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PATIENT CARE PATHWAYSFOR THE EVALUATION OF CORONARY ARTERY DISEASE
Frontline providers are increasingly
responsible for a growing, aging
population at risk for coronary artery
disease (CAD).
Those who see at-risk patients first
may become more involved in disease
evaluation and care coordination for
appropriate cardiac testing.
The more we can understand about
the noninvasive cardiac testing options
available, the more we can work
together to help improve the quality of
care for what matters most—the patient.
1
1 INTRODUCTION ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 2
Considering Pathways for Patient Care
2 ASSESSING RISK ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 9
Initial Patient Evaluation
3 APPROPRIATE USE CRITERIA •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 14
Is Cardiac Imaging Appropriate?
4 SPECT MPI ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 21
Radionuclide Imaging
5 CARE COORDINATION •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••26
Working Together for the Patient
6 PATIENT EDUCATION ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••33
Focusing on the Patient
7 RESOURCES •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••36
Learn More About Cardiac Testing
2
INTRODUCTION
Considering Pathways for Patient CarePatient evaluation pathways can help
determine whether cardiac testing or
treatment may be appropriate.
It is important to understand who is at risk for CAD and
who may be appropriate for noninvasive cardiac testing
or treatment. More than 1 in 3 adults are estimated to have
cardiovascular disease—it is the leading cause of death in
the United States.1
This booklet examines several patient pathways
that may be considered for the evaluation of CAD.
Although the information within includes considerations
for testing and treatment, it is not intended to replace
clinical judgment. It should not independently be
used for patient risk assessment or diagnosis.
Whether you’re a frontline providera or a cardiology
specialist, by following appropriate evaluation pathways,
you can help ensure that your patients get the right
tests or treatment at the right time.
a Frontline providers are the first to see patients at risk for CAD and may include primary care physicians (PCPs), obstetrician/gynecologists, internists, hospitalists, nurse practitioners (NPs), physician assistants (PAs), or other referring or ordering providers.
3Introduction |
4
PCP, NP, PA, or Cardiologist
ECG interpretability and/or exercise
capability
WHO TO TREAT?
Modification of Risk Factors
• Lifestyle modifications7
• Management of cholesterol8
• Management of weight and obesity9
WHO TO TEST?
Appropriate Use of Cardiac Testing10,11
• Global risk in asymptomatic patients
• Pretest probability in symptomatic patients
• AUC
Global Risk Scoring• Framingham:
10-year risk of MI or CHD death5
• Pooled cohort: 10-year and lifetime risk of ASCVD6
ED Physician, Internist,
Cardiologist, Hospitalist, NP, or PA
Pretest Probability of CAD2
• Based on sex, age, and symptoms
• Low, intermediate, or high risk
ASCVD = atherosclerotic cardiovascular disease; AUC = appropriate use criteria; CAD = coronary artery disease; CHD = coronary heart disease; ECG = electrocardiogram; ED = emergency department; MI = myocardial infarction; NP = nurse practitioner; PA = physician assistant; PCP = primary care provider.
Test or Treat?
Guideline-based pathways may help support
clinical decisions for patient-centered care.
According to guidelines from the American
Heart Association (AHA) and other leading
professional organizations involved with
assessing cardiovascular risk, the evaluation
of stable patients for suspected CAD follows
2 distinct pathways: one for patients who are
asymptomatic, and another for those with
symptoms (Figure 1).2
Figure 1. Patient-Centered Pathways for Evaluating CAD2,5-11
Asymptomatic
Stable Symptomatic(eg, known or
suspected CAD)
Following these guideline-recommended
pathways may help identify which patients
require management of risk factors for
CAD, and which patients would benefit
from further testing to diagnose CAD
or assess the risk of a cardiac event.2 Of
note, patients who have acute coronary
syndrome (ACS), including myocardial
infarction (MI), enter a separate evaluation
and management pathway.3,4
5Introduction |
Table 1. Pretest Probability of CAD by Age, Sex, and Symptoms10
Age (Years)
Sex Typical/Definite Angina Pectoris
Atypical/ProbableAngina Pectoris
Nonanginal Chest Pain
≤39 Men INTERMEDIATE INTERMEDIATE LOW
Women INTERMEDIATE VERY LOW VERY LOW
40-49 Men HIGH INTERMEDIATE INTERMEDIATE
Women INTERMEDIATE LOW VERY LOW
50-59 Men HIGH INTERMEDIATE INTERMEDIATE
Women INTERMEDIATE INTERMEDIATE LOW
≥60 Men HIGH INTERMEDIATE INTERMEDIATE
Women HIGH INTERMEDIATE INTERMEDIATE
HIGH RISK: >90% INTERMEDIATE: 10%-90% LOW: <10% VERY LOW: <5%
Evaluation and Risk Assessment
The first step for all patients is a thorough
initial evaluation of medical history, cardiac
risk factors, symptoms, stability, and any
prior cardiac test results.2,12 For symptomatic
patients, the initial evaluation may also
include a resting electrocardiogram (ECG).2
For patients who have symptoms suggestive
of CAD, the probability of CAD can be
estimated based on the patient’s sex,
age, and type of symptoms (Table 1).2,10,13
Pretest probability of CAD, exercise
capacity, and ECG interpretability are
factors that help to determine if a patient
should undergo further cardiac testing, as
well as which tests may be appropriate.10
For patients who are asymptomatic,
global risk scoring can be used to estimate
10-year and lifetime risk of a cardiac event,
including MI, fatal or nonfatal stroke,
or coronary heart disease (CHD) death.5,6
The global risk score, along with exercise
capacity and interpretability of ECG results,
can help inform decisions about further
testing or initiating lifestyle modifications or
treatments to manage CAD risk factors.7-10
6
WHEN TO TREAT?
WHO TO TREAT?
HOW TO TREAT?
Guideline for Percutaneous Coronary Intervention,14
2013 Blood Cholesterol Guideline8
2013 Prevention Guidelines,6-9 2012 SIHD Guideline2
COURAGE,15 BARI 2D,16 FAME 2,17 FREEDOM,18 ISCHEMIA,19
2012 SIHD Guideline2
Figure 2. CAD Treatment Guidelines and Information
Patient Evaluation Pathways
Medical organizations such as the AHA
and American College of Cardiology
Foundation (ACCF) have clear guideline-
based pathways for patients with known or
suspected CAD, from initial presentation to
referral for cardiac evaluation.2
Different evaluation pathways are
suggested for patients with ACS or MI3
and for patients who are indicated for
perioperative cardiac evaluation.20
Referring providers—those who request
imaging tests or send patients to a
specialist for further evaluation—may
include PCPs, emergency department
(ED) physicians, internists, and general
cardiologists. NPs and PAs may refer
patients for cardiac testing as well.21
Referring providers should have a solid
understanding of which indications may
require cardiovascular evaluation.
Patients referred to the nuclear laboratory
may require advanced diagnostic imaging
tests to determine whether further cardiac
testing or treatment is necessary. Ordering
providers can specify which imaging tests
are appropriate for these patients.21
Although every scenario is different and
patients are managed on a case-by-case
basis, current published guidelines and
clinical studies can help frontline providers
make more informed decisions for
individual patient treatment.
This booklet is meant to be used as a
starting point for further reading—for more
on cardiac testing and treatment, refer to
the published guidelines listed here and in
Figures 2 and 3.
7
ACC = American College of Cardiology; ACCF = American College of Cardiology Foundation; ACR = American College of Radiology; AHA = American Heart Association; ASNC = American Society of Nuclear Cardiology; CAD = coronary artery disease; ED = emergency department; SIHD = stable ischemic heart disease; SPECT MPI = single-photon emission computed tomography myocardial perfusion imaging.
ACCF/AHA Multimodality Appropriate Use Criteria
for SIHD10
ACR/ACC Appropriate Utilization of Cardiovascular
Imaging in ED Patients With Chest Pain11
ACR Appropriateness Criteria® for Chronic Chest
Pain With a High Probability of CAD22
ASNC Patient-Centered Imaging Guide
(ASNC ImageGuide Registry® for MPI)23
ASNC Model Coverage Policy for SPECT MPI24
PROMISE Trial25
WHEN TO TEST?
WHO TO TEST?
HOW TO TEST?
Introduction |
Figure 3. CAD Testing Guidelines and Information
To learn more about who to treat, refer to the 2013 Prevention Guidelines6-9
and the 2012 Guideline for the Diagnosis
and Management of Patients With Stable
Ischemic Heart Disease (SIHD).2
For further information about when to treat, review the Guideline for Percutaneous Coronary
Intervention,14 as well as the 2013 Guideline on
the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults.8
Information on how to treat may be helpful
from large-scale clinical studies (COURAGE,15
BARI 2D,16 FAME 2,17 FREEDOM,18 and
ISCHEMIA19), as well as the aforementioned
SIHD Guideline2 (Figure 2). To determine
patient risk and management for CAD, it is
important to establish the right test for the
right patient at the right time.
Guidelines and Information
To help determine individual patient test
selection, the questions of who, when, and
how to test for known or suspected CAD are
supported by the ACCF/AHA Multimodality
Appropriate Use Criteria for SIHD,10 the
American College of Radiology (ACR)/ACC
appropriate utilization of cardiovascular
imaging in ED patients with chest pain,11
the American Society of Nuclear Cardiology
(ASNC) ImageGuide Registry for MPI,23
the ASNC Model Coverage Policy for SPECT
MPI,24 and the PROspective Multicenter
Imaging Study for Evaluation of chest pain
(PROMISE) trial25 (Figure 3).
Refer to these materials for further
information on appropriate patient-
centered testing.
8
9Assessing Risk |
ASSESSING RISK
Initial Patient EvaluationA thorough risk evaluation should be
conducted for patients with known or
suspected CAD.
The initial evaluation can help
give frontline providers a better
understanding of each patient’s risk.
As each patient is different,
individualized assessment is an integral
part of patient-centered care.
10
aAccess the ASCVD Risk Estimator on CardiacTesting.com
therefore, providers must consider the
possibility of overestimating ASCVD risk in
Hispanic and Asian American patients and
underestimating ASCVD risk when using the
equations in American Indian patients.6
Framingham Risk Score
The Framingham Risk Score takes into
account age, sex, cholesterol levels, blood
pressure, treatment for hypertension, diabetes
status, and whether the patient is a smoker.5
Compared with the ASCVD Risk Estimator,
the Framingham Risk Score was derived
using data from Caucasians exclusively and
only assesses the 10-year risk of experiencing
an MI or CHD death. It cannot be used to
estimate the risk of ASCVD or the lifetime risk
of a cardiac event.5,6
Reynolds Risk Score
The Reynolds Risk Score was initially
developed to improve the assessment of
cardiovascular event risk in women by taking
into account additional factors such as family
history of MI and high-sensitivity C-reactive
protein (hsCRP).26 The Reynolds Risk Score
was subsequently found to improve risk
assessment for men.27
For patients with suspected CAD,
evaluation may include noninvasive tests
that provide additional information about
overall risk of cardiac events and the
likelihood of a CAD diagnosis.
Initial Evaluation
As part of an initial evaluation, global risk
scores can be used to estimate the risk of a
future cardiac event6 and identify patients
who would benefit from treatments aimed at
management of risk.7-9
There are several helpful risk score
calculators you can access online to evaluate
your patients. These calculators are meant
to help inform decision-making but are not
intended to replace clinical judgment.
ASCVD Risk Estimator
The ACC/AHA Task Force on Practice
Guidelines developed a risk score based on
data from large community-based cohorts
that are representative of the US population
of Caucasians and African Americans.6
The Atherosclerotic Cardiovascular Disease
(ASCVD) Risk Estimatora (also referred to as
the Pooled Cohort Equations) provides sex-
and race-specific estimates of the 10-year
risk and lifetime risk for ASCVD for African
American and Caucasian men and women
aged 40 to 79 years, taking into account6:
• Age
• Total and HDL cholesterol levels
• Systolic blood pressure (including
treated or untreated status)
• Diabetes
• Current smoking status
A first ASCVD event is defined as the first
occurrence of a nonfatal MI, CHD death,
or fatal or nonfatal stroke.6 Of note, when
compared with non-Hispanic Caucasians,
the estimated 10-year risk for ASCVD
is generally lower in Hispanic American
and Asian American populations and
higher in American Indian populations;
11Assessing Risk |
This score is a composite
index that provides an
estimate of cardiovascular
risk based on results from
the exercise stress test,
including ST-segment
depression, chest pain,
and exercise duration.
Low Risk ≥5
Moderate Risk –10 to 4
High Risk ≤–11
Exercise time in minutes– (5 x ST deviation)– (4 x exercise anginaa)
a 0 = No angina
1 = Nonlimiting angina
2 = Exercise-limiting angina
= Duke Treadmill Score(–25 to 15)
Figure 4. Duke Treadmill Score28
Exercise Stress Testing
Exercise stress testing is the preferred
method of stress testing to assess cardiac
ischemia and determine the likelihood of
CAD and risk for future events.2,28
This noninvasive method not only provides
information about exercise-induced chest
pain but also measures exercise capacity,
hemodynamic response to exercise, and the
presence of cardiovascular abnormalities,2 all
of which can be used to predict the risk of a
cardiac event. Calculating the Duke Treadmill
Score (Figure 4) can help evaluate patient
cardiovascular risk.28
Further Testing
For patients whose ASCVD Risk Estimator
score does not provide sufficient information
on whether they would benefit from initiation
of a statin, further testing including coronary
artery calcium (CAC) scoring, ankle-brachial
index (ABI) testing, and hsCRP testing
may help clarify risk and inform treatment
decision-making.8
12
CAC Scoring
The CAC score is a measurement of
coronary atherosclerotic burden (Figure 5
shows the disease progression) detected
by cardiac computed tomography (CT).29
Several studies have shown a linear
relationship between the score and
global risk,30 coronary events,31 and
abnormal results from single-photon
emission computed tomography myocardial
perfusion imaging (SPECT MPI) procedures
(see page 21 for more on SPECT).32-36
Patients with CAC scores ≥300 or who are
at or over the 75th percentile of calcium
distribution for age, sex, and race may
benefit from initiation of statin therapy
to reduce the risk for a cardiac event.8
CAC scoring may also be considered
in asymptomatic patients who have an
intermediate risk for CHD based on global
risk scores to further refine their risk for
future cardiac events.31
ABI and hsCRP
Using Doppler measurement of blood
pressure in all 4 extremities, the ABI is
calculated by dividing the highest
lower-extremity value by the highest
upper-extremity value. The hsCRP is a
blood marker of inflammation. Both ABI
and hsCRP can help clarify patients’ risk
for future cardiac events.31
13
Figure 5. Progression of Atherosclerosis37,38
Assessing Risk |
1 Healthy artery
3 Plaque collects, restricting
arterial blood flow
2 Plaquea forms in the lining of
the artery
4 Plaque ruptures, forming blood
clots and limiting blood flow
aMade up of calcium, fat, cholesterol, and other substances in the blood.
14
APPROPRIATE USE CRITERIA
Is Cardiac Imaging Appropriate?For patients who may need further
cardiac testing to diagnose CAD
or determine risk, it is important to
determine which test is most appropriate.
Appropriate use criteria (AUC) may help
support clinical decision-making for the
selection of advanced diagnostic cardiac
imaging tests.39
15Appropriate Use Criteria |
16
Multimodality AUC
Consistent with the call for patient-centered
cardiac imaging to improve quality of care
and outcomes, the ACCF initiated a process
to determine the appropriateness of various
types of cardiac imaging tests in common
clinical situations and patient types (AUC
ratings are listed in Figure 6). Physician
judgment and practice experience
may be needed in certain cases where
appropriateness is not clear.10
In 2013, the ACCF and AHA partnered with
key specialty and subspecialty societies to
align on the appropriate use of 7 invasive
and noninvasive testing modalities for the
detection of SIHD and risk assessment across
80 common patient presentations10:
1. Exercise ECG
2. Stress radionuclide imaging (RNI),
including SPECT and positron emission
tomography (PET)
3. Stress echocardiography (echo)
4. Stress cardiovascular magnetic
resonance (CMR) imaging
5. CAC scoring
6. Coronary computed tomography
angiography (CCTA)
7. Invasive coronary angiography
a Negative consequences of cardiovascular imaging include the risks of the procedure (ie, radiation or contrast exposure) and the downstream impact of poor test performance, such as delay in diagnosis (false negatives) or inappropriate diagnosis (false positives).
From the ACCF/AHA Multimodality AUC.10
An appropriate imaging study is one in which the
expected incremental information, combined with
clinical judgment, exceeds the expected negative
consequencesa by a sufficiently wide margin for a
specific indication that the procedure is generally
considered acceptable care and a reasonable
approach for the indication.
17Appropriate Use Criteria |
Figure 6. AUC Ratings for Cardiac Imaging Tests Based on the ACCF/AHA Multimodality AUC10
RARELY APPROPRIATE
• Lack of evidence that benefits clearly outweigh risks
• Rarely an effective option
• Exceptions should have documentation of clinical reasons
APPROPRIATE
• Benefits generally outweigh risks
• Generally an effective option
• Dependent on physician judgment and patient-specific preferences
MAY BE APPROPRIATE
• Variable evidence regarding the risk-benefit ratio
• Potentially an effective option
• Dependent on clinical variables, physician judgment, and patient preferences
ACCF = American College of Cardiology Foundation;AHA = American Heart Association;AUC = appropriate use criteria.
18
Figure 7. The Hierarchy of Indications for Ordering Tests Based on the ACCF/AHA Multimodality AUC10,a
Noncardiac surgery indications
Post-revascularization
indications
Prior testing or procedure indications
YES
YES
YES
YESPrior procedure?
YESAsymptomatic (without ischemic equivalent)?
NO
NO
NO
NO
NO
PREOPERATIVE CARDIAC ASSESSMENT
PRIOR EVALUATION OR KNOWN CAD
NO PRIOR EVALUATION OF CAD
NO
Exercise prescription? YES
Preoperative assessment?
PCI or CABG
Prior testReferral to cardiac rehab indications
Cardiac rehab
evaluation
YES
YESOther CV conditions?
Symptomatic indications
Asymptomatic indications
Indications for other CV conditions
Indication for exercise prescription
YESSymptomatic (ischemic equivalent)?
ACCF = American College of Cardiology Foundation; AHA = American Heart Association; AUC = appropriate use criteria; CABG = coronary artery bypass graft; CAD = coronary artery disease; CV = cardiovascular; PCI = percutaneous coronary intervention.
Adapted from Wolk MJ, et al. J Am Coll Cardiol 2014;63:380-406. aRefer to the published guidelines for further information on test appropriateness for specific patient indications.
19Appropriate Use Criteria |
Since their introduction, AUC have been
used to help guide clinical decision-making
for patient-centered, appropriate use of
various cardiac imaging tests.
The Protecting Access to Medicare Act
(PAMA) of 2014 set forth a mandate for the
development or endorsement of AUC by
national professional medical societies or
other provider-led entities.39,b
Medicare reimbursement for advanced
diagnostic imaging services in the
outpatient setting (including advanced
cardiac imaging services such as MPI, CT,
and CMR) will require39:
• Consultation of applicable AUC
• Identification of AUC that were used
to order the test selection
• Documentation showing that the test
ordered is consistent with AUC used
According to PAMA, for outlier ordering
professionals, prior authorization will
be required for imaging services.39
Properly documenting the use of AUC
will be important to help providers meet
PAMA requirements.
Using the Multimodality AUC
For these “multimodality” AUC, each imaging test is rated for each indication, based on
current understanding of the technical capabilities of the procedures examined, evidence
base, and clinical experience.10 For patients who may have multiple clinical indications,
a flowchart that places conditions into a hierarchy can be used to help assess test
appropriateness (Figure 7).
Legislation Relevant to AUC: What Referring and Ordering Providers Should Know
b Learn more about the Centers for Medicare & Medicaid Services (CMS) federal
mandate at CardiacTesting.com
20
21SPECT MPI |
SPECT MPI
Radionuclide ImagingFor more than 40 years, noninvasive
RNI has been used to evaluate
myocardial perfusion.40
As the most commonly used
imaging modality in nuclear
cardiology, SPECT MPI plays an
essential role in the diagnosis and
management of CAD.40,41
22
Figure 8. SPECT MPI Scans
STRESS
REST
STRESS
REST
REVERSIBILITY
These scans show the heart at stress and rest. Color indicates areas of perfusion
where the radiotracer has entered the myocardium. Areas that appear lighter in
color at rest and darker during stress indicate areas of stress-induced ischemia,
where blood flow is blocked. The reversibility bull’s-eye scan shows the extent
that an abnormality is reversible on rest imaging.40,42
Images courtesy of Kim Allan Williams, MD.
Although there are several noninvasive
cardiac imaging modalities available
that may be appropriate for each patient
indication, here we’ll focus on the most
widely used imaging procedure in nuclear
cardiology—SPECT MPI.40,41
SPECT increases the diagnostic accuracy
of traditional exercise stress tests and can
help guide clinical management decisions
for at-risk patients.40 Gated SPECT MPI
can provide functional information about
wall motion abnormalities to help detect
extensive CAD. Normal SPECT MPI results
are consistently associated with good
prognosis and low-risk outcomes.2,40
The Most Widely Used Nuclear Imaging Modality
23SPECT MPI |
SPECT MPI = single-photon emission computed tomography myocardial perfusion imaging.
Figure 8. SPECT MPI Scans
STRESS
STRESS
STRESS
REST
REST
REST
The Basics of SPECT MPI
During a SPECT scan, the radiotracers thallium
(TI-201) or technetium (Tc-99m sestamibi or
Tc-99m tetrofosmin)40 can be used to track
myocardial blood flow and reveal regional
differences in tracer uptake during stress
(either exercise or pharmacologic) compared
with rest (Figure 8).40 The presence, extent,
and severity of stress-induced perfusion
abnormalities revealed by SPECT MPI can help
detect CAD, assess the risk of cardiac events,
and inform clinical decisions.2
A Modality by Many Names
You may have heard SPECT MPI referred
to as one of the following terms:
• Nuclear stress test
• Noninvasive cardiac testing
• Cardiac nuclear scan
• Radionuclide imaging (RNI)
24
When Is a SPECT Stress Test Appropriate According to the ACCF/AHA Multimodality AUC?10
MAY BE APPROPRIATE
For asymptomatic patients • With a high global CAD risk
• With an uninterpretable ECG or
inability to exercise
In postrevascularization (PCI or CABG) • Prior left main coronary stent
• ≥2 years after PCI
• ≥5 years after CABG
With other cardiovascular conditions • Arrhythmias with infrequent PVCs
or new-onset atrial fibrillation
• Syncope with low global CAD risk
For follow-up testing • Within 90 days of abnormal or
uncertain stress imaging study result
• Asymptomatic or stable symptoms with
last study ≥2 years ago;
abnormal calcium score
• New or worsening symptoms
and abnormal prior stress imaging
study result
• With intermediate to high global CAD
risk with last study ≥2 years ago
For preoperative evaluation before noncardiac surgery • In patients with poor or unknown
functional capacity with ≥1 clinical
risk factor prior to intermediate-risk
surgery
APPROPRIATE
For symptomatic patients • With intermediate to high risk for CAD
• With uninterpretable ECG
In postrevascularization (percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) • Only if symptomatic, or if
revascularization was incomplete and
additional revascularization is feasible
With other cardiovascular conditions • Newly diagnosed heart failure
(systolic or diastolic)
• Arrhythmia with ventricular
tachycardia, frequent premature
ventricular contractions (PVCs),
or ventricular fibrillation
• Arrhythmia prior to therapy with
high global CAD risk
• Syncope and intermediate or
high global CAD risk
For follow-up testing: new or worsening symptoms • With normal or abnormal
exercise ECG
• With nonobstructive CAD on
angiography or normal prior
stress imaging study result
• With obstructive CAD on CCTA
or invasive coronary angiography
• With abnormal calcium score
For preoperative evaluation before noncardiac surgery • In patients with poor or unknown
functional capacity prior to kidney or
liver transplant, or vascular surgery
with ≥1 clinical risk factor
25SPECT MPI |
Advances in SPECT MPI40
Advances in SPECT camera
technology, image acquisition, and
processing software have made it
possible to improve image quality
and lower radiation exposure to
patients and staff.
New SPECT cameras can acquire
images in a fraction of the time
of older cameras and can detect
signals from lower doses of
radiotracers. New software can
process images taken during shorter
acquisition times or with lower
radiotracer doses while maintaining
image resolution.
RARELY APPROPRIATE
For symptomatic patients • With low risk for CAD and
interpretable ECG
For asymptomatic patients • With low global CHD risk
• With intermediate global CHD risk
but interpretable ECG and ability
to exercise
In postrevascularization (PCI or CABG) • <2 years after PCI
• <5 years after CABG
For follow-up testing • Asymptomatic or stable symptoms
with last test <2 years ago
For preoperative evaluation before noncardiac surgery • Prior to low-risk surgery
• In asymptomatic patients with normal
prior test result or revascularization
<1 year ago
• In patients with moderate to good
functional capacity or no clinical risk
factors
For evaluation prior to exercise prescription or cardiac rehabilitation, except in patients with heart failure
26
CARE COORDINATION
Working Together for the PatientPatients with heart disease are often
managed by multiple providers for a
range of medical conditions.
Provider communication and
coordination are essential to
achieving patient-centered care.
27Care Coordination |
28
Provider Communication
Communication between the referring or
ordering provider and cardiac imaging
specialist can aid in making informed
decisions regarding patient management.
Coordination with the specialist may help
your patients understand what is needed
before and after the cardiac imaging test.
Figure 9 highlights the importance of
communication between referring or
ordering providers and specialists in the
nuclear laboratory.
For each patient scenario, ongoing
communication is necessary
in order to coordinate appropriate
patient-centered care.
For SPECT MPI tests, ASNC has published
imaging guidelines with more detailed
information on how to properly prepare
your patients for testing.43
29Care Coordination |
CAD = coronary artery disease; ED = emergency department; MI = myocardial infarction; UA = unstable angina.
Figure 9. Delivering Patient-Centered Care2-4,20
Cardiaccatheterization,
revascularization
Normal results,no treatment
PATIENTS
Unstable(eg, UA, MI, known or
suspected CAD)
Stable symptomatic
(eg, known or suspected CAD)
Stable asymptomatic
(eg, follow-up previous MI, revascularization)
Stable inpatient
(eg, preoperative evaluation)
ED physician
APPROPRIATE PATIENT-CENTERED CARE
Risk factormodification/
medication
Internist
Cardiologist
Other referring/ordering provider
Hospitalist
Cardiologist
Surgeon
Other referring/ordering provider
ED physician
Internist
Cardiologist
Other referring/ordering provider
Nuclear Cardiologist Radiologist Imaging
SpecialistCardiologist
COORDINATED CARE REQUIRES ONGOING COMMUNICATION
REFERRING OR ORDERING PROVIDERS
SPECIALISTS
30
Considerations for the SPECT MPI Test
Determining the Test10
• Consult AUC and/or communicate
with a cardiac imaging specialist to
determine the most appropriate test
for each patient
• Discuss test options with patients,
covering risks and benefits
Preparing the Patient
• Forward prior testing results and
medical history to the nuclear
laboratory because these factors
may impact which protocol is used44
• Ensure the correct patient weight is
recorded for accurate selection of
radiotracer dose and test protocol43
• Share your assessment of patient
exercise capacity with the cardiac
imaging specialist. Patients who
cannot exercise adequately may
need a pharmacologic stress test10
• Help your patients understand the
test preparation requirements to
avoid rescheduling a test44
31Care Coordination |
Reviewing the Results45
• Request a summary of patient test
results from the nuclear laboratory,
along with any recommendations
for further testing
• Discuss next steps and patient
treatment strategies with the
cardiologist before reviewing
results with your patients
Cardiac Testing Communication Tips
• Reach out to the cardiac imaging
specialist or cardiologist with any
questions or concerns you may have
about your patients—a quick phone
call may save time in the long run
• Coordinate with the specialist
to ensure your patients have the
information they need for their
cardiac imaging experience
• Ask any questions you may have
about the test results to help your
patients understand the next steps
32
33Patient Education |
PATIENT EDUCATION
Focusing on the PatientInformed patients are more likely to be
prepared for their cardiac imaging tests.
Research has shown that patients who
are informed about the benefits and
risks of specific tests and procedures
are more likely to postpone or decline
invasive procedures.2
34
Preparing Your Patients for a SPECT MPI Test
A comprehensive dialogue with your
patients will help them understand and
properly prepare for the test.2
Explain why the test is being performed and
how the test results may be used to make
decisions about their care.2
Patients seek health information from a
variety of sources, but education from a
frontline provider may be most helpful.
Reviewing results with your patients may help
explain next steps and motivate patients to
follow your directions.
Questions Your Patients May Ask About SPECT MPI46
ABOUT THE TEST
• What is this test?
• How is it performed?
• Will the test tell me if I have
heart disease?
• Will the test tell me about my
risk of a having a heart attack?
ABOUT THE BENEFITS
• How will the test help me?
• What will you learn from the
test results?
• How will this test help you make
decisions about my care?
ABOUT APPROPRIATE USE
• Is this the most appropriate
test for me?
• Are there any alternative tests?
• If my results are normal, does it mean
I should not have taken the test?
ABOUT THE POTENTIAL RISKS
• How much radiation is used for the
test? How does it compare with the
amount of radiation I am normally
exposed to in other aspects of my life?
• Is the radiation from this test harmful?
• Does radiation from a SPECT MPI test
increase my cancer risk?
Go over risks and benefits of
the test. For an appropriate test,
benefits will typically outweigh
radiation risks.10
Identify medications that your
patients may need to abstain
from that could interfere with the
scheduled procedure.43
Clarify fasting requirements—
patients may need to fast
and avoid caffeine prior to a
pharmacologic stress test.43
Check that your patients know
the location of the testing facility,
how to prepare for the test, and
what they can expect on the day
of the test.
Encourage your patients to
contact the testing facility with
any specific questions.
35Patient Education |
REFERENCES
1. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update. Circulation 2017;135(10):e146-603. Errata in: Circulation 2017;135(10):e646; Circulation 2017;136(10):e196. 2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol 2012;60(24):e44-164. 3. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. Circulation 2014;130(25):e344-426. Erratum in: Circulation 2014;130(25):e433-4. 4. O’Gara PT, Kushner FG, Aschiem DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Circulation 2013;127(4):e362-425. Erratum in: Circulation 2013;128(25):e481. 5. D’Agostino RB Sr, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care. Circulation 2008;117(6):743-53. Erratum in: Circulation 2008;118:e86. 6. Goff DC, Lloyd-Jones DM, Benett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk. Circulation 2014;129(25 Suppl 2):S49-73. Erratum in: J Am Coll Cardiol 2014;63(25 Pt B):3026. 7. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk. J Am Coll Cardiol 2014;63(25 Pt B):2960-84. Erratum in: J Am Coll Cardiol 2014;63(25 Pt B):3027-28. 8. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. Circulation 2014;129(25 Suppl 2):S1-45. Erratum in: Circulation 2014;129(25 Suppl 2):S46-8. 9. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults. Circulation 2014;129(25 Suppl 2):S102-38. Erratum in: Circulation 2014;129(25 Suppl 2):S139-40. 10. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol 2014;63(4):380-406. 11. 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. J Am Coll Cardiol 2016;67(7):853-79. 12. Fang JC, O’Gara PT. The history and physical examination: an evidence-based approach. In: Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders, 2015:95-113. 13. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing. J Am Coll Cardiol 2002;40(8):1531-40. Erratum in: J Am Coll Cardiol 2006;48(8):1731. 14. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention. J Am Coll Cardiol 2011;58(24):e44-122. 15. Shaw LJ, Berman DS, Maron DJ, et al. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden. Circulation 2008;117(10):1283-91. 16. Frye RL, August P, Brooks MM, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med 2009;360(24):2503-15. 17. De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367(11):991-1001. Erratum in: N Engl J Med 2012;367(18):1768. 18. Abdallah MS, Wang K, Magnuson EA, et al. Quality of life after PCI vs CABG among patients with diabetes and multivessel coronary artery disease. JAMA 2013;310(15):1581-90. 19. ClinicalTrials.gov. International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) (10-13-2017). http://clinicaltrials.gov/ct2/show/study/NCT01471522. Accessed 11-14-2017. 20. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol 2014;64(22):e77-137. 21. Centers for Medicare & Medicaid Services. Medicare Enrollment Guidelines for Ordering/Referring Providers (11-2016). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf. Accessed 12-11-2017. 22. Akers SR, Panchal V, Ho VB, et al. ACR Appropriateness Criteria® chronic chest pain—high probability of coronary artery disease. J Am Coll Radiol 2017;14(5S):S71-80. 23. American
Society of Nuclear Cardiology. ImageGuide Performance Measures. https://www.asnc.org/imageguidemeasures. Accessed 11-14-2017. 24. Wolinsky DG, Calnon DA, Hansen CL, et al. ASNC model coverage policy. J Nucl Cardiol 2011;18(5):811-29. 25. Douglas PM, Hoffman U, Lee KL, et al. PROspective Multicenter Imaging Study for Evaluation of chest pain. Am Heart J 2014;167(6):796-803. 26. Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women. JAMA 2007;297(6):611-9. Erratum in: JAMA 2007;297(13):1433. 27. Ridker PM, Paynter NP, Rifai N, Gaziano JM, Cook NR. C-reactive protein and parental history improve global cardiovascular risk prediction. Circulation 2008;118(22):2243-51. 28. Shaw LJ, Peterson ED, Shaw LK, et al. Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups. Circulation 1998;98(16):1622-30. 29. Naghavi M, Libby P, Falk E, et al. From vulnerable plaque to vulnerable patient. Circulation 2003;108(14): 1664-72. 30. Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004;291(2): 210-5. 31. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults. J Am Coll Cardiol 2010;56(25):e50-103. 32. He ZX, Hedrick TD, Pratt CM, et al. Severity of coronary artery calcification by electron beam computed tomography predicts silent myocardial ischemia. Circulation 2000;101(3):244-51. 33. Anand DV, Lim E, Hopkins D, et al. Risk stratification in uncomplicated type 2 diabetes. Eur Heart J 2006;27(6):713-21. 34. Moser KW, O’Keefe JH Jr, Bateman TM, McGhie IA. Coronary calcium screening in asymptomatic patients as a guide to risk factor modification and stress myocardial perfusion imaging. J Nucl Cardiol 2003;10(6):590-8. 35. Berman DS, Wong ND, Gransar H, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol 2004;44(4):923-30. 36. Chang SM, Nabi F, Xu J, et al. The coronary artery calcium score and stress myocardial perfusion imaging provide independent and complementary prediction of cardiac risk. J Am Coll Cardiol 2009;54(20):1872-82. 37. American Heart Association. Atherosclerosis (07-05-2017). http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/Atherosclerosis_UCM_305564_Article.jsp#. Accessed 11-06-2017. 38. American Heart Association. Atherosclerosis (Animation; 07-05-2017). https://watchlearnlive.heart.org/CVML_Player.php?moduleSelect=athero. Accessed 11-06-2017. 39. Centers for Medicare & Medicaid Services. Medicare program; revisions to payment policies under the physician fee schedule and other revisions to Part B for CY 2016; final rule with comment period. Fed Regist 2015;80(220):70885-1386. 40. Udelson JE, Dilsizian V, Bonow RO. Nuclear cardiology. In: Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders, 2015:271-319. 41. American Society of Nuclear Cardiology, MedAxiom. 2013 nuclear cardiology trend survey. J Nucl Cardiol 2014;21(Suppl 1): 5-88. 42. American Heart Association. Single Photon Emission Computed Tomography (SPECT) (09-19-2016). http://www.heart.org/HEARTORG/Conditions/HeartAttack/DiagnosingaHeart Attack/Single-Photon-Emission-Computed-Tomography-SPECT_UCM_446358_Article.jsp. Accessed 07-05-2017. 43. Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures. J Nucl Cardiol 2016;23(3):606-39. Erratum in: J Nucl Cardiol 2016;23(3):640-2. 44. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories. Circulation 2009;119(24):3144-61. 45. Douglas PS, Hendel RC, Cummings JE, et al. ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 health policy statement on structured reporting in cardiovascular imaging. J Am Coll Cardiol 2009;53(1):76-90. Erratum in: J Am Coll Cardiol 2009;53(16):1473. 46. Fazel R, Dilsizian V, Einstein AJ, Ficaro EP, Henzlova M, Shaw LJ. Strategies for defining an optimal risk-benefit ratio for stress myocardial perfusion SPECT. J Nucl Cardiol 2011;18(3):385-92.
36
RESOURCES
Learn More About Cardiac Testing
Access online resources
Use an interactive ASCVD risk score calculator
Download educational materials for your patients and practice
Register for a cardiac testing speaker event
For the latest information in cardiovascular care,
go to CardiacTesting.com
For more than 20 years, Astellas has offered practical
resources to help providers make decisions focused on
patient-centered care. Our educational materials are designed
to increase understanding of cardiac testing and encourage
communication between providers—all to help each patient
get the right cardiac test at the right time.
The Cardiac Testing Educational Series is intended to be a
starting point for further reading.
37Resources |
Astellas® and the flying star logo are registered trademarks of Astellas Pharma Inc.All other trademarks or registered trademarks are the property of their respective owners.©2018 Astellas Pharma US, Inc. All rights reserved. 014-0028-PM 4/18
Shared Understanding of Cardiovascular Care
Astellas is committed to bringing you the latest information on cardiac testing, so your entire care team can be better equipped to help what matters most—the patient.
Go to CardiacTesting.com to learn more about patient pathways for cardiovascular care.
