR Practice Guideline for Continuing Medical Education (CME)ACR Practice Guideline for Communication of Diagnostic Imaging FindingsACRSIR Practice Guideline on Informed Consent for Image-Guided ProceduresACR Practice Guideline on the Physician Expert Witness in Radiology and Radiation OncologyACRAAPM Practice Guideline on the Expert Witness in Medical PhysicsACRSPR Practice Guideline for General RadiographyACRSIR Practice Guideline for Sedation/AnalgesiaACR Practice Guideline for Radiologist Coverage of Imaging Performed in Hospital Emergency DepartmentsACRSPR Practice Guideline for the Use of Intravascular Contrast MediaACRSPR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing RadiationACRAAPM Practice Guideline for Diagnostic Reference Levels and Achievable Doses in Medical X-Ray ImagingACRSIIM Practice Guideline for Electronic Medical Information Privacy and Security

    RADIOGRAPHYACRSPR Practice Guideline for General RadiographyACRSPR Practice Guideline for the Performance of Abdominal RadiographyACRAAPMSIIM Practice Guideline for Digital RadiographyACR Practice Guideline for the Performance of Adult Cystography and UrethrographyACR Practice Guideline for the Performance of Excretory UrographyACR Practice Guideline for the Performance of HysterosalpingographyACRSPR Practice Guideline for the Performance of Voiding Cystourethrography in ChildrenACRASSRSPRSSR Practice Guideline for the Performance of Spine RadiographyACRSIR Practice Guideline for the Performance of Diagnostic Infusion VenographyACRAAPM Technical Standard for Management of the Use of Radiation in Fluoroscopic ProceduresACRSPRSSR Practice Guideline for the Performance of Dual-Energy X-Ray Absorptiometry (DXA)ACRSPRSSR Practice Guideline for the Performance of Radiography of the ExtremitiesACRSPR Practice Guideline for the Performance of Radiography for Scoliosis in ChildrenACRSPR Practice Guideline for Skeletal Surveys in ChildrenACRSPR Practice Guideline for the Performance of Chest RadiographyACRSPR Practice Guideline for the Performance of Portable (Mobile Unit) Chest RadiographyACRASNR Practice Guideline for the Performance of Myelography and CisternographyACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Radiographic and Fluoroscopic Equipment

    COMPUTED TOMOGRAPHY (CT)ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT)ACRSPR Practice Guideline for the Performance of Pediatric Computed Tomography (CT)ACRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the Abdomen and Computed Tomography (CT) of the PelvisACRASNR Practice Guideline for the Performance and Interpretation of Cervicocerebral Computed Tomography Angiography (CTA)ACRNASCISIRSPR Practice Guideline for the Performance and Interpretation of Body Computed Tomography Angiography (CTA)ACRASNR Practice Guideline for the Performance of Computed Tomography (CT) of the BrainACRNASCISPR Practice Guideline for the Performance and Interpretation of Cardiac Computed Tomography (CT)ACRNASCISPR Practice Guideline for the Performance of Quantification of Cardiovascular Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)ACR Practice Guideline for the Performance of Computed Tomography (CT) Colonography in AdultsACRASNRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the Extracranial Head and NeckACR Practice Guideline for the Performance of High-Resolution Computed Tomography (HRCT) of the Lungs in AdultsACRSPRSSR Practice Guideline for the Performance of Quantitative Computed Tomography (QCT) Bone DensitometryACRASNRASSRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the SpineACRSCBT-MRSPR Practice Guideline for the Performance of Thoracic Computed Tomography (CT)ACRASNRSPR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in Neuroradiologic ImagingACRSPR Practice Guideline for Performing FDG-PET/CT in OncologyACRAAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Computed Tomography (CT) EquipmentACRAAPM Technical Standard for Medical Physics Performance Monitoring of PET/CT Imaging EquipmentACR Technical Standard for Medical Physics Performance Monitoring of SPECT-CT Imaging Equipment

    MAGNETIC RESONANCE IMAGING (MRI)ACR Practice Guideline for Performing and Interpreting Magnetic Resonance Imaging (MRI)ACRSPR Practice Guideline for the Performance and Interpretation of Pediatric Magnetic Resonance Imaging (MRI)ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Abdomen (Excluding the Liver)ACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Ankle and HindfootACRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone and Soft Tissue TumorsACRNASCISPR Practice Guideline for the Performance of Body Magnetic Resonance Angiography (MRA)ACRASNRSNISSPR Practice Guideline for the Performance of Cervicocerebral Magnetic Resonance Angiography (MRA)ACRASNRSPR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the BrainACRASNRSPR Practice Guideline for the Performance of Functional Magnetic Resonance Imaging (fMRI) of the BrainACRASNRSPR Practice Guideline for the Performance of Intracranial Magnetic Resonance Perfusion ImagingACRNASCISPR Practice Guideline for the Performance and Interpretation of Cardiac Magnetic Resonance Imaging (MRI)ACRNASCISPR Practice Guideline for the Performance of Quantification of Cardiovascular Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)ACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the ElbowACRSPR Practice Guideline for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)ACRASNRSPR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Head and NeckACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Hip and Pelvis for Musculoskeletal DisordersACRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the KneeACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the LiverACRASNR Practice Guideline for the Performance of Non-Breast Magnetic Resonance Imaging (MRI) Guided ProceduresACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the BreastACR Practice Guideline for the Performance of Magnetic Resonance Imaging-Guided Breast Interventional ProceduresACRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the ShoulderACRASNRSPR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Spectroscopy of the Central Nervous SystemACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Soft-Tissue Components of the PelvisACRASNRSCBT-MR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult SpineACRSCBT-MRSPRSSR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the WristACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Fingers and ToesACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone, Joint, and Soft Tissue Infections in the ExtremitiesACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Magnetic Resonance Imaging (MRI) Equipment

    NUCLEAR MEDICINEACRSPR Practice Guideline for the Performance of Single Photon Emission Computed Tomography (SPECT) Brain Perfusion and for Brain Death ExaminationsACRSNMSPR Practice Guideline for the Performance of Cardiac ScintigraphyACRSPR Practice Guideline for Performing FDG-PET/CT in OncologyACRSNMSPR Practice Guideline for the Performance of Gastrointestinal ScintigraphyACRSPR Practice Guideline for the Performance of Hepatobiliary ScintigraphyACRSNMSPR Practice Guideline for the Performance of Scintigraphy for Inflammation and InfectionACRSNMSPR Practice Guideline for the Performance of Liver and Spleen ScintigraphyACRSPR Practice Guideline for the Performance of Pulmonary ScintigraphyACRSPR Practice Guideline for the Performance of Parathyroid ScintigraphyACRSNMSPR Practice Guideline for the Performance of Radionuclide CystographyACRSPR Practice Guideline for the Performance of Renal ScintigraphyACRSPR Practice Guideline for the Performance of Skeletal Scintigraphy (Bone Scan)ACRSNMSPR Practice Guideline for the Performance of Thyroid Scintigraphy and Uptake MeasurementsACRSPR Practice Guideline for the Performance of Tumor Scintigraphy (with Gamma Cameras)ACRASTRO Practice Guideline for the Performance of Therapy with Unsealed Radiopharmaceutical SourcesACRSNM Technical Standard for Diagnostic Procedures Using RadiopharmaceuticalsACRAAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of Gamma CamerasACR Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging EquipmentACRAAPM Technical Standard for Medical Physics Performance Monitoring of PET/CT Imaging EquipmentACR Technical Standard for Medical Physics Performance Monitoring of SPECT CT Imaging Equipment

    ULTRASOUNDACRSPRSRU Practice Guideline for Performing and Interpreting Diagnostic Ultrasound ExaminationsACRAIUMSPRSRU Practice Guideline for the Performance of an Ultrasound Examination of the Abdomen and/or RetroperitoneumACRAIUMSRU Practice Guideline for the Performance of Diagnostic and Screening Ultrasound of the Abdominal Aorta in AdultsACR Practice Guideline for the Performance of a Breast Ultrasound ExaminationACRAIUMSPRSRU Practice Guideline for the Performance of the Ultrasound Examination for Detection and Assessment of Developmental Dysplasia of the HipACRAIUMSRU Practice Guideline for the Performance of an Ultrasound Examination of the Extracranial Cerebrovascular SystemACRAIUMSPRSRU Practice Guideline for the Performance of the Musculoskeletal Ultrasound ExaminationACRAIUMSPRSRU Practice Guideline for the Performance of an Ultrasound Examination of the Neonatal SpineACRAIUMSPRSRU Practice Guideline for the Performance of Neurosonography in Neonates and InfantsACRACOGAIUMSRU Practice Guideline for the Performance of Obstetrical UltrasoundACRACOGAIUMSRU Practice Guideline for the Performance of Pelvic UltrasoundACRAIUMSRU Practice Guideline for the Performance of Peripheral Arterial Ultrasound Using Color and Spectral DopplerACRAIUMSRU Practice Guideline for the Performance of Peripheral Venous Ultrasound ExaminationACRAIUMSIRSRU Practice Guideline for the Performance of Physiologic Evaluation of Extremity ArteriesACRAIUMSRU Practice Guideline for the Performance of Ultrasound Evaluation of the Prostate (and Surrounding Structures)ACRAIUMSPRSRU Practice Guideline for the Performance of Native Renal Artery Duplex SonographyACRAIUMSRU Practice Guideline for the Performance of Scrotal Ultrasound ExaminationsACRACOGAIUMSRU Practice Guideline for the Performance of SonohysterographyACRAIUMSPRSRU Practice Guideline for the Performance of Transcranial Doppler UltrasoundACRAIUMSPRSRU Practice Guideline for the Performance of a Thyroid and Parathyroid Ultrasound ExaminationACRAIUMSRU Practice Guideline for the Performance of Ultrasound Vascular Mapping for Preoperative Planning of Dialysis AccessACRAIUM Practice Guideline for the Performance of Vascular Ultrasound for Postoperative Assessment of Dialysis AccessACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Real Time Ultrasound Equipment

    ORGAN-SPECIFIC AND SUBSPECIALTY-SPECIFIC IMAGING: PEDIATRIC AND ADULTABDOMEN - GASTROINTESTINALACRSPR Practice Guideline for the Performance of Abdominal RadiographyACRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the Abdomen and Computed Tomography (CT) of the PelvisACR Practice Guideline for the Performance of Computed Tomography (CT) Colonography in AdultsACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Abdomen (Excluding the Liver)ACR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the LiverACR Practice Guideline for the Performance of a Barium Small Bowel Examinations in AdultsACRSPR Practice Guideline for the Performance of Pediatric Contrast Examinations of the Small BowelACR Practice Guideline for the Performance of Fluoroscopic Contrast Enema Examination in AdultsACR Practice Guideline for the Performance of an Enteroclysis Examination in AdultsACR Practice Guideline for the Performance of Esophagrams and Upper Gastrointestinal Examinations in AdultsACRSPR Practice Guideline for the Performance of Contrast Esophagrams and Upper Gastrointestinal Examinations in Infants and ChildrenACR Practice Guideline for the Performance of the Modified Barium SwallowACRSPR Practice Guideline for the Performance of Pediatric Fluoroscopic Contrast Enema ExaminationsACRSNMSPR Practice Guideline for the Performance of Gastrointestinal ScintigraphyACRSPR Practice Guideline for the Performance of Hepatobiliary ScintigraphyACRSNMSPR Practice Guideline for the Performance of Liver and Spleen Scintigraphy

    ABDOMEN - GENITOURINARYACR Practice Guideline for the Performance of Adult Cystography and UrethrographyACR Practice Guideline for the Performance of Excretory UrographyACR Practice Guideline for the Performance of HysterosalpingographyACRSPR Practice Guideline for the Performance of Voiding Cystourethrography in ChildrenACRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the Abdomen and Computed Tomography (CT) of the PelvisACRSNMSPR Practice Guideline for the Performance of Radionuclide CystographyACRSPR Practice Guideline for the Performance of Renal ScintigraphyACRAIUMSPRSRU Practice Guideline for the Performance of an Ultrasound Examination of the Abdomen and/or RetroperitoneumACRACOGAIUMSRU Practice Guideline for the Performance of Pelvic UltrasoundACRAIUMSRU Practice Guideline for the Performance of Ultrasound Evaluation of the Prostate (and Surrounding Structures)ACRAIUMSRU Practice Guideline for the Performance of Scrotal Ultrasound ExaminationsACRAIUMSPRSRU Practice Guideline for the Performance of Native Renal Artery Duplex SonographyACRACOGAIUMSRU Practice Guideline for the Performance of Sonohysterography

    BREAST IMAGING AND INTERVENTIONACR Practice Guideline for the Performance of Screening and Diagnostic MammographyACR Practice Guideline for the Imaging Management of DCIS and Invasive Breast CarcinomaACR Practice Guideline for the Performance of a Breast Ultrasound ExaminationACR Practice Guideline for the Performance of Contrast-Enhanced Magnetic Resonance Imaging (MRI) of the BreastACR Practice Guideline for the Performance of Magnetic Resonance Imaging-Guided Breast Interventional ProceduresACRAAPMSIIM Practice Guideline for Determinants of Image Quality in Digital MammographyACR Practice Guideline for the Performance of Stereotactically Guided Breast Interventional ProceduresACR Practice Guideline for the Performance of Ultrasound-Guided Percutaneous Breast Interventional Procedures

    CARDIOVASCULARACRASNR Practice Guideline for the Performance and Interpretation of Cervicocerebral Computed Tomography Angiography (CTA)ACRNASCISIRSPR Practice Guideline for the Performance and Interpretation of Body Computed Tomography Angiography (CTA)ACRNASCISPR Practice Guideline for the Performance of Quantification of Cardiovascular Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)ACRASNRSNISSPR Practice Guideline for the Performance of Cervicocerebral Magnetic Resonance Angiography (MRA)ACRNASCISPR Practice Guideline for the Performance of Body Magnetic Resonance Angiography (MRA)ACRNASCISPR Practice Guideline for the Performance and Interpretation of Cardiac Computed Tomography (CT)ACRNASCISPR Practice Guideline for the Performance and Interpretation of Cardiac Magnetic Resonance Imaging (MRI)ACRSNMSPR Practice Guideline for the Performance of Cardiac Scintigraphy

    CHESTACRSPR Practice Guideline for the Performance of Chest RadiographyACRSPR Practice Guideline for the Performance of Portable (Mobile Unit) Chest RadiographyACRSCBT-MRSPR Practice Guideline for the Performance of Thoracic Computed Tomography (CT)ACR Practice Guideline for the Performance of High-Resolution Computed Tomography (HRCT) of the Lungs in AdultsACRSPR Practice Guideline for the Performance of Pulmonary Scintigraphy

    MUSCULOSKELETALACRSPRSSR Practice Guideline for the Performance of Dual-Energy X-Ray Absorptiometry (DXA)ACRSPRSSR Practice Guideline for the Performance of Radiography of the ExtremitiesACRSPRSSR Practice Guideline for the Performance of Quantitative Computed Tomography (QCT) Bone DensitometryACRSPR Practice Guideline for the Performance of Radiography for Scoliosis in ChildrenACRSPR Practice Guideline for Skeletal Surveys in ChildrenACRSPR Practice Guideline for the Performance of Skeletal Scintigraphy (Bone Scan)ACRASSRSPRSSR Practice Guideline for the Performance of Spine RadiographyACRASNRASSRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the SpineACRASNRSCBT-MR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult SpineACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Ankle and HindfootACRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone and Soft Tissue TumorsACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the ElbowACRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the KneeACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Hip and Pelvis for Musculoskeletal DisordersACRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the ShoulderACRSCBT-MRSPRSSR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the WristACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Fingers and ToesACRSPRSSR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of Bone, Joint, and Soft Tissue Infections in the Extremities

    NEURORADIOLOGYACRASNRSPR Practice Guideline for the Performance of Intracranial Magnetic Resonance Perfusion ImagingACRASNR Practice Guideline for the Performance of Non-Breast Magnetic Resonance Imaging (MRI) Guided ProceduresACRASNR Practice Guideline for the Performance of Computed Tomography (CT) of the BrainACRASNRSPR Practice Guideline for the Performance of Functional Magnetic Resonance Imaging (fMRI) of the BrainACRASNRSPR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the BrainACRSPR Practice Guideline for the Performance of Single Photon Emission Computed Tomography (SPECT) Brain Perfusion and for Brain Death ExaminationsACRASNRSNISSPR Practice Guideline for the Performance of Cervicocerebral Magnetic Resonance Angiography (MRA)ACRASNR Practice Guideline for the Performance and Interpretation of Cervicocerebral Computed Tomography Angiography (CTA)ACRASNRSIRSNIS Practice Guideline for the Performance of Diagnostic Cervicocerebral Catheter Angiography in AdultsACRASNRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the Extracranial Head and NeckACRASNRSPR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Head and NeckACRASNRSPR Practice Guideline for the Performance of Myelography and CisternographyACRASNRSPR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in Neuroradiologic ImagingACRASNRSPR Practice Guideline for the Performance and Interpretation of Magnetic Resonance Spectroscopy of the Central Nervous SystemACRASNRASSRSPR Practice Guideline for the Performance of Computed Tomography (CT) of the SpineACRASNRSCBT-MR Practice Guideline for the Performance of Magnetic Resonance Imaging (MRI) of the Adult SpineACRASNRASSRSIRSNIS Practice Guideline for the Performance of Vertebral AugmentationACRNASCISPR Practice Guideline for the Performance of Quantification of Cardiovascular Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)

    INTERVENTIONALACRSIR Practice Guideline for Sedation/AnalgesiaACRSIR Practice Guideline on Informed Consent for Image-Guided ProceduresACRSIRSNIS Practice Guideline for Interventional Clinical PracticeACRSIR Practice Guideline for the Reporting and Archiving of Interventional Radiology ProceduresACRAIUMSIRSRU Practice Guideline for the Performance of Physiologic Evaluation of Extremity ArteriesACRASNRSIRSNIS Practice Guideline for the Performance of Diagnostic Cervicocerebral Catheter Angiography in AdultsACRSIR Practice Guideline for Endovascular Management of the Thrombosed or Dysfunctional Dialysis AccessACRSIRSPR Practice Guideline for Performance of ArteriographyACRSIR Practice Guideline for the Performance of Inferior Vena Cava (IVC) Filter Placement for the Prevention of Pulmonary EmbolismACRSIRSPR Practice Guideline for the Performance of Percutaneous NephrostomyACRSIRSPR Practice Guideline for Specifications and Performance of Image-Guided Percutaneous Drainage/Aspiration of Abscesses and Fluid Collections (PDAFC)ACRSIRSPR Practice Guideline for the Performance of Image-Guided Percutaneous Needle Biopsy (PNB)ACRSIR Practice Guideline for the Performance of Angiography, Angioplasty, and Stenting for the Diagnosis and Treatment of Renal Artery Stenosis in AdultsACRASTROSIR Practice Guideline for Radioembolization with Microsphere Brachytherapy Device (RMBD) for Treatment of Liver MalignanciesACRSIRSPR Practice Guideline for the Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS)ACRSIR Practice Guideline for the Performance of Diagnostic Infusion VenographyACRASNRASSRSIRSNIS Practice Guideline for the Performance of Vertebral Augmentation

    PEDIATRICACRSPR Practice Guideline for the Performance of Radiography for Scoliosis in ChildrenACRASSRSPRSSR Practice Guideline for the Performance of Spine RadiographyACRSPR Practice Guideline for Skeletal Surveys in ChildrenACRSPR Practice Guideline for the Performance of Voiding Cystourethrography in ChildrenACRSPR Practice Guideline for the Performance of Pediatric Computed Tomography (CT)ACRSPR Practice Guideline for the Performance and Interpretation of Pediatric Magnetic Resonance Imaging (MRI)ACRSPR Practice Guideline for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)ACRAIUMSPRSRU Practice Guideline for the Performance of the Ultrasound Examination for Detection and Assessment of Developmental Dysplasia of the HipACRAIUMSPRSRU Practice Guideline for the Performance of an Ultrasound Examination of the Neonatal SpineACRAIUMSPRSRU Practice Guideline for the Performance of Neurosonography in Neonates and InfantsACRSPR Practice Guideline for the Performance of Pediatric Fluoroscopic Contrast Enema ExaminationsACRSPR Practice Guideline for the Performance of Pediatric Contrast Examinations of the Small Bowel

    RADIATION ONCOLOGY - GENERALACR Practice Guideline for Continuing Medical Education (CME)ACR Practice Guideline for Communication: Radiation OncologyACR Practice Guideline on Informed Consent Radiation OncologyACR Practice Guideline on the Physician Expert Witness in Radiology and Radiation Oncology

    RADIATION ONCOLOGY - PRACTICE GUIDELINESACR Practice Guideline for Radiation OncologyACRASTRO Practice Guideline for 3D External Beam Radiation Planning and Conformal TherapyACRASTRO Practice Guideline for the Performance of High-Dose-Rate BrachytherapyACRASTRO Practice Guideline for the Performance of Low-Dose-Rate BrachytherapyACRASTRO Practice Guideline for Image-Guided Radiation Therapy (IGRT)ACRASTRO Practice Guideline for Intensity-Modulated Radiation Therapy (IMRT)ACRASTRO Practice Guideline for the Performance of Proton Beam Radiation TherapyACRASTRO Practice Guideline for Transperineal Permanent Brachytherapy of Prostate CancerACRASTRO Practice Guideline for the Performance of Stereotactic RadiosurgeryACRASTROSIR Practice Guideline for Radioembolization with Microsphere Brachytherapy Device (RMBD) for Treatment of Liver MalignanciesACRASTRO Practice Guideline for the Performance of Stereotactic Body Radiation TherapyACRASTRO Practice Guideline for the Performance of Total Body IrradiationACRASTRO Practice Guideline for the Performance of Therapy with Unsealed Radiopharmaceutical SourcesACR Technical Standard for the Performance of Radiation Oncology Physics for External Beam TherapyACR Technical Standard for Medical Physics Performance Monitoring of Image-Guided External Beam Radiation Therapy (IGRT)ACR Technical Standard for the Performance of Low-Dose-Rate Brachytherapy PhysicsACR Technical Standard for the Performance of High-Dose-Rate Brachytherapy Physics

    MEDICAL PHYSICS - PRACTICE GUIDELINESACR Practice Guideline for Continuing Medical EducationACRAAPM Practice Guideline on the Expert Witness in Medical PhysicsACRSIIM Practice Guideline for Electronic Medical Information Privacy and SecurityACR-AAPM Practice Guideline for Diagnostic Reference Levels and Achievable Doses in Medical X-Ray ImagingACRAAPMSIIM Practice Guideline for Determinants of Image Quality in Digital MammographyACRAAPMSIIM Practice Guideline for Digital Radiography

    MEDICAL PHYSICS - TECHNICAL STANDARDSACRAAPMSIIM Technical Standard for Electronic Practice of Medical ImagingACRAAPM Technical Standard for the Performance of Proton Beam Radiation TherapyACRAAPM Technical Standard for Management of the Use of Radiation in Fluoroscopic ProceduresACR Technical Standard for Medical Physics Performance Monitoring of Image-Guided External Beam Radiation Therapy (IGRT)ACR Technical Standard for the Performance of Low-Dose-Rate Brachytherapy PhysicsACR Technical Standard for the Performance of High-Dose-Rate Brachytherapy PhysicsACRAAPM Technical Standard for Medical Nuclear Physics Performance Monitoring of Gamma CamerasACRAAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Computed Tomography (CT) EquipmentACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Magnetic Resonance Imaging (MRI) EquipmentACR Technical Standard for Medical Nuclear Physics Performance Monitoring of PET Imaging EquipmentACRAAPM Technical Standard for Medical Physics Performance Monitoring of PET/CT Imaging EquipmentACR Technical Standard for Medical Physics Performance Monitoring of SPECT CT Imaging EquipmentACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Radiographic and Fluoroscopic EquipmentACR Technical Standard for Diagnostic Medical Physics Performance Monitoring of Real Time Ultrasound EquipmentACRSNM Technical Standard for Diagnostic Procedures Using Radiopharmaceuticals

    SEARCHTABULAR INDEXPRACTICE GUIDELINES & TECHNICAL STANDARDSDOCUMENTATION AND REPORTINGACR Practice Guideline for Communication of Diagnostic Imaging FindingsACR Practice Guideline for Communication: Radiation OncologyACRSIR Practice Guideline for the Reporting and Archiving of Interventional Radiology Procedures

    DIAGNOSTIC RADIOLOGY: ADULT AND PEDIATRICGENERALACR Practice Guideline for Continuing Medical Education (CME)ACR Practice Guideline for Communication of Diagnostic Imaging FindingsACRSIR Practice Guideline on Informed Consent for Image-Guided ProceduresACR Practice Guideline on the Physician Expert Witness in Radiology and Radiation OncologyACRAAPM Practice Guideline on the Expert Witness in Medical PhysicsACRSPR Practice Guideline for General RadiographyACRSIR Practice Guideline for Sedation/AnalgesiaACR Practice Guideline for Radiologist Coverage of Imaging Performed in Hospital Emergency DepartmentsACRSPR Practice Guideline for the Use of Intravascular Contrast MediaACRSPR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing RadiationACRAAPM Practice Guideline for Diagnostic Reference Levels and Achievable Doses in Medical X-Ray ImagingACRSIIM Practice Guideline for Electronic Medical Information Privacy and Security

    RADIOGRAPHYACRSPR Practice Guideline for General RadiographyACRSPR Practice Guideline for the Performance of Abdominal RadiographyACRAAPMSIIM Practice Guideline for Digital RadiographyACR Practice Guideline for the Performance of Adult Cystography and UrethrographyACR Practice Guideline for the Performance of Excretory UrographyACR Practice Guideline for the Performance of HysterosalpingographyACRSPR Practice Gui


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Cardiac CT and Nuclear Cardiology in Stable CAD Director, Cardiac ... · Nuclear Cardiology and Cardiac CT • CT coronary calcium: effective – Class IIa ACC/AHA prevention guidelines

Cardiac CT and Nuclear Cardiology in Stable CAD Director, Cardiac ... · Nuclear Cardiology and Cardiac CT • CT coronary calcium: effective – Class IIa ACC/AHA prevention guidelines

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