Download Appropriate Utilization of Cardiovascular Imaging in Heart Failure

2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR
Appropriate Utilization of Cardiovascular
Imaging in Heart Failure
A Joint Report of the American College of Radiology Appropriateness Criteria® Committee and the
American College of Cardiology Foundation Appropriate Use Criteria Task Force
HEART FAILURE WRITING PANEL
Manesh R. Patel, MD, FACC Co-Chair a
Michael Picard, MD, FACC a
Leslee J. Shaw, PhD, FACC a
Marc Silver, MD, FACC a
James Udelson, MD, FACC a
Richard D. White, MD, FACR, FACC, Co-Chair b
Suhny Abbara, MD b
David A. Bluemke, MD, PhD, FACR b
Robert J. Herfkens, MD b
Arthur E. Stillman, MD, PhD, FACR b
HEART FAILURE RATING PANEL
Peter Alagona, MD a
Gerard Aurigemma, MD c
Javed Butler, MD, MPH d
Don Casey, MD, MPH, MBA e
Ricardo Cury, MD f
Scott Flamm, MD g
Tim Gardner, MD h
Rajesh Krishnamurthy, MD i
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Joseph Messer, MD a
Michael W. Rich, MD j
Henry Royal, MD k
Gerald Smetana, MD e
Peter Tilkemeier, MD l
Mary Norine Walsh, MD d
Pamela Woodard, MD b
American College of Cardiology Representative
American College of Radiology Representative
American Society of Echocardiography Representative
Heart Failure Society of America Representative
American College of Physicians Representative
Society of Cardiovascular Computed Tomography Representative
Society for Cardiovascular Magnetic Resonance Representative
American Heart Association Representative
Radiological Society of North America Representative
American Geriatric Society Representative
Society of Nuclear Medicine and Molecular Imaging Representative
American Society of Nuclear Cardiology Representative
Society of Thoracic Surgeons Representative
Intersocietal Accreditation Commission Representative
North American Society for Cardiovascular Imaging Representative
American College of Chest Physicians Representative
HEART FAILURE REVIEW PANEL
G. Michael Felker, MD, MHS, FACC, FAHA d
Victor Ferrari, MD g
Myron Gerson, MD l
Michael M. Givertz, MD d
Daniel J. Goldstein, MD, FACS, FACC m
Paul A. Grayburn, MD h
Jill E. Jacobs, MD, FACR i
Warren R. Janowitz, MD k
Scott Jerome, DO, FACC, FASNC, FSCCT n
John Lesser, MD f
Michael McConnell, MD g
Sherif F. Nagueh, MD, FACC, FAHA, FASE n
Karen G. Ordovas, MD, MAS o
Prem Soman, MD, PhD, FRCP (UK), FACC l
Kirk Spencer, MD c
Raymond Stainback, MD, FACC, FASE a
W.H. Wilson Tang, MD, FACC, FAHA d
Krishnaswami Vijayaraghavan, MD, MS, FACP,
FACC, FCCP, FNLA p
APPROPRIATE UTILIZATION OF CARDIOVASCULAR IMAGING OVERSIGHT COMMITTEE
Michael A. Bettmann, MD, FACR, Co-Chair b
J. Jeffrey Carr, MD, MSc, FACR, b
Frank J. Rybicki, MD, FACR b
Richard D. White, MD, FACR b
Pamela K. Woodard, MD, FACR b
E. Kent Yucel, MD, FACR b
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Michael J. Wolk, MD, MACC, Co-Chair a
Pamela Douglas, MD, MACC a
James T. Dove, MD, MACC a
Robert C. Hendel, MD, FACC a
Christopher Kramer, MD, FACC a
Manesh R. Patel, MD, FACC a
American College of Cardiology Representative
American College of Radiology Representative
American Society of Echocardiography Representative
Heart Failure Society of America Representative
American College of Physicians Representative
Society of Cardiovascular Computed Tomography Representative
Society for Cardiovascular Magnetic Resonance Representative
American Heart Association Representative
Radiological Society of North America Representative
American Geriatric Society Representative
Society of Nuclear Medicine and Molecular Imaging Representative
American Society of Nuclear Cardiology Representative
Society of Thoracic Surgeons Representative
Intersocietal Accreditation Commission Representative
North American Society for Cardiovascular Imaging Representative
American College of Chest Physicians Representative
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Contents
Preface ......................................................................................................................................................................................................6
Introduction............................................................................................................................................................................................7
Heart Failure Overview......................................................................................................................................................................7
Prevalence ......................................................................................................................................................................................... 7
Clinical Significance....................................................................................................................................................................... 7
Economic Impact ............................................................................................................................................................................ 7
Basic Therapeutic Options ......................................................................................................................................................... 7
Methods for Establishing Appropriate Use of Imaging in HF.............................................................................................8
Need For Appropriate Utilization of Imaging in HF ......................................................................................................... 8
Definition of Appropriateness .................................................................................................................................................. 8
Clinical Scenario and Indication Identification by Writing Group ............................................................................. 8
Guidance for Clinical Scenario and Indication ................................................................................................................... 9
The Rating Panel and Its Function ....................................................................................................................................... 10
Relationships with Industry and Other Entities............................................................................................................. 11
Rating Appropriate Use ............................................................................................................................................................ 11
Identification and Description of Cardiovascular Imaging Modalities ................................................................. 13
Section References – Introduction .......................................................................................................................... 14
Clinical Scenario 1 Initial Evaluation of Cardiac Structure and Function for Newly Suspected or
Potential Heart Failure.............................................................................................................................................................. 16
Clinical Rationale......................................................................................................................................................................... 16
Imaging Rationale ....................................................................................................................................................................... 16
Literature Review ....................................................................................................................................................................... 17
Summary Statement ............................................................................................................................................................ 17
Echocardiography................................................................................................................................................................. 17
Cardiovascular Magnetic Resonance ............................................................................................................................ 17
Single Photon Emission Computed Tomography .................................................................................................... 18
Radionuclide Ventriculography (RNV) ........................................................................................................................ 18
Positron Emission Tomography ..................................................................................................................................... 18
Cardiovascular Computed Tomography ..................................................................................................................... 18
Conventional Diagnostic Cardiac Catheterization................................................................................................... 18
Guidelines ................................................................................................................................................................................ 19
Table 1.
Initial Evaluation of Cardiac Structure and Function for Newly Suspected or Potential Heart
Failure ................................................................................................................................................................................. 20
Section References - Clinical Scenario 1: Initial Evaluation of Cardiac Structure and Function
for Newly Suspected or Potential Heart Failure ................................................................................... 21
Clinical Scenario 2 Evaluation for Ischemic Etiology ......................................................................................................... 24
Clinical Rationale......................................................................................................................................................................... 24
Imaging Rationale ....................................................................................................................................................................... 24
Literature Review ....................................................................................................................................................................... 25
Summary Statement ............................................................................................................................................................ 25
Echocardiography................................................................................................................................................................. 25
Cardiovascular Magnetic Resonance ............................................................................................................................ 25
Single Photon Emission Computed Tomography .................................................................................................... 25
Radionuclide Ventriculography (RNV) ........................................................................................................................ 26
Positron Emission Tomography ..................................................................................................................................... 26
Cardiovascular Computed Tomography ..................................................................................................................... 26
Conventional Diagnostic Cardiac Catheterization................................................................................................... 26
Guidelines ................................................................................................................................................................................ 27
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Table 2.
Evaluation for Ischemic Etiology................................................................................................................. 28
Section References – Clinical Scenario 2: Evaluation for Ischemic Etiology .......................................... 29
Clinical Scenario 3 Viability Evaluation (After Ischemic Etiology Determined) Known to Be Amenable
to Revascularization With or Without Clinical Angina ................................................................................................ 32
Clinical Rationale......................................................................................................................................................................... 32
Imaging Rationale ....................................................................................................................................................................... 32
Literature Review ....................................................................................................................................................................... 33
Summary Statement ............................................................................................................................................................ 33
Echocardiography................................................................................................................................................................. 33
Cardiovascular Magnetic Resonance ............................................................................................................................ 33
Single Photon Emission Computed Tomography .................................................................................................... 33
Radionuclide Ventriculography (RNV) ........................................................................................................................ 34
Positron Emission Tomography ..................................................................................................................................... 34
Cardiovascular Computed Tomography ..................................................................................................................... 34
Conventional Diagnostic Cardiac Catheterization................................................................................................... 34
Guidelines ................................................................................................................................................................................ 35
Table 3.
Viability Evaluation (After Ischemic Etiology Determined) Known to be Amenable to
Revascularization With or Without Clinical Angina......................................................................................... 35
Section References - Clinical Scenario 3: Viability Evaluation (After Ischemic Etiology
Determined) Known to Be Amenable to Revascularization With or Without Clinical
Angina ..................................................................................................................................................................... 36
Clinical Scenario 4 Consideration and Follow-Up for Implantable Cardioverter-Defibrillator (ICD) /
Cardiac Resynchronization Therapy (CRT) ..................................................................................................................... 38
Clinical Rationale......................................................................................................................................................................... 38
Imaging Rationale ....................................................................................................................................................................... 38
Literature Review ....................................................................................................................................................................... 39
Implantable Cardioverter-Defibrillator ....................................................................................................................... 39
Cardiac Resynchronization Therapy ............................................................................................................................ 39
Post-Implantation – Follow -Up Imaging .................................................................................................................... 40
Literature Review – By Imaging Test.................................................................................................................................. 40
Echocardiography................................................................................................................................................................. 40
Cardiovascular Magnetic Resonance ............................................................................................................................ 40
Radionuclide Ventriculography (RNV) and Gated SPECT.................................................................................... 41
Positron Emission Tomography ..................................................................................................................................... 41
Cardiovascular Computed Tomography ..................................................................................................................... 41
Guidelines ................................................................................................................................................................................ 42
Table 4.
Consideration and Follow-Up for Implantable Cardioverter-Defibrillator (ICD/Cardiac
Resynchronization Therapy (CRT) ......................................................................................................................... 43
Section References - Clinical Scenario 4: Consideration and Follow-Up for Implantable
Cardioverter-Defibrillator (ICD) / Cardiac Resynchronization Therapy (CRT) ...................... 45
Clinical Scenario 5 Repeat Evaluation of HF .......................................................................................................................... 49
Clinical Rationale......................................................................................................................................................................... 49
Imaging Rationale ....................................................................................................................................................................... 49
Literature Review ....................................................................................................................................................................... 49
Summary Statement ............................................................................................................................................................ 49
Radionuclide Ventriculography (RNV) and Gated SPECT.................................................................................... 50
Table 5. Repeat Evaluation of HF.......................................................................................................................................... 50
Section References - Clinical Scenario 5: Repeat Evaluation of HF ........................................................... 51
Discussion ............................................................................................................................................................................................. 52
Clinical Indications ..................................................................................................................................................................... 52
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APPENDIX – Relationships with Industry Disclosures ...................................................................................................... 55
APPENDIX – Imaging Parameter Evidence ............................................................................................................................. 59
Clinical Scenario 1 – Evaluation for Newly Suspected or Potential Heart Failure ........................................... 60
Section References – Clinical Scenario 1 Imaging Parameters – Evaluation for Newly
Suspected or Potential Heart Failure......................................................................................................... 68
Clinical Scenario 2 – Ischemic Etiology in Patients with HF...................................................................................... 72
Section References – Clinical Scenario 2 Imaging Parameters – Ischemic Etiology in Patients
with HF ................................................................................................................................................................... 74
Clinical Scenario 3 – Therapy – Consideration of Revascularization (PCI or CABG) in Patients with
Ischemic HF and Known Coronary Anatomy Amenable to Revascularization ..................................... 76
Section References - Clinical Scenario 3 Imaging Parameters – Therapy – Consideration of
Revascularization (PCI or CABG) in Patients with Ischemic HF and Known Coronary
Anatomy Amenable to Revascularization................................................................................................ 80
Clinical Scenario 4 – ICD & CRT............................................................................................................................................. 82
Section References- Clinical Scenario 4 Imaging Parameters– ICD & CRT ............................................. 92
Clinical Scenario 5 – Repeat Imaging Evaluation of HF ............................................................................................... 99
Section References - Clinical Scenario 5: Repeat Imaging Evaluation of HF ....................................... 101
Complete Reference List .............................................................................................................................................................. 103
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Preface
In an effort to respond to the need for thoughtful and objective use of health care services in the delivery of
high-quality care; the American College of Radiology (ACR) and the American College of Cardiology
Foundation (ACCF) have taken on the important process of jointly determining the appropriate use of
cardiovascular imaging modalities for specific important clinical scenarios in patients with heart failure
(HF). The ultimate objective of an Appropriate Utilization of Imaging (AUI) document is to improve patient
care and health outcomes. The ACR, ACCF, and the collaborators in this document believe that careful
balancing of a broad range of clinical experiences and available evidence-based information will help guide
a more effective, efficient and equitable allocation of health care resources.
The publication of the AUI in HF document reflects the first collaboration between the ACR and ACCF. This
effort is aimed at critically and systematically creating, reviewing, and categorizing clinical situations
where physicians order or use imaging tests for patients with suspected, incompletely characterized, or
known HF. This document is based on our current understanding of the technical capabilities and potential
patient benefits of the various imaging modalities examined. The clinical scenarios do not directly
correspond to the Ninth Revision of the International Classification of Diseases (ICD-9) system. Rather, the
scenarios presented represent common clinical scenarios seen in contemporary practice, but do not
include every conceivable clinical situation. Thus, some patients seen in clinical practice are not
represented in this document or have additional extenuating features compared with the clinical scenarios
presented. Of course, both the ACR and ACCF support personalized patient care, emphasizing utilization of
diagnostic and therapeutic approaches to meet the specific needs of each patient. These AUI criteria are
intended to provide guidance for patients and clinicians, but are not intended to diminish the
acknowledged difficulty or uncertainty of clinical decision-making and cannot act as substitutes for sound
clinical judgment and practice experience. This document provides a framework for decisions regarding
judicious utilization of imaging in the management of patients with suspected, incompletely characterized
or known HF seen in clinical practice.
In developing the AUI for HF document, the joint Radiology and Cardiology writing panel implemented a
process that evaluated the technical abilities of the multiple imaging modalities being rated and the
evidence for each modality with respect to the clinical indication and the imaging parameters important to
each clinical indication. Therefore, the method for development of this AUI for HF document highlights the
best aspects of both the current ACR and ACCF processes. A multi-disciplinary rating panel comprised of
imagers, cardiovascular clinicians, general practitioners, and outcomes experts assessed whether
performing an imaging procedure for each clinical indication was appropriate, maybe appropriate, or
rarely appropriate, based on available evidence at the time of their review.
Michael Bettmann, MD
Co-Chair, AUI Oversight Committee
Michael J. Wolk, MD
Co-Chair, AUI Oversight Committee
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Introduction
Clinicians, payers, and patients are interested in the specific benefits offered by imaging to both the
diagnosis and clinical management of disease conditions. This document addresses the appropriate use of
imaging procedures in patients with HF.
Other appropriate-use publications from the ACCF and their collaborating organizations reflect an ongoing
effort to critically and systematically create, review, and categorize the appropriate utilization of imaging
by modality.
The ACR Appropriateness Criteria® documents critically examine and categorize
appropriateness of multiple imaging modalities used in the diagnosis and management of over 170 specific
clinical conditions and their common variants. This document follows the methods described in greater
detail in a joint publication by ACCF and ACR that itself combines the individual methodology publications
of the ACCF and the ACR [1]. The intent of the current document is to examine the benefits of imaging by
explicitly considering two complex questions: 1) Is any imaging at all justified for a given clinical scenario?
and 2) If yes, which imaging modality or modalities are most likely to provide meaningful incremental
information? This evidence-based document presents the results of this effort.
Heart Failure Overview
Prevalence
HF represents a rapidly growing epidemic [2-6]. Approximately 5.8 million patients in the United States
currently suffer from HF, and over 670,000 of them are newly diagnosed with HF each year [7].
Clinical Significance
More deaths result from HF causing sudden cardiac death than from all forms of cancer combined; the 5year mortality after a diagnosis of HF is approximately 50% [7].
Economic Impact
Annual medical expenditures related to HF in the United States exceed $39.2 billion [7].
Although medical imaging has been reported as one of the fastest growing segments of Medicare
expenditures, with cardiovascular imaging accounting for nearly one-third of those costs [8], recent data
demonstrate declining rates of use, potentially reflecting the ongoing efforts to encourage appropriate use
[9].
Basic Therapeutic Options
In general, the ACCF/AHA Heart Failure Guidelines provide in-depth information on the management and
prevention of HF [10]. The main objectives of imaging for HF evaluation revolve primarily around
understanding both cardiac structure and function, and, secondarily, in determining the underlying
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etiology, so that proven medical and invasive therapies may be targeted to appropriate patients. Therefore,
the clinical indications presented in this report focus on these management principles in patients with
suspected, incompletely characterized, or known HF.
Methods for Establishing Appropriate Use of Imaging in HF
The methods are described in detail in a recent related joint publication [1]. A summary is given in the
following text. In brief, this process combines evidence-based medicine, guidelines and practice experience
by engaging a technical panel in a modified Delphi exercise [11].
Need For Appropriate Utilization of Imaging in HF
There is heightened interest regarding the appropriateness of imaging in HF patients due to:
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The increasing prevalence of HF, especially in the elderly;
Dramatic developments in advanced imaging modalities with overlapping capabilities;
Advancements in surgical and percutaneous therapies for conditions causing HF;
Improvements in medical therapy for HF; and
The high costs of in-hospital and out-patient HF management
Importantly, utilization of imaging categorized as rarely appropriate may generate unwarranted costs to
the health care system and cause harm due to unnecessary follow-up testing or treatments to HF patients,
whereas appropriate utilization of imaging procedures should improve management and clinical outcomes
in HF patients, justifying their use.
Definition of Appropriateness
The definition of an “appropriate” imaging test, according to the joint methods of ACR and ACCF is, is based
on the definition of appropriateness in “AQA Principles for Appropriateness Criteria” [12]. (The principles
are a subset of the general “AQA Parameters for Selecting Measures for Physician Performance” [13] and
are not to be viewed independently of that document.)
The concept of appropriateness, as applied to health care, balances risk and benefit
of a treatment, test, or procedure in the context of available resources for an
individual patient with specific characteristics. Appropriateness criteria provide
guidance to supplement the clinician’s judgment as to whether a patient is a
reasonable candidate for the given treatment, test or procedure ([12], Para. 2).
This definition highlights the central intent of achieving of the greatest yield of clinically valuable
diagnostic information from imaging with the least negative impact on the patient.
Clinical Scenario and Indication Identification by Writing Group
The writing panel for this HF project comprised practicing Radiology and Cardiology representatives from
the relevant professional societies. The writing panel initially recognized key areas of HF clinical care from
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which general clinical scenarios leading to the consideration of imaging use were identified. The identified
key clinical entry points for HF-directed imaging included (see Figure 1). The identified key clinical entry
points for HF-directed imaging included:
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Newly Suspected or Potential HF
HF Associated With Myocardial Infarction (MI) HF Assessment for Consideration of
Revascularization Consideration of and Follow-Up for Device Therapy (Implantable CardioverterDefibrillator [ICD] or Cardiac Resynchronization Therapy [CRT])
Repeat Evaluation of HF
These clinical scenarios are intended to be broad and representative of the most common patient situations
in HF for which assistance from diagnostic imaging is considered. Information gained from imaging may
contribute to the original diagnosis but is not sufficient by itself to establish a HF diagnosis. HF is a clinical
syndrome which can only be diagnosed through an evaluation of the patient for a constellation of signs and
symptoms consistent with HF. Once a diagnosis is made or a high likelihood established, imaging may be
used in the evaluation and management of HF.
Early in the preparation of this document, the Writing Panel concluded that non-ischemic etiologies of
heart failure represent an important subset of patients; however, addressing this clinical scenario would
significantly expand the scope of this document. While a few of the indications for suspected or potential
heart failure may be the result of non-ischemic etiologies, these patients were generally not addressed in
this document. The intent is to include non-ischemic etiologies in a subsequent document. The
development of the relationships between the five remaining clinical scenarios highlights the complexity of
the decision-making process for clinical management and use of imaging in patients with suspected,
incompletely characterized or known HF. The document is intended to address the use of imaging within
the five described broad clinical scenarios. Entry into a given scenario may be based on history, signs,
symptoms or other factors, such as incidental diagnosis of low left ventricular ejection fraction (LVEF)
Guidance for Clinical Scenario and Indication
This document includes 5 clinical scenarios. For each of the 5 general clinical scenarios, the Writing Panel
identified specific clinical indications, emphasizing that each indication represents the specific “point-oforder” for an imaging study. These clinical indications are meant to capture the salient features seen at the
time of patient encounter before a procedure is ordered. Some of the important features represented in the
indications of patients with HF included:
a) The clinical presentation (e.g. dyspnea, exertional fatigue, chest pain or angina/ischemic equivalent,
murmur, crackles, edema),
b) Severity of HF (New York Heart Association [NYHA] functional class I, II, III, or IV),
c) Prior determination of underlying etiology (e.g., ischemic / non-ischemic etiology of HF),
d) Exacerbating conditions (e.g., dietary indiscretion, new angina/ischemic equivalent)
The Writing Panel recognized that for routine patient care, symptom status, underlying etiology of HF, and
the level of medical therapy are factors that play critical roles in decision making but may not be
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completely represented in a clinical scenario. The reader should note that the clinical indications focus on
imaging modalities in HF, rather than biomarkers or other clinical management procedures.
Once the indications were drafted, reviewers from collaborating medical specialty and subspecialty groups,
including Radiology, Cardiology and general medical societies, along with other stakeholders, were given
the opportunity to review and provide feedback regarding the appropriate-use document for HF, and this
was incorporated into the document
The following was written to clarify the different sections for the Rating Panel, as well as the general user of
this document. The procession of clinical scenarios was chosen to reflect the clinical work-up of a patient
and to highlight the diagnostic imaging query at a given clinical indication. The first clinical scenario
reflects the de novo evaluation of heart failure symptoms. This scenario is followed by a secondary step:
the evaluation of ischemic versus non-ischemic etiology in patients presenting for evaluation of heart
failure symptoms. The extent and severity of ischemia is then followed by consideration of a viability
assessment (i.e., scenario #3), largely in the setting of extensive LV dysfunction, where revascularization is
under consideration. These two distinctions between scenario #2 and #3 will help raters to make the
distinction between these two sections. In some cases, the assessment of ischemic burden (i.e., scenario #2)
may be combined with or circumvent the need for a viability assessment (i.e., scenario #3), where the
former case of severe ischemia may be the principal driver for considering revascularization. The next
scenario, #4, focuses on the application of imaging for decisions regarding ICD and CRT. The final scenario
addresses the role of serial imaging in the evaluation of heart failure patients. Raters should take care to
evaluate the role of imaging in each of these scenarios separately and to rely to as great an extent as
possible on the evidence presented here that relates to the evaluation of patients with heart failure
symptoms.
The Rating Panel and Its Function
In order to reduce bias in the rating process, the Rating Panel comprised of physicians with varying
perspectives on imaging in HF and not solely of technical experts (e.g., cardiac imagers).
Overrepresentation of technical experts in a rating panel might create a perceived preference for imaging
in general or for a specific imaging modality when other clinical alternatives (including no testing
strategies) may be more commonly employed.
Stakeholders in HF care had the opportunity to participate in the appropriate-use HF assessment process
by submitting nominees for the Rating Panel from their organizations through a Call-for-Nominations
released in May 2009. From this list of nominees, the Oversight Committee and Writing Panel selected
Rating Panel members to ensure that a balance with respect to expertise was achieved.
In addition, care was taken to provide objective, peer-reviewed, unbiased information, including a broad
range of key references, to the Rating Panel members. Recognizing variability in many patient factors, local
practice patterns, and a lack of data on use of imaging across clinical scenarios and indications, the Rating
Panel members were asked to independently rate the appropriateness of using each imaging modality for
the general scenario and specific indication based on the available evidence. Specifically, each Rating Panel
member was asked to go through the following steps in developing their individual rating:
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1) Review all the clinical scenarios / indications for HF imaging
2) Review the descriptions of all imaging modalities – both safety table and table of imaging
parameters addressing the capabilities of each imaging modality.
3) Review the Literature Review for HF (summary statements, key reference evidence tables, and
parameter-based evidence lists)
4) Rate each imaging modality for each indication by level of appropriateness first (Appropriate /
Maybe appropriate / Rarely appropriate).
5) Provide numeric scores (described in next section) for modalities in each level based on amount
and quality of evidence and additional factors such as safety and cost.
The Rating Panel used a 1-9 scale to rate the appropriateness of an imaging procedure for the specific
indication/scenario (see the Rating Appropriate Use section). Rating Panel members initially voted
independently on the appropriateness of each imaging procedure for all the clinical indications. The results
were then tabulated and returned to the Rating Panel members in the form of their individual scores along
with the de-identified scores from the other members. A mandatory in-person meeting of the Rating Panel
was then held to review and propose indication revisions to the Writing Panel. The in-person meeting
included non-rating representatives of the Writing Panel and Oversight Committee who provide guidance
relative to procedural and operational issues and ensured continuity throughout the process. The
Oversight Committee representative also served as an unbiased moderator to the Rating Panel and
facilitates optimal group dynamics during the process. The Oversight Committee moderator was free of
significant relationships with industry and unbiased relative to the topics under consideration. The revised
narrative and indications then underwent a second round of independent rating. For indications with
significant dispersion of scores, a conference call and third round of rating occurred.
Relationships with Industry and Other Entities
The American College of Cardiology Foundation, American College of Radiology, and partnering
organizations rigorously avoid any actual, perceived, or potential conflicts of interest that might arise as a
result of an outside relationship or personal interest of a member of the technical panel. Specifically, all
panelists are asked to provide disclosure statements of all relationships that might be perceived as real or
potential conflicts of interest. These statements were reviewed by the Appropriate Use Criteria
Task Force, discussed with all members of the technical panel at the face-to-face meeting, and updated and
reviewed as necessary. A table of disclosures by all participants is presented in the Appendix.
Rating Appropriate Use
Based on available evidence, the Rating Panel members assigned a rating to each imaging procedure for a
specific clinical scenario / indication on a continuous scale from 1 to 9. Final ratings are reported as
categories. The category and complete definitions used in this document were modified by the AUI
Oversight group after the final ratings were completed to align with terms used in other documents
produced by ACR and ACC. The new terminology is similar to the UCLA RAND Appropriateness Method
labels used by the rating panel (appropriate, uncertain, and inappropriate) but clarifies that
appropriateness is a continuum as discussed in the remainder of the document and discussed with the
rating panel during the meeting.
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Appropriate Rating (7, 8 or 9)
An appropriate option for management of patients in this population due to benefits generally outweighing
risks; effective option for individual care plans although not always necessary depending on physician
judgment and patient specific preferences (i.e., procedure is generally acceptable and is generally
reasonable for the indication).
Maybe Appropriate Rating (4, 5, or 6)
At times an appropriate option for management of patients in this population due to variable evidence or
agreement regarding the benefits risks ratio, potential benefit based on practice experience in the absence
of evidence, and/or variability in the population; effectiveness for individual care must be determined by a
patient’s physician in consultation with the patient based on additional clinical variables and judgment
along with patient preferences (i.e., procedure may be acceptable and may be reasonable for the
indication).
The “maybe appropriate” category indicates that the Rating Panel agreed that: 1) there was insufficient
evidence whether the imaging procedure was appropriate or not or 2) the available evidence was equivocal
or conflicting, or 3) additional factors beyond those described must be considered.
A “Maybe
Appropriate” rating is more likely with procedures using new technology or protocols for which the
evidence is limited and additional research is required. All raters recognize that a rating in the “maybe
appropriate” category does not invalidate the use of specific imaging on a case-by-case basis when the best
interests of an individual patient are being considered by the caring physician. The ACCF and the ACR
recommend that a “maybe appropriate” category not be used as justification for the non-payment of
imaging services.
Rarely Appropriate Rating (1, 2, or 3)
Rarely an appropriate option for management of patients in this population due to the lack of a clear
benefit/risk advantage; rarely an effective option for individual care plans; exceptions should have
documentation of the clinical reasons for proceeding with this care option (i.e., procedure is not generally
acceptable and is not generally reasonable for the indication).
The following specific assumptions were conveyed to the Rating Panel members:
 All imaging is performed in accredited laboratories using approved/certified imaging equipment
[14-18].
 All interpreting physicians are qualified to supervise the imaging procedure and report the findings
on the resulting images.
 All imaging will be performed according to peer-reviewed published medical literature.
 In the clinical scenarios/indications, no unusual extenuating circumstances (e.g., clinically unstable,
inability to undergo the imaging modality considered, resuscitation status, patient unwilling to
continue medical care or revascularization), exist or have been specifically noted.
 Prior diagnostic imaging may have been performed by the time of the clinical presentation. The
panel should rate the appropriateness of imaging in the clinical scenario independent of the
appropriateness of prior imaging.
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 The potential drawbacks of the imaging procedures include those presented in the Imaging
Procedures and Safety Information table (Appendix B) of the ACCF/ACR methodology document and
those associated with poor test performance [1]. While specific patient groups (e.g., end-stage renal
disease, advanced age), which are not well represented in the literature, are not presented in the
current clinical scenarios/indications, the Writing Group recognizes that decisions about imaging in
such patients are frequently required.
 All patients are receiving standard care, including guideline-based risk factor modification for
primary or secondary prevention in cardiovascular patients, and standard HF care unless
specifically noted.
 Cost may be a consideration, in particular as it relates to the use of lower cost, noninvasive vs. more
costly, invasive procedures. However, clinical benefits should always be considered first and costs
should be considered in relationship to these benefits. Use of a lower cost procedure, though less
expensive at a given moment in time, may ultimately be more costly due to subsequent expenses. A
procedure may initially be more costly, but it may be better able to address the clinical questions at
hand.
Identification and Description of Cardiovascular Imaging Modalities
The cardiovascular imaging modalities considered in this report included the following: echocardiography
(Echo), cardiovascular magnetic resonance (CMR), single photon emission computed tomography (SPECT),
positron emission tomography (PET), cardiovascular computed tomography (CTT includes CT angiography
and calcium scoring), and conventional diagnostic cardiac catheterization (catheterization includes
coronary angiography, left ventriculography, left heart catheterization). All of these modalities represent
multiple capabilities which are selectively used alone or in combination during an episode of care or
serially throughout a patient’s life in order to provide general insights into a clinical condition or to assess
specific issues pertaining to the individual patient. In fact, the specific performance of the same imaging
modality may vary considerably between disease entities and even between patients with the same general
disease. This variability in the description of the imaging technology applied is also reflected in the
literature. Thus, for the sake of establishing (by evidence-based analysis) the appropriateness of imaging it
is essential to delineate the key clinical parameters for imaging to address on an indication-by-indication
basis to be able to assess the relative roles of the various modalities. That is the intent of the Imaging
Parameters Evidence appendix.
To ensure that the rating panel and users of the criteria can apply the indications to practice, the specific
parameters, included in clinical evaluations and levels-of-evidence validation for use, are provided in the
following tables. The expectation is that the modalities and imaging techniques used are not experimental,
but rather that they represent a reasonable and usual high quality of imaging, as available in general
practice.
13
Figure 1. Entry Points into Clinical Imaging Scenarios
Newly Suspected or
Potential Heart Failure
Baseline Evaluation of
Structure and Function
See Clinical
Scenario #1
Heart Failure Associated
With MI
Known Heart Failure
Without Established
Etiology
Evaluation for Ischemic
Etiology
Evaluation for NonIschemic Etiology of HF
Heart Failure Assessment
for Consideration of
Revascularization
Evaluation of Viability /
Ischemic Burden Prior to
Revascularization
See Clinical
Scenario #2
Not Covered
(See Comments)
See Clinical
Scenario #3
Consideration of and
Follow-up for Device
Therapy (ICD or CRT)
See Clinical
Scenario #4
Repeat Evaluation of Heart
Failure
See Clinical
Scenario #5
Section References – Introduction
1.
2.
3.
4.
5.
6.
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Methodology for the Development of Joint Criteria for the Appropriate Utilization of Cardiovascular
Imaging by the American College of Cardiology Foundation and American College of Radiology. J Am
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Fox KA, Steg PG, Eagle KA, Goodman SG, Anderson FA, Jr., Granger CB, Flather MD, Budaj A, Quill A,
Gore JM. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA
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Loehr LR, Rosamond WD, Chang PP, Folsom AR, Chambless LE. Heart failure incidence and survival
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Masoudi FA, Havranek EP, Krumholz HM. The burden of chronic congestive heart failure in older
persons: magnitude and implications for policy and research. Heart Fail Rev 2002; 7(1):9-16.
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Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K,
Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D,
Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL,
Rosamond W, Sacco R, Sorlie P, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J. Heart
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Ghio S, Freemantle N, Scelsi L, Serio A, Magrini G, Pasotti M, Shankar A, Cleland JG, Tavazzi L. Longterm left ventricular reverse remodelling with cardiac resynchronization therapy: results from the
CARE-HF trial. Eur J Heart Fail 2009; 11(5):480-8.
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA,
Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update
incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure
in Adults A Report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines Developed in Collaboration With the International Society for
Heart and Lung Transplantation. J Am Coll Cardiol 2009; 53(15):e1-e90.
Fitch K. The Rand/UCLA appropriateness method user's manual. Santa Monica: Rand; 2001.
Ypenburg C, Van Bommel RJ, Marsan NA, Delgado V, Bleeker GB, van der Wall EE, Schalij MJ, Bax JJ.
Effects of interruption of long-term cardiac resynchronization therapy on left ventricular function
and dyssynchrony. Am J Cardiol 2008; 102(6):718-21.
Lindner O, Sorensen J, Vogt J, Fricke E, Baller D, Horstkotte D, Burchert W. Cardiac efficiency and
oxygen consumption measured with 11C-acetate PET after long-term cardiac resynchronization
therapy. J Nucl Med 2006; 47(3):378-83.
Sundell J, Engblom E, Koistinen J, Ylitalo A, Naum A, Stolen KQ, Kalliokoski R, Nekolla SG, Airaksinen
KE, Bax JJ, Knuuti J. The effects of cardiac resynchronization therapy on left ventricular function,
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http://www.intersocietal.org/echo/. Accessed September 1, 2010.
15
Clinical Scenario 1
Initial Evaluation of Cardiac Structure and Function for Newly Suspected or Potential
Heart Failure
Clinical Rationale
The cardinal presenting symptoms of HF are dyspnea and fatigue, resulting from variable combinations of
fluid retention (manifested as pulmonary congestion and/or peripheral edema) and exercise intolerance
[10]. Symptoms of heart failure also may be accompanied by signs such as murmur, abnormal jugular
venous pressure, crackles, other signs of volume overload, or edema.
The clinical syndrome of HF is common and can be caused by any disorder impairing the ability of the
ventricles to contract, relax, fill, or empty during the cardiac cycle [10]. Although HF may be due to
abnormalities of the myocardium, valves, or pericardium, the majority of HF patients are symptomatic from
LV myocardial functional abnormalities, which may be seen in settings ranging from markedly reduced
LVEF with/without severe LV dilatation (predominantly, systolic dysfunction) [10,19]to preserved LVEF
with normal LV size (predominantly, diastolic dysfunction) [10,20]. In many cases, systolic and diastolic
myocardial dysfunctions co-exist. Coronary Artery Disease (CAD), hypertension, valvular disease and
dilated cardiomyopathy are the causes of HF in a substantial proportion of patients, with aging being an
important contributor to diastolic dysfunction [10,21,22].
In patients presenting with signs and symptoms that raise suspicion of HF, assessment of LV systolic and
diastolic function is important and can be performed with a variety of imaging techniques. The same holds
true for patients who are at risk for HF, such as patients after acute myocardial infarction, those with
hypertension and Left Ventricular (LV) hypertrophy , those who are exposed to potentially cardiotoxic
chemotherapeutic agents, and first-degree relatives of those with an inherited cardiomyopathy.
Imaging Rationale
Although a complete history and physical examination are the first steps in evaluating the etiology of newly
suspected HF, or factors predisposing to HF, identification of structural abnormalities leading to HF
generally requires imaging of the cardiac chambers and great vessels [10,23]. Imaging may be used in new
onset HF to determine whether abnormalities of the myocardium, valves, or pericardium are present,
which chambers are involved and whether secondary pulmonary arterial hypertension is present. Imaging
is also often very useful in such patients for early prognostication. For example, LVEF after MI remains a
strong predictor of risk with lower LVEF associated with worse outcome [24-27].
Use of imaging allows the following fundamental questions to be addressed in patients with newly
suspected or potential HF:
1)
2)
3)
4)
Is LV structure normal or abnormal?
Is LVEF preserved or reduced?
Is ventricular relaxation normal? and
Are there other structural abnormalities accounting for the clinical presentation?
16
Evaluation, however, is not limited to the LV.
For this clinical scenario, the following imaging parameters are most relevant:
A. Anatomy
1.
2.
3.
4.
Chamber Anatomy Abnormalities (geometry/dimension/wall thickness)
Valve Structural Abnormalities
Congenital Abnormalities
Pericardial Abnormalities (including calcification/ fluid /thickness/constriction)
B. Function
1. Global Ventricular Systolic Dysfunction (including reduced ejection fraction and stroke volume)
2. Global Ventricular Diastolic Dysfunction (including altered [reduced or increased] early
ventricular filling)
3. Valve Dysfunction (stenosis/regurgitation/other abnormalities)
C. Myocardial Status
1. Regional Ventricular Systolic Dysfunction (including wall thickening)
Literature Review
Summary Statement
The literature review does not support routine use of stress imaging with Echo, CMR, SPECT or PET for
initial evaluation of HF symptoms.
Echocardiography
The strongest recommendations in favor of imaging of patients with newly suspected HF are with
echocardiography to include two-dimensional transthoracic ultrasound and Doppler [10]. Among its most
attractive attributes are its wide spread availability, lack of ionizing radiation, and the application of
imaging in real-time. Assessments of cardiac structure and function can be made accurately to guide
therapy. Multi-center studies have demonstrated the value of various echocardiographic measures of
cardiac structure and function as indicators of subclinical HF and risk for subsequent HF events [28-32].
Additionally, assessment of LV systolic function using echo in patients with suspected HF improved the
disease identification by general practitioners as well as the application of appropriate medical care[33].
Resting echocardiography has also been shown to identify patients with heart failure with preserved
systolic function and abnormal diastolic function [34,35] and to predict subsequent poor outcomes [36-38].
Cardiovascular Magnetic Resonance
Studies over the last decade support the use of CMR for this cohort of patients, as noted in a recently
published ACC expert consensus statement [39]. Although LV volume and EF measurements are at least as
17
accurate as those obtained with echo [40], myocardial perfusion, viability and fibrosis imaging can assist in
identification of etiology and assess prognosis [41]. LV mass quantitation by CMR predicts future risk in
patients with HF [42]. A key strength of CMR is the high resolution of the anatomy of all aspects of the heart
and surrounding structures [43]. This has led to recommendations for use in patients with known or
suspected complex congenital heart disease [44]. The accuracy of CMR and its utility in the initial
assessment of valve function appear substantial, although some questions are not yet entirely answered.
Single Photon Emission Computed Tomography
SPECT is not primarily used to determine LV systolic global and regional function; unless these parameters
are quantified from the resultant images during myocardial perfusion assessment (see Scenario #2)
[45,46].
Radionuclide Ventriculography (RNV)
Similar to CMR and Echo, RNV is an additional alternative that may be applied to the evaluation of cardiac
function [47]. RNV is a planar technique and it may be particularly useful for the assessment of LV volumes
in patients with significant resting wall motion abnormalities or distorted geometry. Due to the
quantitative methods employed in this technique, it is high reproducibility [48]. Serial RNV measurements
of LV volumes have been reported to track the efficacy of a variety of therapeutic interventions for patients
with heart failure [49-51]. RNV is a technique that is less commonly performed today than in years past
and is not routinely used in patients with adult congenital heart disease.
Positron Emission Tomography
There are relatively few data to support the use of PET as an initial test, but reports do note the utility of
peak stress LVEF measurements [52].
Cardiovascular Computed Tomography
Cardiac computed tomography (CCT) can provide accurate assessment of cardiac structure and function.
This technique has high anatomic resolution for the heart and surrounding structures, including the
coronary arteries. One current limitation is the loss in accuracy with high heart rate values. An advantage of
CCT over echo may be its ability to characterize the myocardium but studies have yet to demonstrate the
importance of this factor. Currently, limited reports are available with CCT in patients with suspected HF.
Conventional Diagnostic Cardiac Catheterization
The invasive assessment of hemodynamics and valvular and ventricular function by catheterization with
left ventriculography is considered the traditional reference standard [53]. However the invasive nature of
the test, radiation exposure, and necessary geometric assumptions in calculations have gradually reduced
reliance on this approach as an initial diagnostic test for LV function, especially in subjects who are deemed
low risk.
18
Guidelines
The relevant guideline recommendations for this clinical scenario are:
1. Initial clinical assessment of patients presenting with HF:
ACC/AHA Heart Failure Guidelines [10]
Class I
 2-dimensional Echo with Doppler should be performed during initial evaluation of patients
presenting with HF to assess LVEF, LV size, LV wall thickness, and valve function. Radionuclide
left ventriculography can also be performed to assess LVEF and volumes. (Level of Evidence: C)
ACC/AHA ST-Segment Elevation MI (STEMI) Guidelines [54]
Class IIa
 Echocardiography is reasonable in patients with STEMI to re-evaluate ventricular function during
recovery when results are used to guide therapy. (Level of Evidence: C)
2. Assessment of patients at risk for developing heart failure:
ACC/AHA Heart Failure Guidelines [10]
Class I
 Healthcare providers should perform a noninvasive evaluation of LV function (i.e., LVEF) in patients
with a strong family history of cardiomyopathy or in those receiving cardiotoxic interventions.
(Level of Evidence: C)
ACC/AHA ST-Segment Elevation MI (STEMI) Guidelines [54]
Class IIa
 Echocardiography is reasonable in patients with STEMI to re-evaluate ventricular function during
recovery when results are used to guide therapy. (Level of Evidence: C)
19
TABLE 1. INITIAL EVALUATION OF CARDIAC STRUCTURE AND FUNCTION FOR NEWLY
SUSPECTED OR POTENTIAL HEART FAILURE
Rest Only
INDICATION
Rest + Stress
CCT
Cath
R
M
R
R
R
R
R
R
R
R
R
R
R
R
R
R
M
M
M
M
R
R
R
A
Echo
RNV
SPECT
PET
CMR
Echo
SPECT
PET
CMR
Symptoms of Heart Failure
1. Shortness of Breath OR
2. Decreased Exercise Tolerance
OR
3. Symptoms of Fluid Retention
AND
Findings of Heart Failure
4. Abnormal chest radiograph
(e.g., enlarged silhouette,
pulmonary venous
congestion) OR
5. Abnormal biomarker(s)
(e.g., BNP, pro-BNP)
OR
Signs of Heart Failure
6. Evidence of Impaired
Perfusion OR
7. Evidence of Volume
Overload
A
A
M
R
A
R
R
R
Malignancy
8. Current or Planned Cardiotoxic
Therapy
AND
9.No prior Imaging Evaluation
A
A
R
R
A
R
R
Familial or Genetic Dilated
Cardiomyopathy in first degree
relative
A
M
R
R
A
R
4.
Known Adult Congenital Heart
Disease
A
M
R
R
A
5.
Acute Myocardial Infarction
10.
Evaluation of LV
function during Initial
Hospitalization
A
M
M
R
A
1.
2.
3.
BNP = B-type natriuretic peptide
20
Section References - Clinical Scenario 1: Initial Evaluation of Cardiac Structure and Function for
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Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, Hochman JS, Krumholz
HM, Lamas GA, Mullany CJ, Pearle DL, Sloan MA, Smith SC, Jr., Anbe DT, Kushner FG, Ornato JP, Jacobs
AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Lytle BW,
Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 focused update of the ACC/AHA 2004
guidelines for the management of patients with ST-elevation myocardial infarction: a report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am
Coll Cardiol 2008; 51(2):210-47.
23
Clinical Scenario 2
Evaluation for Ischemic Etiology
Clinical Rationale
The increasing prevalence of chronic ischemic heart disease (CIHD), reflecting the significant
accomplishment of improved survival among patients after acute coronary events (e.g., acute myocardial
infarction), combined with the general aging of the population [2-6], has resulted in an increasing
prevalence of HF. Based on patient enrollment in therapeutic randomized trials, approximately two-thirds
of patients have an ischemic etiology of their HF symptoms [55]. Thus, identification of an underlying
ischemic etiology is central to clinical management strategies for HF.
Imaging Rationale
It is assumed that patients in this clinical scenario have evidence for heart failure with a reasonable
suspicion of cardiac ischemia, whether by prior cardiac events, risk factors or current symptoms and signs.
Cardiovascular imaging can help evaluate the severity of CAD and associated myocardial ischemia. It can
also aid identification of the extent of either infarcted or hibernating myocardium. Although the primary
rationale for quantitating the extent and severity of myocardial ischemia is to guide important clinical
decisions regarding medical therapy versus revascularization, there are but a few small clinical trials and
observational reports supporting this approach [56,57]. While there is limited randomized trial evidence
available regarding the benefits of therapeutic intervention [58], the assessment of myocardial ischemia is
valuable due to evidence of a higher relative hazard for CAD events in patients with severe ischemia treated
medically [56]. Evaluation of coronary anatomy and pathology currently requires the consideration of
modalities that may utilize a contrast agent, so renal functional status must be considered. A specific
classification scheme for renal function in this setting has not yet been widely accepted, despite the use of
Chronic Kidney Disease (CKD) class, and, therefore, institution-specific classifications should be used.
As noted in the Preface, this scenario focuses on defining whether or not ischemia is the etiology for heart
failure symptoms and should be seen as preceding a viability assessment which may be performed if
needed to further guide therapeutic decision making.
For this clinical scenario, the following imaging parameters are most relevant:
Anatomy
1. Coronary Artery Abnormalities (including atherosclerotic disease, anomalies)
Function
1. Global Ventricular Systolic Dysfunction (including reduced ejection fraction and stroke volume)
2. Valve Dysfunction (stenosis/regurgitation/other abnormalities)
24
Myocardial Status
1.
2.
3.
4.
Fibrosis/Scarring (transmural extent/mural distribution/pattern)
Regional Ventricular Systolic Dysfunction including wall thickening)
Inducible Ischemia-Decreased Perfusion
Inducible Ischemia-Decreased Contraction
Literature Review
Summary Statement
Available evidence regarding the optimal method for evaluation of patients with classical angina, ischemic
equivalent pain, dyspnea-equivalent angina, or extensive proven or suspected silent myocardial ischemia
and HF is characterized by observational studies with various imaging modalities that demonstrate
diagnostic performance and additional prognostic series [59]. The recently published STICH (Surgical
Treatment for Ischemic Heart Failure) trial evaluating medical versus surgical revascularization [60]
provides evidence regarding the benefit of revascularization with regards to cardiovascular events.
In patients with increasing renal dysfunction, modalities that use iodinated or gadolinium-based contrast
agents pose increased risk and should be avoided when suitable alternatives exist.
Echocardiography
Stress Echo has been shown to identify both resting and post-stress systolic wall motion abnormalities in
many observational studies [61-63]. In many of these observational studies ischemia was defined as
new/worsening wall motion abnormality (WMA) or a biphasic response (defined as WMA augmentation at
low dose with deterioration at high dose dobutamine stress echocardiography). These findings have been
related to clinical outcomes.
Cardiovascular Magnetic Resonance
Perfusion CMR studies have been performed in patients without systolic dysfunction for the identification
of CAD, but have not been extensively studied in HF patients. CMR has been studied in small series used to
evaluate wall motion with stress in patients with HF [64]. CMR with high resolution has more often been
used to detect fibrosis, a technique that, in observational studies, has identified ischemic versus nonischemic cardiomyopathy in HF patients. Recent preliminary reports have linked fibrosis with clinical
outcome [65,66].
Single Photon Emission Computed Tomography
SPECT has been studied extensively in HF patients to determine both ischemia and prognosis. Moreover,
observational evidence supports the concept that patients referred to stress MPI (myocardial perfusion
imaging) with dyspnea are high risk [59]. A benefit to the use of SPECT imaging is the addition of rest and
post-stress gated LVEF and wall motion information in addition to MPI measurements, including both
visual (qualitative) and quantitative measurements [67]. For patients referred for evaluation of symptoms
25
suggestive of HF, the results of stress MPI have been applied to differentiate ischemic from non-ischemic
cardiomyopathy. Significant and extensive angiographic CAD occurs frequently in patients with high risk
stress MPI findings. Finally, reports on the use of stress MPI have focused on the utility of ischemia as a
marker of downstream improvement in left ventricular function. In the CHRISTMAS (Carvedilol
Hibernation Reversible Ischaemia Trial, Marker of Success) trial, a total of 305 patients with HF were
enrolled and randomized to carvedilol versus placebo [68]. There was a gradient relationship, with the
number of ischemic segments and improvement in left ventricular function noted at approximately 6
months of follow-up. In a recent prospective, controlled clinical trial, 201 patients following index
hospitalization for HF underwent stress MPI [69]. This cohort included a broad range of LVEF
measurements including 36% of patients with preserved systolic function. When the stress MPI (i.e.,
summed stress score >3, indicating at least mildly abnormal) results were compared with invasive
coronary angiography in 75 patients, the sensitivity and specificity of stress MPI for detection of any
significant CAD stenosis were 82% and 57%, respectively. For extensive CAD in the proximal left anterior
descending (LAD) or left main (LM) or multivessel CAD, the sensitivity and specificity were 96% and 56%,
respectively.
Radionuclide Ventriculography (RNV)
As noted in the previous text, gated SPECT or PET measures of LV volumes provide similar information and
with concomitant performance of rest and stress myocardial perfusion imaging, the use of RNV is generally
not indicated for ascertaining ischemic etiologies for HF.
Positron Emission Tomography
Data regarding the use of PET in this setting are largely derived from studies that include patients
undergoing evaluation of myocardial viability. An advantage of the use of stress MPI with PET is its
improved accuracy for the detection of severe, multivessel CAD, which may appear as balanced reduction
and normal SPECT findings. Moreover, PET markers of absolute peak stress LVEF measurements and
myocardial perfusion reserve may improve detection of patients with CAD [41,52]. Some small series have
noted the advantage of quantifying the extent of myocardial scarring and insulin resistance as important
prognostic findings from PET [70]. Finally, altered glucose metabolism and myocardial efficiency have also
been studied in small series and may offer an added means to identify high risk patients with HF using PET
[71,72].
Cardiovascular Computed Tomography
CCT has been examined in some preliminary studies of patients with HF and has been shown to have a high
negative predictive value, in confirming the absence of CAD [73-75]. In a small study, electron beam CT
showed promise in identifying CAD in HF patients when compared with catheterization [42,74].
Conventional Diagnostic Cardiac Catheterization
Cardiac catheterization has shown obstructive CAD in patients with HF with and without angina/ischemic
equivalent in observational studies [76-78] and is considered a central study by the ACC/AHA guidelines.
26
Additionally, cardiac catheterization was used solely as the entry criteria for determination of obstructive
CAD in patients enrolled in the STICH trial and other trials of coronary revascularization versus medical
therapy.
Guidelines
The relevant guideline recommendations for this clinical scenario are:
1. Patient with Angina/Ischemic equivalent Syndrome/Angina:
ACC/AHA Heart Failure Guidelines [10]
Class I
 Coronary arteriography should be performed in patients presenting with HF who have angina or
significant ischemia unless the patient is not eligible for revascularization of any kind. (Level of
Evidence B)
Class – IIa
 Coronary arteriography is reasonable for patients presenting with HF who have angina/ ischemic
equivalent that may or may not be of cardiac origin who have not had evaluation of their coronary
anatomy and who have no contraindications to coronary revascularization. (Level of Evidence: C)
Class – IIb
 Noninvasive imaging may be considered to define the likelihood of CAD in patients with HF and
LV dysfunction. (Level of Evidence: C)
2. Patient without Angina/Ischemic Equivalent Syndrome/Angina
ACC/AHA Heart Failure Guidelines [10]
Class IIa
 Coronary arteriography is reasonable for patients presenting with HF who have known or
suspected CAD, but who do not have angina, unless the patient is not eligible for revascularization
of any kind. (Level of Evidence: C)
 Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients
presenting with HF who have known CAD and no angina unless the patient is not eligible for
revascularization of any kind [22]. (Level of Evidence: B)
Class IIb
 Noninvasive imaging may be considered to define the likelihood of CAD in patients with HF and
LV dysfunction. (Level of Evidence: C)
27
TABLE 2. EVALUATION FOR ISCHEMIC ETIOLOGY
(In this table, all patients have known HF, are suspected of ischemia, and are assumed to be
revascularization candidates)
Rest Only
INDICATION
Rest + Stress
Echo
RNV
SPECT
PET
CMR
Echo
SPECT
PET
CMR
CCT
Cath
6.
Angina/Ischemic equivalent
syndrome
M
R
R
M
M
A
A
A
A
A
A
7.
WITHOUT angina/ischemic
equivalent syndrome
M
R
R
M
M
A
A
A
A
M
A
28
Section References – Clinical Scenario 2: Evaluation for Ischemic Etiology
2.
3.
4.
5.
6.
10.
22.
41.
42.
52.
55.
56.
57.
58.
59.
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JJ, Poldermans D. Prognostic significance of akinesis becoming dyskinesis during dobutamine stress
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Link KM, Case D, Hundley WG. Prediction of cardiac events in patients with reduced left ventricular
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31
Clinical Scenario 3
Viability Evaluation (After Ischemic Etiology Determined) Known to Be
Amenable to Revascularization With or Without Clinical Angina
Clinical Rationale
A subpopulation of patients with known CAD and chronic LV dysfunction is thought to have potential
reversibility of LV dysfunction if successfully revascularized by coronary artery bypass graft (CABG) or
percutaneous coronary intervention (PCI). The underlying pathophysiologic substrate has been termed
“hibernating myocardium” [79], and is thought to result from significant coronary arterial luminal
compromise limiting myocardial blood flow with even minimal demand, such that the myocardium “down
regulates” contractility, gradually or through repetitive stunning, to match the diminished blood flow as a
possible compensatory or adaptive mechanism. The result is a state of chronic LV dysfunction, which often
may manifest clinically as HF with or without anginal symptoms.
The clinical scenario in which identification of such a patient is important is: 1) history of CAD amenable to
revascularization by CABG or PCI; 2) chronic regional and/or global LV dysfunction, and 3) symptoms of HF
and/or angina.
Imaging Rationale
The goal of imaging is to define whether dysfunctional myocardial regions are the result of prior infarction,
current hibernating state, or a combination. The important implication of making such a distinction is that
if sufficient myocardial viability (hibernation or inducible ischemia) is present, the patient may benefit
clinically from revascularization. If the regional dysfunction is predominantly due to infarction, then the
clinical implication is that revascularization would confer no benefit, and thus the risks of revascularization
outweigh the potential benefits. A property of dysfunctional but viable myocardium in the setting of
chronic ischemic heart disease is “contractile reserve,” that is, the ability to increase contractility for a brief
period of time during an inotropic stimulus. Unfortunately, its assessment is limited in the setting of
ischemic HF. The presence of clinical angina may indicate the presence of viable myocardium; however this
is often clinically weighed against the degree of LV dysfunction. Scenarios based on the presence of angina
(or angina/ischemic equivalent), the level of LV dysfunction, and wall thinning are used to help identify
situations in which differing imaging tests for viability may add value.
For this clinical scenario, the following imaging parameters are most relevant:
Anatomy
1. Chamber anatomy abnormalities (geometry/dimension/wall thickness)
2. Coronary artery abnormalities (including atherosclerotic disease)
Function
1. Global ventricular systolic dysfunction (including reduced ejection fraction and stroke volume)
32
2. Valve dysfunction (stenosis/regurgitation/other abnormalities)
Myocardial Status
1.
2.
3.
4.
5.
6.
7.
Fibrosis/scarring (transmural extent/mural distribution/pattern)
Regional Ventricular Systolic Dysfunction (including wall thickening)
Inducible ischemia-decreased perfusion
Inducible ischemia-decreased contraction
Hibernating state- positive contractile reserve
Hibernating state-anaerobic metabolism/glucose utilization
Hibernating state-minimal scarring
LITERATURE REVIEW
Summary Statement
Evidence for the use of viability imaging in patients with impaired LV dysfunction is currently available
from several meta-analyses of observational studies that demonstrate recovery of function and clinical
improvement in patients undergoing revascularization with evidence of viable myocardium [80,81]. The
recently published small substudy of the STICH trial did not find improved outcomes in a nonrandomized
cohort of patients undergoing viability testing.
Echocardiography
Contractile reserve with echo can be imaged using dobutamine echo, and manifests in the dysfunctional
region of interest as an increase in wall thickening and motion during low doses of dobutamine, with a
subsequent impairment of contractility at higher doses, a finding termed “biphasic response.” This
technique has been shown in observational studies to identify myocardial segments with higher likelihood
of functional recovery after coronary revascularization in patients with moderately reduced LVEF (median
31%) [76]. Contractile reserve may be limited in patients with thinned LV walls [82].
Cardiovascular Magnetic Resonance
CMR identification of hibernating myocardium and potential reversibility of LV dysfunction is based on the
use of late enhancement gadolinium imaging, in combination with information on regional function
available with cine CMR techniques. Observational studies have demonstrated that “viability”, defined by
the relative absence of scarring, resulted in improvement in myocardial function following coronary
revascularization in patients with preserved [83] and severely depressed LV function [84]. Post-infarction
risk stratification with pharmacologic stress CMR data is also available [85]. Dobutamine stress CMR is
also useful for diagnosing CAD [86]. Additionally, CMR has been shown to demonstrate subendocardial
infarction with a greater sensitivity than SPECT in small observational series [85,87].
Single Photon Emission Computed Tomography
Studies with SPECT tracers involving biopsies of regional myocardium in patients undergoing CABG have
demonstrated that the degree of uptake of the tracers (by quantitative analysis) correlates directly with the
33
magnitude of regional myocyte tissue viability on biopsies, thus validating the use of this technique in this
scenario. Observational studies of SPECT imaging in patients with HF have identified worse prognosis in
patients without viable myocardium [88]. In a large systematic review of 24 published reports, the
accuracy of SPECT, PET, and Echo for prognostication was similar [80].
Radionuclide Ventriculography (RNV)
As noted earlier in the text, gated SPECT or PET measures of LV volumes provide similar information, and
with concomitant performance of rest and stress MPI, the use of RNV is generally not indicated for the
assessment of myocardial viability.
Positron Emission Tomography
In 2 randomized trials, a strategy of fluorodeoxyglucose (FDG) -PET-directed revascularization has been
compared with standard care for decisions regarding revascularization (PARR 1 and PARR 2 [Positron
Emission Tomography and Recovery Following Revascularization 1 and 2]) trials [89,90]. These studies
demonstrated that patients with viability who underwent revascularization had evidence of improved
myocardial function. In addition, when compared with SPECT, FDG-PET was able to identify viable
myocardium with a higher sensitivity [91]. Although PET is reported to have greater sensitivity, the clinical
relative value in comparison to SPECT with regard to decision making and clinical outcomes has not clearly
been demonstrated [92] .
Cardiovascular Computed Tomography
Preliminary studies suggest that CCT imaging may provide similar information as CMR using contrast
enhancement with regard to delineation of etiology of LV dysfunction and to identify areas of regional
infarction, in combination with readily available information on regional function [93,94]. However, this
technique has not as yet been widely used for this purpose, and validation studies are more preliminary in
nature compared to the robust literature on all of the other noninvasive imaging modalities.
Conventional Diagnostic Cardiac Catheterization
There is limited initial evidence on the use of left ventriculography for the determination of viability and
response to revascularization. With the advent of newer non-invasive techniques this has not been
subsequently studied.
34
Guidelines
The relevant guideline recommendations for this clinical scenario are:
ACCF/AHA UA/NSTEMI [95,96]
Class I
 Percutaneous coronary intervention or CABG for patients with 1- or 2-vessel CAD without
significant proximal LAD CAD, but with a large area of viable myocardium and high-risk criteria
on noninvasive testing (Level of Evidence: B)
Class IIa
 Use of PCI or CABG for patients with 1-or 2-vessel CAD without significant proximal LAD disease,
but with a moderate area of viable myocardium and demonstrable ischemia on noninvasive
testing (Level of Evidence: B)
Class III
 Use of PCI or CABG for patients with 1-or 2-vessel CAD without significant proximal LAD disease
who have mild symptoms that are unlikely to be due to myocardial ischemia, or who have not
received an adequate trial of medical therapy and have only:
o A small area of viable myocardium; or
o Have no demonstrable ischemia on noninvasive testing. (Level of Evidence: C)
TABLE 3. VIABILITY EVALUATION (AFTER ISCHEMIC ETIOLOGY DETERMINED) KNOWN TO
BE AMENABLE TO REVASCULARIZATION WITH OR WITHOUT CLINICAL ANGINA
Rest Only
INDICATION
Rest + Stress
Echo
RNV
SPECT*
PET
CMR
Echo
SPECT
PET
CMR
CCT
Cath
8.
Severely reduced ventricular
function (EF < 30)
M
R
A
A
A
A
A
A
A
M
R
9.
Moderately reduced
ventricular function (EF 3039%)
M
R
M
A
A
A
A
M
A
M
R
10.
Mild ventricular function (EF
40% - 49%)
M
R
M
M
A
A
A
A
A
M
R
*SPECT Rest/ Redistribution
35
Section References - Clinical Scenario 3: Viability Evaluation (After Ischemic Etiology Determined) Known
to Be Amenable to Revascularization With or Without Clinical Angina
76.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
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coronary artery surgery in patients with poor left ventricular function (CASS). Circulation 1983;
68(4):785-95.
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37
Clinical Scenario 4
Consideration and Follow-Up for Implantable Cardioverter-Defibrillator (ICD) /
Cardiac Resynchronization Therapy (CRT)
Clinical Rationale
The LV dilation and dysfunction associated with significant HF frequently lead to ventricular
tachyarrhythmias, the most common rhythms causing sudden cardiac death in HF patients [10,97]. Sudden
cardiac death in HF can be decreased by the use of an ICD [98].
HF with severely depressed LV function is frequently accompanied by impaired electromechanical
coupling, leading to prolonged ventricular conduction (usually left bundle-branch block) with regional
mechanical delays [98]. Approximately one-third of HF patients with low LVEF and NYHA functional class
III to IV symptoms demonstrate a QRS duration > 0.12s, the primary marker for dyssynchronous
ventricular contraction[10,98]. The mechanical consequences of LV dyssynchrony include:
1.
2.
3.
4.
5.
Accentuated LV dysfunction with increased metabolic demand;
Suboptimal ventricular filling;
Functional mitral regurgitation;
Paradoxical interventricular septal motion; and
Adverse remodeling with increased LV dilatation [10,98-103].
For HF patients, dyssynchronous LV contraction is also associated with increases in cardiac mortality
[10,104-106].
In persistently symptomatic patients, cardiac resynchronization therapy (CRT) alone results in significant
improvements in:
1.
2.
3.
4.
Quality of life;
Functional class;
Exercise capacity; and
LVEF [10,98,107].
CRT also reduces repeat hospitalizations and mortality due to NYHA functional class III to IV HF when
compared with standard medical therapy [107-109].
Imaging Rationale
Use of an ICD requires placement of standard intracavitary leads into the right atrium and right ventricle
for proper monitoring and pulse delivery.
LV dyssynchrony, and its adverse effects, can be reduced by synchronous electromechanical activation of
the LV, using a biventricular pacing device for CRT [10,98,110,111]. CRT requires advancement of an LV
lead retrograde through the coronary sinus into a tributary overlying the LV free wall, as well as placement
of standard right atrium and right ventricular leads.
38
Currently, the major reasons for imaging in the setting of consideration for ICD or CRT device implantation
are, first, demonstration of LVEF < 35% and secondly, delineation of the amount and the location of
ventricular asynchrony. Both have a major impact on outcomes following device placement.
For this clinical scenario, the following imaging parameters are most relevant:
Anatomy
1. Cardiac vein variations (for CRT implantation)
Function
1. Global ventricular systolic dysfunction (including reduced ejection fraction)
2. Valve dysfunction (stenosis/regurgitation/other abnormalities
Myocardial Status
1.
2.
3.
4.
Inflammation
Fibrosis/scarring (transmural extent/mural distribution/pattern)
Regional ventricular systolic dysfunction (including wall thickening)
Myocardial Wall Mechanics (including strain and synchrony analysis)
Miscellaneous
1. Thrombus-atrial
2. Thrombus-ventricular
LITERATURE REVIEW
Implantable Cardioverter-Defibrillator
Cardiovascular imaging for consideration of ICD implantation is mainly based on the evaluation LV systolic
function. In the SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial), the distribution of LVEF values
measured by echo, contrast left ventriculography, and radionuclide angiography differed, but clinical
outcomes did not [112]. Repeat imaging for ICD implantation may be done to determine whether a course
of therapy (either revascularization or medical) has improved the ventricular function or whether the
patient still meets LVEF criteria. Therefore, again the goals of imaging are dependent on LV systolic
function as described in the preceding text.
Cardiac Resynchronization Therapy
Cardiovascular imaging for consideration of CRT implantation also is mainly based on the evaluation of LV
systolic function. The majority of the large randomized CRT studies have used echo to evaluate LV systolic
function before and after implantation. Other imaging modalities have been used to evaluate LV systolic
function, but with limited studies in patients undergoing CRT. Identification of cardiac vein anatomy for
CRT implantation has been shown with CCT and, in some smaller studies, with CMR, and invasive cardiac
39
catheterization. CCT does provide the means to assess LV dyssynchrony and pulmonary vein anatomy with
a single study, as, in theory, does CMR. Despite several observational studies that evaluated different
imaging modalities for identifying potential predictors of clinical response to CRT, however, available
randomized trial data do not demonstrate improved outcomes. Up to 30% of carefully selected HF
candidates do not show benefit from CRT and possibly progressive worsening despite CRT [113,114]. It
should be noted that the literature for CRT use and the concomitant use of imaging modalities to direct
therapy is one of the fastest evolving fields. This report captures the best available literature for existing
standard technologies; however, several newer techniques and technologies may prove important in the
upcoming years. Finally, several available guideline recommendations are provided, and they currently
only require an EF evaluation and dyssynchrony based on the QRS duration.
Post-Implantation – Follow -Up Imaging
Studies with repeat imaging after ICD implantation for clinically stable patients without a change in status
have not been conducted. For patients with clinical deterioration or change in arrhythmia status,
evaluation of a change in ventricular function or in CAD / ischemia may be warranted based on guideline
recommendations for standard care of symptomatic HF.
In patients with improved HF class and LV systolic function following CRT implantation, routine clinical
imaging has not been studied.
LITERATURE REVIEW – BY IMAGING TEST
Echocardiography
Echo has been studied in the assessment of LVEF prior to ICD implantation such as in the SCD-HeFT [44].
Several observational studies have evaluated the value of echo in identifying and predicting response to
CRT [115-118]. Tissue Doppler imaging is superior to strain rate imaging and post-systolic shortening on
the prediction of reverse remodeling in both ischemic and nonischemic heart failure after CRT [119,120]. A
large randomized trial using echo-based parameters to identify patients that will respond to CRT did not
show a clinical benefit [121].
In patients with failure to respond to CRT or with worsening clinical status, studies with echo have been
used to maximize atrioventricular intervals and programming of the CRT device while monitoring LV
systolic function and mitral regurgitation [122,123]. Echo has also been shown to identify patients with
dyssynchrony who are missed by electrocardiography criteria alone [124,125].
Cardiovascular Magnetic Resonance
CMR has been demonstrated to reliably image LV systolic function, but with limited studies to date in
patients being considered for ICD placement. CMR has been shown to identify fibrosis that may lead to
future ventricular tachycardia/ventricular fibrillation in patients with [87] and those without an ICD
[126,127]. CMR has also shown the ability to demonstrate LV thrombus and pulmonary vein anatomy and
relationships.
40
Repeat imaging with CMR is not routinely performed in patients with an intracardiac device due to both
safety concerns and limitations in the ability to acquire diagnostic images.
Observational studies with CMR in patients under consideration for CRT have shown that patients with
areas of fibrosis, specifically near potential lead placement areas, do not demonstrate clinical improvement
with CRT [128]. One study found CMR to be more sensitive for fibrosis than SPECT in prospective CRT
patients.
Radionuclide Ventriculography (RNV) and Gated SPECT
RNV for LVEF is highly reproducible when compared to echo and has been used as an inclusion test for
randomized trials demonstrating the benefit of ICD implantation [48,112]. Rest and post-stress gated LVEF
measurements are also routinely applied and are highly reproducible as part of a CAD evaluation [67].
Various SPECT measures of dyssynchrony in patients undergoing CRT have been studied with some studies
correlating with echocardiographic measures. Observational studies have evaluated SPECT measures of
dyssynchrony in patients undergoing CRT to determine patients that will respond to the therapy [129].
From a recent report in 44 patients, phase analysis of gated SPECT was accurate in predicting acute change
in LV synchrony and patient outcome following CRT [130,131].
Positron Emission Tomography
Data for the use of PET in patient being considered for ICD implantation are limited. Initial PET studies
have identified potential areas of fibrosis in patients with CRT, and attempted to differentiate responders
from nonresponders to CRT.
Cardiovascular Computed Tomography
CCT has had promising initial studies evaluating LV systolic function. Recent reports have noted the utility
of CCT for ICD placement, including venous imaging before ICD, quantitation of dyssynchrony, and EF
assessment.
41
Guidelines
The relevant guideline recommendations for this clinical scenario are:
ACC/AHA Heart Failure Guidelines [10]
ICD
Class I
 Primary prevention of sudden cardiac death in HF are for patients with:
a. Nonischemic dilated cardiomyopathy or ischemic heart disease > 40 days post-MI;
b. LVEF < 35%;
c. NYHA functional class II or III despite optimal medical therapy; and
d. A reasonable expectation of survival with a good functional status for more than 1 year.
 Secondary prevention [10,132] in order to prolong survival in HF patients with:
a. Current or prior HF symptoms;
b. Reduced LVEF; and
c. A history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular
tachycardia.
Class I
 CRT (with or without ICD) use in patients with HF are:
a. LVEF < 35%;
b. Sinus rhythm;
c. NYHA functional class III or ambulatory class IV symptoms despite optimal medical therapy;
and
d. Cardiac dyssynchrony (defined as QRS duration > 0.12s), CRT (with or without combined ICD).
42
Table 4. Consideration and Follow-Up for Implantable Cardioverter-Defibrillator
(ICD/Cardiac Resynchronization Therapy (CRT)
Rest Only
INDICATION
Echo
Rest + Stress
CMR
CCT
Cath
RNV
SPECT
PET
CMR
Echo
SPECT
PET
A
A
M
R
A
R
R
R
R
R
R
R
R
R
R
R
R
R
R
A
R
M
R
R
R
R
R
R
M
R
A
R
M
R
R
R
R
R
R
R
R
A
A
M
R
A
R
R
R
R
M
R
Implantable Cardioverter-Defibrillator Therapy
11.
Evaluation determine patient
candidacy [98]


12.

Change in arrhythmia status
Appropriate ICD discharge
(e.g. VT/VF)
Follow-up after placement


15.
No deterioration in clinical
status AND
No change in arrhythmia
status
Follow-up after placement


14.
R
Routine follow up after
placement

13.
Meets published clinical
standards for device
eligibility
Candidacy requires
assessment of ejection
fraction and/or other
structural information
Change in arrhythmia status
Inappropriate ICD discharge
(e.g. rapid AFib)
Initial evaluation to determine
patient candidacy [98]


Meets published clinical
standards for device
eligibility
Candidacy requires
assessment of ejection
fraction
43
Rest Only
INDICATION
16.
Cath
R
A
R
R
R
M
R
R
R
R
R
RNV
SPECT
PET
CMR
Echo
SPECT
PET
CMR
A
R
R
R
A
R
R
R
A
M
M
R
R
R
R
M
R
R
R
R
R
R
Follow-up early (< 6 months)
after implantation


18.
CCT
Echo
Procedure Planning:
considerations
 Patient meets all published
clinical standards for device
 Evaluation of myocardial
fibrosis/scarring, coronary
vein variations, and intracavitary thrombus (for
dyssynchrony evaluation)
17.
Rest + Stress
No improvement in
symptoms OR
No improvement functional
capacity
Follow-up late (> 6 months)
after implantation


Improved symptoms (i.e.
from class III, IV to class I, II)
OR
Improved functional
capacity
AFib = atrial fibrillation; VF = ventricular fibrillation; VT= ventricular tachycardia
44
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dyssynchrony in a substantial proportion of patients with chronic heart failure. J Am Soc Echocardiogr
2006; 19(10):1257-63.
125. Yu CM, Lin H, Zhang Q, Sanderson JE. High prevalence of left ventricular systolic and diastolic
asynchrony in patients with congestive heart failure and normal QRS duration. Heart 2003; 89(1):5460.
126. Assomull RG, Prasad SK, Lyne J, Smith G, Burman ED, Khan M, Sheppard MN, Poole-Wilson PA, Pennell
DJ. Cardiovascular magnetic resonance, fibrosis, and prognosis in dilated cardiomyopathy. J Am Coll
Cardiol 2006; 48(10):1977-85.
127. Yokokawa M, Tada H, Koyama K, Naito S, Oshima S, Taniguchi K. Nontransmural scar detected by
magnetic resonance imaging and origin of ventricular tachycardia in structural heart disease. Pacing
Clin Electrophysiol 2009; 32 Suppl 1:S52-6.
128. Bilchick KC, Dimaano V, Wu KC, Helm RH, Weiss RG, Lima JA, Berger RD, Tomaselli GF, Bluemke DA,
Halperin HR, Abraham T, Kass DA, Lardo AC. Cardiac magnetic resonance assessment of
dyssynchrony and myocardial scar predicts function class improvement following cardiac
resynchronization therapy. JACC Cardiovasc Imaging 2008; 1(5):561-8.
129. Boogers MM, Van Kriekinge SD, Henneman MM, Ypenburg C, Van Bommel RJ, Boersma E, DibbetsSchneider P, Stokkel MP, Schalij MJ, Berman DS, Germano G, Bax JJ. Quantitative gated SPECT-derived
phase analysis on gated myocardial perfusion SPECT detects left ventricular dyssynchrony and
predicts response to cardiac resynchronization therapy. J Nucl Med 2009; 50(5):718-25.
130. Chen J, Nagaraj H, Bhambhani P, Kliner DE, Soman P, Garcia EV, Heo J, Iskandrian AE. Effect of alcohol
septal ablation in patients with hypertrophic cardiomyopathy on left-ventricular mechanical
dyssynchrony as assessed by phase analysis of gated SPECT myocardial perfusion imaging. Int J
Cardiovasc Imaging 2012; 28(6):1375-84.
131. Friehling M, Chen J, Saba S, Bazaz R, Schwartzman D, Adelstein EC, Garcia E, Follansbee W, Soman P. A
prospective pilot study to evaluate the relationship between acute change in left ventricular
synchrony after cardiac resynchronization therapy and patient outcome using a single-injection gated
SPECT protocol. Circ Cardiovasc Imaging 2011; 4(5):532-9.
132. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, Konstam MA, Mancini DM,
Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 focused update: ACCF/AHA Guidelines for the
47
Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines: developed in
collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009;
119(14):1977-2016.
48
Clinical Scenario 5
Repeat Evaluation of HF
Clinical Rationale
Optimal medical therapy permits HF patients to now lead longer and more functional lives. Regardless of
the etiology, however, HF is a chronic process often characterized by gradual clinical deterioration.
Imaging Rationale
Noninvasive imaging may be used to assess prognosis or to optimize treatment in patients with known and
previously-evaluated HF. Many of the previously discussed imaging parameters are used to re-assess
patients.
For this clinical scenario, the following imaging parameters are most relevant:
Anatomy
1. Coronary artery abnormalities (including atherosclerotic disease)
Function
1. Global ventricular systolic dysfunction (including reduced ejection fraction)
2. Valve dysfunction (stenosis/regurgitation/other abnormalities)
Myocardial Status
1.
2.
3.
4.
5.
6.
7.
Fibrosis/scarring (transmural extent/mural distribution/pattern)
Regional ventricular systolic dysfunction (including wall thickening)
Inducible ischemia-decreased perfusion
Inducible ischemia-decreased contraction
Hibernating state- positive contractile reserve
Hibernating state-anaerobic metabolism/glucose utilization
Hibernating state-resting dysfunction/minimal scarring
LITERATURE REVIEW
Summary Statement
Although a common clinical situation, little published literature exists regarding repeat imaging and
evaluation of patients with HF. The majority of literature is associated with re-evaluation for consideration
of implantable defibrillator therapy or efficacy of resynchronization therapy. Both of these clinical
situations and their relevant literature are reviewed in Scenario #4.
Regarding stable patients without a change in clinical status, a few studies have demonstrated that
radionuclide imaging, echo, and CMR can reliably demonstrate a change in LVEF after medical therapy
49
[133-137]. However, there were no studies found that identified a clinical benefit in routine serial imaging
in patients without a change in clinical status. Measures of rest and stress LVEF measures with gated SPECT
and RNV have been shown to be highly reproducible [138].
Radionuclide Ventriculography (RNV) and Gated SPECT
Measures of rest and stress LVEF measures with gated SPECT and RNV have been shown to be highly
reproducible [138]. Accordingly, numerous reports have evaluated the role of serial measurements of LV
volumes to track the efficacy of a variety of therapeutic interventions for patients with HF [49-51,139,140].
Guidelines
The relevant guideline recommendations for this clinical scenario are:
ACC/AHA Heart Failure Guidelines [10]
CLASS IIa
 Repeat measurement of EF and the severity of structural remodeling can be useful to provide
information in patients with HF who have had a change in clinical status or who have experienced
or recovered from a clinical event or received treatment that might have had a significant effect
on cardiac function. (Level of Evidence: C)
TABLE 5. REPEAT EVALUATION OF HF
Rest Only
INDICATION
Rest + Stress
Echo
RNV
SPECT
PET
CMR
Echo
SPECT
PET
CMR
CCT
Cath
19
New angina or ischemic
equivalent syndrome
A
M
M
M
M
A
A
M
M
M
A
20.
New or increasing HF
symptoms (e.g., shortness of
breath or exertional
dyspnea) AND
Adherent to medical therapy
A
M
M
R
M
A
A
M
M
M
M
No new symptoms AND
No other change in clinical
status
Less than 1year since prior
imaging
R
R
R
R
R
R
R
R
R
R
R
No new symptoms AND
No other change in clinical
status
Greater than or equal to 1
year since prior imaging
M
R
R
R
R
R
R
R
R
R
R
21.
22.
50
Section References - Clinical Scenario 5: Repeat Evaluation of HF
10.
49.
50.
51.
133.
134.
135.
136.
137.
138.
139.
140.
Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA,
Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update
incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure
in Adults A Report of the American College of Cardiology Foundation/American Heart Association
Task Force on Practice Guidelines Developed in Collaboration With the International Society for
Heart and Lung Transplantation. J Am Coll Cardiol 2009; 53(15):e1-e90.
Rizzello V, Poldermans D, Biagini E, Schinkel AF, Boersma E, Boccanelli A, Marwick T, Roelandt JR, Bax
JJ. Prognosis of patients with ischaemic cardiomyopathy after coronary revascularisation: relation to
viability and improvement in left ventricular ejection fraction. Heart 2009; 95(15):1273-7.
Udelson JE, Feldman AM, Greenberg B, Pitt B, Mukherjee R, Solomon HA, Konstam MA. Randomized,
double-blind, multicenter, placebo-controlled study evaluating the effect of aldosterone antagonism
with eplerenone on ventricular remodeling in patients with mild-to-moderate heart failure and left
ventricular systolic dysfunction. Circ Heart Fail 2010; 3(3):347-53.
Vizzardi E, D'Aloia A, Giubbini R, Bordonali T, Bugatti S, Pezzali N, Romeo A, Dei Cas A, Metra M, Dei
Cas L. Effect of spironolactone on left ventricular ejection fraction and volumes in patients with class I
or II heart failure. Am J Cardiol 2010; 106(9):1292-6.
Doherty NE, 3rd, Seelos KC, Suzuki J, Caputo GR, O'Sullivan M, Sobol SM, Cavero P, Chatterjee K,
Parmley WW, Higgins CB. Application of cine nuclear magnetic resonance imaging for sequential
evaluation of response to angiotensin-converting enzyme inhibitor therapy in dilated
cardiomyopathy. J Am Coll Cardiol 1992; 19(6):1294-302.
Grothues F, Moon JC, Bellenger NG, Smith GS, Klein HU, Pennell DJ. Interstudy reproducibility of right
ventricular volumes, function, and mass with cardiovascular magnetic resonance. Am Heart J 2004;
147(2):218-23.
Grothues F, Smith GC, Moon JC, Bellenger NG, Collins P, Klein HU, Pennell DJ. Comparison of
interstudy reproducibility of cardiovascular magnetic resonance with two-dimensional
echocardiography in normal subjects and in patients with heart failure or left ventricular
hypertrophy. Am J Cardiol 2002; 90(1):29-34.
Kasama S, Toyama T, Sumino H, Nakazawa M, Matsumoto N, Sato Y, Kumakura H, Takayama Y,
Ichikawa S, Suzuki T, Kurabayashi M. Prognostic value of serial cardiac 123I-MIBG imaging in patients
with stabilized chronic heart failure and reduced left ventricular ejection fraction. J Nucl Med 2008;
49(6):907-14.
Konstam MA, Rousseau MF, Kronenberg MW, Udelson JE, Melin J, Stewart D, Dolan N, Edens TR, Ahn
S, Kinan D, et al. Effects of the angiotensin converting enzyme inhibitor enalapril on the long-term
progression of left ventricular dysfunction in patients with heart failure. SOLVD Investigators.
Circulation 1992; 86(2):431-8.
McGowan JH, Cleland JG. Reliability of reporting left ventricular systolic function by
echocardiography: a systematic review of 3 methods. Am Heart J 2003; 146(3):388-97.
Borges-Neto S, Shaw LJ, Kesler K, Sell T, Peterson ED, Coleman RE, Jones RH. Usefulness of serial
radionuclide angiography in predicting cardiac death after coronary artery bypass grafting and
comparison with clinical and cardiac catheterization data. Am J Cardiol 1997; 79(7):851-5.
Delagardelle C, Feiereisen P, Vaillant M, Gilson G, Lasar Y, Beissel J, Wagner DR. Reverse remodelling
through exercise training is more pronounced in non-ischemic heart failure. Clin Res Cardiol 2008;
97(12):865-71.
51
Discussion
The current document represents the first joint effort by the American College of Radiology and American
College of Cardiology to address appropriate utilization of cardiovascular imaging in HF patients. As such,
the document represents the efforts of professional societies, countless individuals, and the groups’ hope is
that it will help optimize the care of patients with HF. Because HF is a complex medical syndrome
consisting of several possible underlying etiologies and/or exacerbating conditions, the writing group
attempted to provide a framework for considering the clinical indications, Figure 1. This framework
included indications aimed at evaluating structure and function, underlying ischemic etiology, viability for
revascularization decisions, determination and the need for evaluation of patients being considered for
defibrillators and resynchronization devices, and the use of imaging in longitudinal follow up of patients.
Even with this robust set of scenarios, the writing group and the rating panel recognized that all the
possible indications are not covered in this first document; for example, the evaluation of nonischemic
underlying etiologies for individuals presenting with new -onset HF represents an important area not
covered. Nevertheless, the process of reviewing the available literature, presenting common clinical
scenarios, and having a wide spectrum of clinical experts in both cardiology and radiology rate the
indications for heart failure imaging has provided some important lessons for the clinical community. The
lessons from the literature review and conclusions from the rating panel will be presented as general
concepts and by clinical indications.
The writing group and rating panel acknowledge that there are many diagnostic procedures used to
evaluate patients with HF. The writing group and rating panel did not rate resting electrocardiogram or
chest x-rays because they were felt to be part of the routine data collected with general history and
physical examinations when appropriate. The procedures that were considered included both rest and
rest/stress tests where possible, for echo, radionuclide imaging (including RNV, SPECT, PET), and CMR.
Additionally, imaging of cardiac structures and coronary angiography with cardiac CT and invasive cardiac
catheterization were considered as well. In total, this represented 11 possible tests for several clinical
indications. This required a detailed review of both the possible technical capabilities and the clinical data
reported for these modalities. Finally, the writing group also used available documents from both ACR and
ACCF to determine the safety data for these procedures. The appendix (see Imaging Parameters Evidence)
provide these technical capability and safety data and should provide an important reference for future
reviews.
Clinical Indications
Review of the clinical indications provides some important themes and lessons. For patients undergoing
initial evaluation for potential or suspected HF, the rating panel found no role in general for routine use of
stress cardiovascular imaging, cardiac CT, or invasive angiography. Both echo and CMR were felt to be
procedures that would provide clinically meaningful information. The rating panel felt that if the only
information needed is EF, then RNV may also be a possibly useful test. However, for more routine
evaluation for comprehensive cardiac structure and function, including in patients with familial
cardiomyopathy, congenital heart disease patients, or post- MI patients, both echo and CMR were felt to be
more useful imaging modalities. The panel also noted that ventricular function evaluation (i.e.,
52
ventriculography) might also be performed at the time of coronary arteriography in acute MI or suspected
ischemia.
Once HF has been clinically diagnosed, and the cardiac structure and function has been determined, the
rating panel preferred stress testing with any of the available modalities, or angiography with CTA, or
invasive cardiac catheterization. In patients with HF and angina, invasive cardiac catheterization and
angiography was felt to be appropriate if the patient was otherwise a candidate for revascularization.
With regard to viability, the writing group attempted to provide recommendation stratified by 3 general
categories of ventricular dysfunction, severe (EF < 30%), moderate (EF 30% to 39%), and mild (EF 40% to
49%). It should be noted that patients with LVEF = 35% or less are candidates for defibrillators, and
viability testing was considered independent of determination for need for devices therapy. The literature
and the rating panel opinions suggested many of the modalities were sufficient for determining viability
across a spectrum of patients. Resting CMR and PET were felt to be appropriate and useful in the patients
with severe ventricular dysfunction, along with the possibility of stress echo or SPECT scan.
For patients being considered for devices therapy, both ICD and CRT, many studies are underway to
maximize device function with the use of imaging. However, the available evidence does not as yet support
criteria for device therapy beyond LVEF. Therefore, echo and CMR testing were felt to be useful in patient
selection. Additionally, CMR and cardiac CT were rated as appropriate for device planning often to help
map the coronary vein anatomy for CRT implantation. CMR was felt to be useful for identification of
myocardial fibrosis and possible thrombus. The rating panel felt that most of these patients did not need a
stress evaluation or invasive cardiac catheterization. Finally, the rating panel felt it was appropriate to reevaluate LV function for patients who had a change in clinical status including ICD discharge or who had
their device activated, but thought the indication for routine follow- up EF testing was rarely appropriate,
with the possible exception of echocardiography, which was rated as maybe appropriate.
These concepts were carried for the longitudinal assessment of patients. For the patients with changing
symptoms and presentation with either worsening HF symptoms (where a change in structure or function
was suspected), the rating panel rated the indication similar to the initial evaluation with consideration for
testing. For patients with changing symptoms and additional concerns for ischemia, again the rating panel
thought stress testing was reasonable. For patients with HF and no change in symptoms, the rating panel
in general felt testing was rarely appropriate. These ratings will hopefully provide guidance at the time of
test consideration, especially in patients with HF who are seen in multiple locations within the healthcare
system.
The partnership between the ACR and ACCF should be seen as a model for review of diagnostic imaging
and should be incorporated into future efforts. We acknowledge the great variation in the clinical
presentation of patients with HF, and therefore provide these appropriate use criteria as recommendation
to be used in conjunction with sound clinical judgment. We believe the implementation of these criteria in
decision support tools with population or practice review will augment clinical care and hopefully lead to
high quality and efficient care. Finally, we also recognize that many aspects of clinical care in patients with
heart failure is rapidly evolving with increasing evidence for effective therapies and diagnostic tests, and
53
therefore anticipate that this document will need to be updated in a timely fashion. In the interim, we
believe these ratings will be important useful guidance at the point of care for patients with HF.
54
APPENDIX – Relationships with Industry Disclosures
Appropriate Utilization of Cardiovascular Imaging in Heart Failure Writing Group
Committee
Member
Manesh R.
Patel
Richard D.
White
Suhny
Abbara
David A.
Bluemke
Robert J.
Herfkens
Michael
Picard
Leslee J.
Shaw
Arthur E.
Stillman
Marc Silver
James
Udelson
Speaker’s
Bureau
None
Ownership/
Partnership/
Principal
None
Institutional,
Organizational, or Other
Financial Benefit
None
Expert Witness
None
None
None
Siemens
Medical
Solutions
BRACCO
Diagnostics
None
None
Magellan
Healthcare
Perceptive
Informatics
GE
Healthcare
None
None
None
Partners Imaging
None
None
None
EPIX
None
None
None
None
None
None
None
None
None
None
None
None
None
GE
Healthcare
None
None
None
None
None
None
None
BRACCO
Diagnostics
None
None
None
None
None
None
None
None
Acusphere
Cytori Rx
BoeringerIngleheim
BioLine Rx
General
Electric
Molecular
Insight
Pharm
Healthcare
Otsuka King
Pharm
None
None
Baxter
GlaxoSmithKline
Medtronic
NHLBI
interventional
grant
Circulation Editor
Defendant
Failure to
diagnose case
American Heart
Association
Consultant
Diachii
Sankyo/Lilly
None
Research
Genzyme
Appendix – Relationships with Industry Disclosures
Appropriate Utilization of Cardiovascular Imaging in Heart Failure Rating Panel
Ownership/
Institutional,
Committee
Speaker’s Partnership/
Organizational, or Other
Member
Consultant Bureau
Principal
Research Financial Benefit
Expert
Witness
Peter Alagona
Gerard
Aurigemma
Javed Butler
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
National
Institutes
of Health
None
Don Casey
Ricardo Cury
None
Astellas
Pharma
None
None
None
None
Scott Flamm
Tim Gardner
None
None
None
None
None
None
None
Astellas
Pharma
GE
Healthcare
None
None
AMGEN
Biotronic Trial,
Boston Scientific,
Cardiomems,
Corthera FoldRx,
ICoapsys,
Johnson & Johnson
Medtronic
Rule 90,
Thoratec
World Health Inc
None
None
None
None
Rajesh
Krishnamurthy
Joseph Messer
Michael W.
Rich
Henry Royal
Gerald
Smetana
Peter
Tilkemeier
Mary Norine
Walsh
None
None
None
None
None
NHLBI Cardio surgical
clinical research network
chair
None
None
SanofiAventis
None
None
None
SanofiAventis
None
None
None
None
None
None
None
None
None
None
None
Anvita Health
None
None
None
None
None
None
None
None
None
None
None
None
BioControl,
Emerge,
Medtronic,
United
Healthcare
None
None
None
None
None
None
None
None
Astellas,
Lanthens
None
None
Pamela
Woodard
56
None
None
None
Appendix – Relationships with Industry Disclosures
Appropriate Utilization of Cardiovascular Imaging in Heart Failure External Reviewers
Ownership/
Institutional,
Committee
Speaker’s Partnership/
Organizational, or
Member
Consultant Bureau
Principal
Research
Other Financial Benefit
G. Michael
Felker
Amgen
Cytokinetics
Roche
Novartis
None
None
Victor Ferrari
None
None
None
Myron Gerson
None
None
None
Michael
Givertz
Daniel
Goldstein
Paul Grayburn
None
None
None
GE
Healthcare
Lantheus
Medical
None
None
None
None
None
None
None
Warren R
Janowitz
Jill E. Jacobs
Scott Jerome
John Lesser
None
None
None
None
None
None
None
None
Siemens
Medical
None
None
Astellas,
Bracco,
Diagnostics
GE
Healthcare
None
None
Michael
McConnell
Sherif Nagueh
Karen Ordovas
Prem Soman
Kirk Spencer
Raymond
Amgen
BG
Medicine
Cytokinetics
Diagnostic
Johnson &
Johnson
Medpace
Novartis
Otsuka
Roche
None
Expert
Witness
None
None
Journal of Cardiovascular
Magnetic Resonance
Society for Cardiovascular
Magnetic Resonance
None
None
None
None
None
None
None
Everest IL,
STICH trial,
STICHES
trial,
US Core
Valve
Pivotal Trial
None
None
None
None
None
None
None
None
None
None
Siemens
Medical
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
57
None
Appendix – Relationships with Industry Disclosures
Committee
Member
Stainback
Krishnaswami
Vijayaraghavan
W. H .Wilson
Tang
Consultant
Amarin
GILEAD
Sanofi
Medtronic
St. Jude
Medical
Speaker’s
Bureau
Amarin
Astrazeneca
GILEAD
Jansen
Johnson &
Johnson
Otsuka
None
Ownership/
Partnership/
Principal
Research
Institutional,
Organizational, or
Other Financial Benefit
Expert
Witness
None
Epic
Jansen
Johnson &
Johnson
Otsuka
None
None
None
Abbott Lab
National
Institutes of
Health
None
None
58
Appropriate Utilization of Imaging in Heart
Failure
APPENDIX – Imaging Parameter Evidence
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Scenario 1 – Evaluation for Newly Suspected or Potential Heart Failure
Relevant Imaging Parameters
Anatomy
A. Chamber Anatomy Abnormalities (dimension/wall thickness/geometry)
F. Pericardial Abnormalities (including fluid/constriction/ calcification)
Function
G. Global Ventricular Systolic Dysfunction (including reduced ejection fraction)
H. Global Ventricular Diastolic Dysfunction (including reduced early ventricular filling or restriction to filling)
I. Valve Dysfunction (stenosis/regurgitation/other abnormalities)
Myocardial Status
M. Regional Ventricular Systolic Dysfunction (including wall thickening and wall motion)
Clinical Indications
Imaging
Parameter
Modality
1) Symptoms of
Heart Failure
a) Shortness of
breath
Or
b) Decreased
exercise
tolerance
Or
c) Symptoms of
fluid retention
OR
2) Findings of Heart
Failure
a) Abnormal CXR
(e.g. enlarged
silhouette,
pulmonary
venous
hypertension)
Or
b) Abnormal
biomarker(s)
Echo
Chamber
Anatomy
Abnormalities
OR
3) Signs of Heart
Failure
a) Evidence of
impaired
perfusion
Or
b) Evidence of
volume
expansion
CMR
Major Points
Class I Guideline recommendation for
clinical assessment of patients presenting
with HF include Echo during initial
evaluation to assess LV size and LV wall
thickness, along with LVEF and valve
function.
Multi-center studies have demonstrated
the value of Echo measures of LV
structure (e.g. dimensions/geometry, wall
thickness/mass) and LA size (e.g. area,
volume index) as important indicators of
subclinical HF and independent markers
of subsequent HF events.
Multi-center studies have demonstrated
that Echo measurements of LV mass and
LA volume independently predict
development of HF in patients with stable
coronary artery disease.
LA size independently predicts prognosis
in patients with suspected HF referred
from the community.
LA size (volume index) in patients with
suspected HF and LVEF predicts LV
diastolic dysfunction
Echo assessment of RV dilatation
independently predicts mortality in
patients with new-onset dyspnea.
LA size may provide prognostic value in
patients with in dilated cardiomyopathy
In a large epidemiologic study, body sizeadjusted LV mass was found to predict
incident HF.
In patients with new onset heart failure
and LV systolic dysfunction, CMR is an
accurate method to exclude an ischemic
etiology
References
cited
[132,141]
[16,30]
[20]
[32,141]
[32]
[29]
[142]
[42,132]
[41]
60
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Chamber
Anatomy
Abnormalities
1) Symptoms of
Heart Failure
a) Shortness of
breath
Or
b) Decreased
exercise
tolerance
Or
c) Symptoms of
fluid retention
Modality
CCT
SPECT
PET
Cath
Echo
CMR
Pericardial
Abnormalities
OR
CCT
2) Findings of Heart
Failure
a) Abnormal CXR
(e.g. enlarged
silhouette,
pulmonary
venous
hypertension)
Or
b) Abnormal
biomarker(s)
Cath
Global or
Regional
Ventricular
Systolic
Dysfunction
Echo
References
cited
[143]
none
none
none
A variety of Echo parameters can be used
to differentiate constrictive pericarditis
from restrictive cardiomyopathy in
symptomatic patients.
Abnormal diastolic septal motion
identified on CMR is helpful to
differentiate constrictive pericarditis
from restrictive cardiomyopathy
Assessment of ventricular function and
pericardial anatomy by CMR can be
helpful in the diagnosis of pericardial
constriction
Assessment of diastolic filling on CT can
differentiate normals from those with
constrictive pericarditis
SPECT
PET
OR
3) Signs of Heart
Failure
a) Evidence of
impaired
perfusion
Or
b) Evidence of
volume
expansion
Major Points
CT appearance of the myocardium differs
in cardiomyopathy compared to normals.
[144]
[145]
[43]
[146]
none
none
Invasive hemodynamic criteria for
diagnosis of constrictive pericarditis
Class I Guideline recommendation for
clinical assessment of patients presenting
with HF include Echo during initial
evaluation to assess LVEF, along with LV
size, LV wall thickness, and valve
function.
Multi-center studies have shown the
ability of Echo to identify measures of
subclinical systolic dysfunction (e.g.
reduced fractional shortening) that
predict subsequent HF.
Multi-center studies have demonstrated
that Echo measures of systolic function
(e.g. LVOT VTI) independently predict
development of HF in patients with stable
coronary artery disease.
Echo assessment of LV systolic function in
patients with suspected HF resulted in
improved disease classification by
general practitioners; this knowledge of
LV function changed management in up
to two-thirds of these patients.
[147]
[132]
[28]
[20]
[33]
61
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Global or
Regional
Ventricular
Systolic
Dysfunction
Modality
Echo
CMR
1) Symptoms of
Heart Failure
a) Shortness of
breath
Or
b) Decreased
exercise
tolerance
Or
c) Symptoms of
fluid retention
Global or
Regional
Ventricular
Systolic
Dysfunction
CCT
SPECT
PET
Cath
OR
2) Findings of Heart
Failure
a) Abnormal CXR
(e.g. enlarged
silhouette,
pulmonary
venous
hypertension)
Or
b) Abnormal
biomarker(s)
OR
3) Signs of Heart
Failure
a) Evidence of
impaired
perfusion
Or
b) Evidence of
volume
expansion
Major Points
Contractile reserve on Echo predicts
prognosis
Echo assessment of LVEF independently
predicts mortality in patients with newonset dyspnea.
In asymptomatic patients, increased LV
mass and decreased myocardial
perfusion, are related to delayed
myocardial contraction and greater
dyssynchrony on CMR
MDCT can be used to evaluate LV
segmental wall motion showing good
agreement with echocardiography, except
for the right coronary artery segments
Coronary artery disease extent on SPECT
predicts occult LV systolic dysfunction
Global
Ventricular
Diastolic
Dysfunction
Echo
References
cited
[148]
[29]
[149]
[150]
none
Patients with mild generalized LV
impairment in the absence of coronary
artery disease on Cath have good longterm prognosis compared to those with
moderate dysfunction.
Multi-center studies have shown the
ability of Echo to identify subclinical
abnormalities of diastolic filling that
predict subsequent HF
Multi-center studies have demonstrated
that Echo measurements of diastolic
dysfunction independently predict
development of HF in patients with stable
coronary artery disease.
Peak velocity of early diastolic mitral
annular velocity (Ea) on Echo can
differentiate restrictive cardiomyopathy
from constriction with 89% sensitivity
and 100% specificity.
Although experiences are conflicting,
diastolic dysfunction identified by Echo
may occur in up to 25% of populations
and is a marker of increased mortality.
Echo measures of diastolic function
correlate with Brain Naturietic Peptides
Single center studies have shown the
ability of measures of diastolic function to
predict outcome in patients with
symptoms of heart failure
Echo Doppler parameters are important
components of the algorithm for
diagnosis of heart failure with preserved
ejection fraction
[151]
[28]
[20]
[152]
[153-155]
[29]
[156]
[157]
62
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
1) Symptoms of
Heart Failure
a) Shortness of
breath
Or
b) Decreased
exercise
tolerance
Or
c) Symptoms of
fluid retention
Modality
CMR
CCT
SPECT
OR
3) Signs of Heart
Failure
a) Evidence of
impaired
perfusion
Or
b) Evidence of
volume
expansion
4) Malignancy
a) Current or
planned
cardiotoxic
therapy
And
b) No prior
imaging
evaluation
Valve
Dysfunction
Valve
Dysfunction
Echo
CCT
Coronary artery disease extent on SPECT
predicts occult LV systolic dysfunction
Myocardial
blood flow
Chamber
Anatomy
Abnormalities
Pericardial
Abnormalities
[158]
[159]
none
none
Class I Guideline recommendation for
clinical assessment of patients presenting
with HF include Echo during initial
evaluation to assess valve function, along
with LVEF, LV size, LV wall thickness.
Multicenter studies have demonstrated
that Echo measurements of mitral
regurgitation severity independently
predict development of HF in patients
with stable coronary artery disease.
CT can identify mitral valve anatomic
abnormalities responsible for functional
mitral regurgitation that accompanies
heart failure.
CMR
SPECT
References
cited
none
PET
Cath
OR
2) Findings of Heart
Failure
a) Abnormal CXR
(e.g. enlarged
silhouette,
pulmonary
venous
hypertension)
Or
b) Abnormal
biomarker(s)
Major Points
LV hypertrophy is associated with
regional diastolic dysfunction on CMR in
patients without clinical cardiac disease
and preserved systolic function.
[132]
[20,160]
[161]
none
Multicenter study demonstrates the value
of myocardial perfusion imaging in
patients with new onset heart failure
[69]
PET
none
Cath
none
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
none
none
none
none
none
none
none
none
none
none
none
none
63
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
4) Malignancy
a) Current or
planned
cardiotoxic
therapy
And
b) No prior
imaging
evaluation
Imaging
Parameter
Global or
Regional
Ventricular
Systolic
Dysfunction
Global
Ventricular
Diastolic
Dysfunction
Valve
Dysfunction
Modality
Echo
Major Points
Reductions in LVEF due to chemotherapy
or adjuvant treatments can be identified
by echo often before symptoms develop
and these measures are used to guide
therapy.
Echocardiography can follow the natural
history of LVEF in patients with
anthracycline cardiomyopathy and
response to therapy
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Chamber
Anatomy
Abnormalities
Echo
CMR
[162]
[163]
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
In hypertrophic cardiomyopathy patients,
single center studies have identified a
relation between Doppler –derived LVOT
gradient and outcome
5) Familial or Genetic
Cardiomyopathy
History
References
cited
For optimal diagnosis of ARVC/D,
multicenter trials have established
echocardiographic/CMR criteria for RV
size and RV function and these are
important components of the criteria for
diagnosis
Echocardiographic assessment of valves
and myocardium can differentiate familial
cardiac amyloidosis from hypertrophic
cardiomyopathy
Echocardiography can assist in
differentiation of infiltrative
cardiomyopathies
Detection by CMR of LV aneurysms in
hypertrophic cardiomyopathy identifies a
high risk group of patients.
[164]
[165]
[166]
[167]
[168]
64
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Modality
CMR
Chamber
Anatomy
Abnormalities
Pericardial
Abnormalities
5) Familial or Genetic
Cardiomyopathy
History
Global or
Regional
Ventricular
Systolic
Dysfunction
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
Valve
Dysfunction
Myocardial
blood flow
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
References
cited
[165]
none
none
none
none
none
none
none
none
none
none
none
In patients with Thalasemia, myocardial
T2* measured by CMR relates to EF and
appears to be a promising approach for
predicting the development of heart
failure and iron overload
cardiomyopathy.
CCT
SPECT
PET
Cath
Echo
Global
Ventricular
Diastolic
Dysfunction
Major Points
For optimal diagnosis of ARVC/D,
multicenter trials have established
echocardiographic/CMR criteria for RV
size and RV function and these are
important components of the criteria for
diagnosis
[169]
none
none
none
none
In infiltrative cardiomyopathy, patterns
of diastolic function assessed by Doppler
relate to outcome
[170]
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
65
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
5) Familial or Genetic
Cardiomyopathy
History
Imaging
Parameter
Myocardial
blood flow
Modality
PET
Major Points
Impaired cardiac oxidative metabolism
can be identified by PET in patients with
Friedrich’s ataxia despite no evidence of
overt structural heart disease
Cath
Echo /
CMR
Chamber
Anatomy
Abnormalities
6) Suspected Adult
Congenital Heart
Disease
Pericardial
Abnormalities
Global or
Regional
Ventricular
Systolic
Dysfunction
Global
Ventricular
Diastolic
Dysfunction
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
References
cited
[171]
none
Assessments of ventricular function and
cardiac anatomy by echo, Doppler and/or
CMR are critical in the adult patient with
history of unrepaired or repaired
congenital heart disease and heart failure
symptoms
Review of value of CMR for assessment of
cardiac structure and function in adults
with congenital heart disease
CMR provides accurate assessment of
anatomical connections, ventricular
function, myocardial viability in adults
with congenital heart disease
[44]
[172]
[173,174]
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
66
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
6) Suspected Adult
Congenital Heart
Disease
Imaging
Parameter
Valve
Dysfunction
Modality
Echo
CMR
CCT
SPECT
PET
Cath
Echo
Chamber
Anatomy
Abnormalities
7) Acute Myocardial
Infarction
a) Evaluation
during initial
hospitalization
And
b) Clinically
stable
Pericardial
Abnormalities
Global or
Regional
Ventricular
Systolic
Dysfunction
Global
Ventricular
Diastolic
Dysfunction
CMR
Major Points
In patients developing HF heart
symptoms after acute myocardial
infarction, Echo assessment of LV
function is associated with more frequent
use of proper medications and
subsequent lower mortality.
Use of CMR in identifying patients at risk
for developing HF after acute myocardial
infarction is advocated because of its
ability to:
Provide accurate/reproducible
longitudinal follow-up of LV volumes and
mass
Delineate infarct size and transmural
extent
Detect microvascular obstruction
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
References
cited
none
none
none
none
none
none
[175]
[176]
none
none
none
none
none
none
none
none
none
none
Assessment of regional dysfunction by
WMI or the number of affected segments
has slightly more prognostic value than
LVEF in patients with LV dysfunction,
heart failure, or both after MI.
[177]
none
none
none
none
none
none
none
none
none
none
none
67
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
7) Acute Myocardial
Infarction
a) Evaluation
during initial
hospitalization
And
b) Clinically
stable
Imaging
Parameter
Valve
Dysfunction
Modality
Echo
CMR
CCT
SPECT
PET
Cath
Echo
7) Peripartum
cardiomyopathy
Major Points
none
LV volume, mass and function can be
measured and followed by echo to
differentiate the presence of peri-partum
cardiomyopathy from normal
In pregnant women with dilated
cardiomyopathy, an index that combines
echocardiographic measures of LVEF and
LA pressure identifies patients at highest
risk for adverse outcome
CMR
CCT
SPECT
PET
Cath
References
cited
none
none
none
none
none
[178]
[179]
none
none
LV volume, and function can be measured
and followed by echo to differentiate the
presence of peri-partum cardiomyopathy
from normal
none
none
none
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177. Thune JJ, Kober L, Pfeffer MA, Skali H, Anavekar NS, Bourgoun M, Ghali JK, Arnold JM, Velazquez EJ, Solomon
SD. Comparison of regional versus global assessment of left ventricular function in patients with left
ventricular dysfunction, heart failure, or both after myocardial infarction: the valsartan in acute myocardial
infarction echocardiographic study. J Am Soc Echocardiogr 2006; 19(12):1462-5.
178. Cole P, Cook F, Plappert T, Saltzman D, St John Sutton M. Longitudinal changes in left ventricular architecture
and function in peripartum cardiomyopathy. Am J Cardiol 1987; 60(10):871-6.
179. Grewal J, Siu SC, Ross HJ, Mason J, Balint OH, Sermer M, Colman JM, Silversides CK. Pregnancy outcomes in
women with dilated cardiomyopathy. J Am Coll Cardiol 2009; 55(1):45-52.
71
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Scenario 2 – Ischemic Etiology in Patients with HF
Relevant Imaging Parameters
Anatomy
B. Coronary Artery Abnormalities (Including atherosclerotic disease, anomalies)
Function
G. Global Ventricular Systolic Dysfunction (Including reduced Ejection Fraction)
I. Valve Dysfunction (Stenosis/Regurgitation/Other Abnormalities) (Recommend removal – MP)
Myocardial Status
K. Fibrosis/Scarring (Transmural Extent/Mural Distribution/Pattern)
M. Regional Ventricular Systolic Dysfunction (Including wall thickening)
O1. Inducible Ischemia-Decreased Perfusion
O2. Inducible Ischemia-Decreased Contraction
Indications of Clinical Scenario #2 (All patients in this table are assumed to be candidates for revascularization
unless otherwise noted)
Imaging
References
Clinical Indications
Parameter Modality
Major Points
cited
Echo
none
CMR
none
Single center studies in HF patients
[73,75,180
CCT
showing high negative predictive value
]
for absence of CAD
SPECT
none
PET
none
Coronary
Cath used as test for CAD identification in
[15]
Artery
CASS revascularization study for CHF
Anatomy
Cath used to determine incident CAD in
[132]
CHF population
Cath shows CAD in patients with acute
Cath
diastolic HF without clinical or ECG
[30]
changes of ischemia
FFR shown to direct revascularization in
1) Normal renal
multi-vessel patients – Few patients
[181]
function
studies who have depressed LVEF
Echo
none
CMR
none
CCT
none
Ventricular
Function
SPECT
none
PET
none
Cath
none
Echo
none
CMR can be used to differentiate HF with
Fibrosis /
CMR
CAD compared to HF without CAD based
[182-184]
Scarring
on detection of fibrosis
(Transmural
Extent / Mural
CCT
none
Distribution /
Several data series on ischemia/fibrosis
Pattern)
SPECT and outcome. Similar to CMR in small
[185,186]
series for fibrosis.
72
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
1) Normal renal
function
Imaging
Parameter Modality
Fibrosis /
PET
Scarring
(Transmural
Extent / Mural
Cath
Distribution /
Pattern)
Regional
Ventricular
Systolic
Dysfunction
(Including
wall
thickening)
Inducible
Ischemia –
Decreased
Perfusion
Inducible
Ischemia –
Decreased
Contraction
2) Moderate Renal
Dysfunction
3) Severe Renal
Dysfunction – NOT
on dialysis 1, 2
4) Severe Renal
Dysfunction – On
dialysis 1, 2
1Imaging
Echo
CMR
Major Points
none
New or worsening wall-motion analysis on
stress Echo for CAD is associated with
worse prognosis
Single Center Dobutamine studies with
WMA
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
References
cited
[186]
Ischemia / ischemia score on SPECT
predict CAD and cardiac events
[62,63]
[64]
none
none
none
none
none
none
none
[57,59,187
]
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
with iodinated contrast has risk of renal failure
CMR with risk for NSF
2Gadolinium
73
AUI Heart Failure Imaging Parameters Document – October 2010
Section References – Clinical Scenario 2 Imaging Parameters – Ischemic Etiology in Patients with HF
15.
30.
57.
59.
62.
63.
64.
73.
75.
132.
180.
181.
182.
183.
184.
Redfield MM. Heart failure--an epidemic of uncertain proportions. N Engl J Med 2002; 347(18):1442-4.
Gardin JM, McClelland R, Kitzman D, Lima JA, Bommer W, Klopfenstein HS, Wong ND, Smith VE, Gottdiener J.
M-mode echocardiographic predictors of six- to seven-year incidence of coronary heart disease, stroke,
congestive heart failure, and mortality in an elderly cohort (the Cardiovascular Health Study). Am J Cardiol
2001; 87(9):1051-7.
Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, Weintraub WS, O'Rourke RA, Dada M,
Spertus JA, Chaitman BR, Friedman J, Slomka P, Heller GV, Germano G, Gosselin G, Berger P, Kostuk WJ,
Schwartz RG, Knudtson M, Veledar E, Bates ER, McCallister B, Teo KK, Boden WE. Optimal medical therapy
with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical
Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy.
Circulation 2008; 117(10):1283-91.
Abidov A, Rozanski A, Hachamovitch R, Hayes SW, Aboul-Enein F, Cohen I, Friedman JD, Germano G, Berman
DS. Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med 2005;
353(18):1889-98.
Maskoun W, Mustafa N, Mahenthiran J, Gradus-Pizlo I, Kamalesh M, Feigenbaum H, Sawada SG. Wall motion
abnormalities with low-dose dobutamine predict a high risk of cardiac death in medically treated patients
with ischemic cardiomyopathy. Clin Cardiol 2009; 32(7):403-9.
Sozzi FB, Elhendy A, Rizzello V, Biagini E, van Domburg RT, Vourvouri EC, Schinkel AF, Danzi GB, Bax JJ,
Poldermans D. Prognostic significance of akinesis becoming dyskinesis during dobutamine stress
echocardiography. J Am Soc Echocardiogr 2007; 20(3):257-61.
Dall'Armellina E, Morgan TM, Mandapaka S, Ntim W, Carr JJ, Hamilton CA, Hoyle J, Clark H, Clark P, Link KM,
Case D, Hundley WG. Prediction of cardiac events in patients with reduced left ventricular ejection fraction
with dobutamine cardiovascular magnetic resonance assessment of wall motion score index. J Am Coll Cardiol
2008; 52(4):279-86.
Andreini D, Pontone G, Pepi M, Ballerini G, Bartorelli AL, Magini A, Quaglia C, Nobili E, Agostoni P. Diagnostic
accuracy of multidetector computed tomography coronary angiography in patients with dilated
cardiomyopathy. J Am Coll Cardiol 2007; 49(20):2044-50.
Cornily JC, Gilard M, Le Gal G, Pennec PY, Vinsonneau U, Blanc JJ, Mansourati J, Boschat J. Accuracy of 16detector multislice spiral computed tomography in the initial evaluation of dilated cardiomyopathy. Eur J
Radiol 2007; 61(1):84-90.
Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, Konstam MA, Mancini DM, Rahko PS,
Silver MA, Stevenson LW, Yancy CW. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and
Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines: developed in collaboration with the International
Society for Heart and Lung Transplantation. Circulation 2009; 119(14):1977-2016.
Budoff MJ, Gillespie R, Georgiou D, Narahara KA, French WJ, Mena I, Brundage BH. Comparison of exercise
electron beam computed tomography and sestamibi in the evaluation of coronary artery disease. Am J Cardiol
1998; 81(6):682-7.
Beohar N, Erdogan AK, Lee DC, Sabbah HN, Kern MJ, Teerlink J, Bonow RO, Gheorghiade M. Acute heart
failure syndromes and coronary perfusion. J Am Coll Cardiol 2008; 52(1):13-6.
McCrohon JA, Moon JC, Prasad SK, McKenna WJ, Lorenz CH, Coats AJ, Pennell DJ. Differentiation of heart
failure related to dilated cardiomyopathy and coronary artery disease using gadolinium-enhanced
cardiovascular magnetic resonance. Circulation 2003; 108(1):54-9.
Soriano CJ, Ridocci F, Estornell J, Jimenez J, Martinez V, De Velasco JA. Noninvasive diagnosis of coronary
artery disease in patients with heart failure and systolic dysfunction of uncertain etiology, using late
gadolinium-enhanced cardiovascular magnetic resonance. J Am Coll Cardiol 2005; 45(5):743-8.
Soriano CJ, Ridocci F, Estornell J, Perez-Bosca JL, Pomar F, Trigo A, Planas A, Nadal M, Jacas V, Martinez V,
Paya R. Late gadolinium-enhanced cardiovascular magnetic resonance identifies patients with standardized
definition of ischemic cardiomyopathy: a single centre experience. Int J Cardiol 2007; 116(2):167-73.
74
AUI Heart Failure Imaging Parameters Document – October 2010
185. Ansari M, Araoz PA, Gerard SK, Watzinger N, Lund GK, Massie BM, Higgins CB, Saloner DA. Comparison of late
enhancement cardiovascular magnetic resonance and thallium SPECT in patients with coronary disease and
left ventricular dysfunction. J Cardiovasc Magn Reson 2004; 6(2):549-56.
186. Wu YW, Tadamura E, Yamamuro M, Kanao S, Marui A, Tanabara K, Komeda M, Togashi K. Comparison of
contrast-enhanced MRI with (18)F-FDG PET/201Tl SPECT in dysfunctional myocardium: relation to early
functional outcome after surgical revascularization in chronic ischemic heart disease. J Nucl Med 2007;
48(7):1096-103.
187. Sharir T, Germano G, Kavanagh PB, Lai S, Cohen I, Lewin HC, Friedman JD, Zellweger MJ, Berman DS.
Incremental prognostic value of post-stress left ventricular ejection fraction and volume by gated myocardial
perfusion single photon emission computed tomography. Circulation 1999; 100(10):1035-42.
75
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Scenario 3 – Therapy – Consideration of Revascularization (PCI or CABG) in Patients with Ischemic
HF and Known Coronary Anatomy Amenable to Revascularization
Relevant Imaging Parameters
Anatomy
A. Chamber Anatomy Abnormalities (Geometry/Dimension/Wall Thickness)
B. Coronary Artery Abnormalities (Including atherosclerotic disease)
Function
G. Global Ventricular Systolic Dysfunction (Including reduced Ejection Fraction)
I. Valve Dysfunction (Stenosis/Regurgitation/Other Abnormalities)
Myocardial Status
K. Fibrosis/Scarring (Transmural Extent/Mural Distribution/Pattern)
M. Regional Ventricular Systolic Dysfunction (Including wall thickening)
O1. Inducible Ischemia-Decreased Perfusion
O2. Inducible Ischemia-Decreased Contraction
P1. Hibernating State- Positive Contractile Reserve
P2. Hibernating State-Anaerobic Metabolism/Glucose Utilization
P3. Hibernating State-Resting Dysfunction/Minimal Scarring
P4. Hibernating State-Preserved myocyte cell membrane integrity
Clinical Indications
Imaging
Parameter
Chamber
Anatomy
Abnormalities
Coronary
1. Severely reduced
Artery
ventricular function
Abnormalities
(EF< 30%)
OR
Global
2. Myocardial region of
Ventricular
interest with thin
Diastolic
walls
Dysfunction
Valve
Dysfunction
Specific
Insights
Modality
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Echo
CMR
CCT
SPECT
PET
Cath
Major Points
Reference
s cited
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
none
76
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Specific
Insights
Regional
Ventricular
Systolic
Dysfunction
Modality
Echo
CMR
CCT
SPECT
Major Points
SPECT assessment of regional
dysfunction defines target for
assessment of viability
PET
Cath
Severe wall
motion /
thickening
abnormalit
y at rest
with no
contractile
reserve
Gadoliniu
m
enhanceme
nt
1. Severely reduced
ventricular function
(EF< 30%)
OR
2. Myocardial region of
interest with thin
walls
Fibrosis /
Scarring
Echo
Stress Echo identifies low
likelihood of functional
recovery and predominant
infarct; it may underestimate
lack of viability if wall is
thinned.
CMR
CMR directly identifies
location, extent and
transmurality of infarct
PET
“match”
pattern
Severe wall
motion /
thickening
abnormalit
Viable
y at rest
myocardial
with no
tissue
contractile
(inducible
reserve
ischemia or
hibernating Gadoliniu
state)
m
enhanceme
nt
SPECT
PET
[188]
none
none
CCT
Severe
resting
defect on
rest study
or severe
fixed
defect on
stress /
rest study
Reference
s cited
none
none
none
[189]
[83,190]
none
SPECT identifies low likelihood
of functional recovery and
predominant infarct; it may
underestimate viability if wall
is thinned
Metabolic PET identifies low
likelihood of functional
recovery and predominant
infarct
[87,91]
[89,191,19
2]
Cath
none
Echo
none
CMR
CCT
CMR directly identifies
location, extent and
transmurality of infarct,
absence of enhancement
suggests viability
[83,85]
none
77
AUI Heart Failure Imaging Parameters Document – October 2010
Specific
Insights
Mild
resting
defect /
normal
uptake on
rest study
1. Severely reduced
or nonViable
ventricular function
myocardial severe
(EF< 30%)
fixed
tissue
OR
(inducible defect or
ischemia or reversible
2. Myocardial region of hibernating defect on
interest with thin
stress /
state)
walls
rest study
Clinical Indications
Imaging
Parameter
PET
“match”
pattern
Major Points
SPECT
SPECT identifies low
likelihood of functional
recovery and predominant
infarct; it may underestimate
lack of viability if wall is
thinned.
[85,91]
PET
PET identifies high likelihood
of functional recovery and
predominant viability /
ischemia / hibernation
[90,193]
Cath
Severe wall
motion /
thickening
abnormalit
y at rest
with no
contractile
reserve
Gadoliniu
m
enhanceme
nt
3. Moderately reduced
ventricular function
(EF 30-39%)
OR
4. Myocardial region of
interests with thin
walls
Fibrosis
Severe
resting
defect on
rest study
or severe
fixed
defect on
stress /
rest study
PET
“match”
pattern
Reference
s cited
Modality
none
Echo
Stress Echo identifies low
likelihood of functional
recovery and predominant
infarct
[194]
CMR
Identifies location, extent and
transmurality of infarct
[195]
CCT
none
SPECT
none
PET
none
Cath
none
78
AUI Heart Failure Imaging Parameters Document – October 2010
Specific
Reference
Insights Modality
Major Points
s cited
Severe wall
motion /
thickening
abnormalit
Echo
none
y at rest
with no
contractile
reserve
Gadoliniu
CMR identifies location, extent
m
and transmurality of infarct;
CMR
[84]
enhanceme
absence of enhancement
nt
suggests viability
CCT
none
Viable
Mild
myocardial resting
tissue
defect /
normal
uptake on
rest study
3. Moderately reduced
or nonSPECT
none
ventricular function
severe
(EF 30-39%)
fixed
defect or
OR
reversible
defect on
4. Myocardial region of
stress /
interests with thin
rest study
walls
PET
none
Cath
none
Echo can detect increased peak
systolic strain and strain rate
Echo
in hypertensive patients
none
undergoing
effective
medical
Wall
therapy
motion and
thickening
CMR detects heterogeneity in
myocardial systolic mechanics
CMR
none
in patients with hypertrophic
Regional
cardiomyopathy
function
CCT
none
Wall
motion and SPECT
none
thickening
PET
none
Left
ventriculog
Cath
none
ram
Clinical Indications
Imaging
Parameter
79
AUI Heart Failure Imaging Parameters Document – October 2010
Specific
Insights Modality
Deteriorati
on of wall
motion /
thickening
with stress. Echo
Abnormal
EF
response
5. Preserved Function
to stress
(EF ≥ 40)
Reversible
Significant regional
defect with
dysfunction in the
vasodilator
territory of a
stress.
stenotic vessel
Assessment of Deteriorati
inducible on of wall
CMR
OR
ischemia motion /
6. No regional wall
thickening
motion
with
abnormalities in the
dobutamin
territory of a
e stress
stenotic vessel
CCT
Reversible
SPECT
defects
Reversible
defect with
PET
vasodilator
stress.
Cath
Clinical Indications
Imaging
Parameter
Major Points
Reference
s cited
none
none
none
none
none
none
Section References - Clinical Scenario 3 Imaging Parameters – Therapy – Consideration of Revascularization (PCI
or CABG) in Patients with Ischemic HF and Known Coronary Anatomy Amenable to Revascularization
83.
84.
85.
87.
89.
Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, Klocke FJ, Bonow RO, Judd RM. The use of contrastenhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;
343(20):1445-53.
Selvanayagam JB, Kardos A, Francis JM, Wiesmann F, Petersen SE, Taggart DP, Neubauer S. Value of delayedenhancement cardiovascular magnetic resonance imaging in predicting myocardial viability after surgical
revascularization. Circulation 2004; 110(12):1535-41.
Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, Klocke FJ, Bonow RO, Kim RJ, Judd RM.
Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion
imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet 2003; 361(9355):3749.
Roes SD, Kaandorp TA, Marsan NA, Westenberg JJ, Dibbets-Schneider P, Stokkel MP, Lamb HJ, van der Wall
EE, de Roos A, Bax JJ. Agreement and disagreement between contrast-enhanced magnetic resonance imaging
and nuclear imaging for assessment of myocardial viability. Eur J Nucl Med Mol Imaging 2009; 36(4):594-601.
Beanlands RS, Nichol G, Huszti E, Humen D, Racine N, Freeman M, Gulenchyn KY, Garrard L, deKemp R, Guo A,
Ruddy TD, Benard F, Lamy A, Iwanochko RM. F-18-fluorodeoxyglucose positron emission tomography
imaging-assisted management of patients with severe left ventricular dysfunction and suspected coronary
disease: a randomized, controlled trial (PARR-2). J Am Coll Cardiol 2007; 50(20):2002-12.
80
AUI Heart Failure Imaging Parameters Document – October 2010
90.
Beanlands RS, Ruddy TD, deKemp RA, Iwanochko RM, Coates G, Freeman M, Nahmias C, Hendry P, Burns RJ,
Lamy A, Mickleborough L, Kostuk W, Fallen E, Nichol G. Positron emission tomography and recovery
following revascularization (PARR-1): the importance of scar and the development of a prediction rule for
the degree of recovery of left ventricular function. J Am Coll Cardiol 2002; 40(10):1735-43.
91. Slart RH, Bax JJ, de Boer J, Willemsen AT, Mook PH, Oudkerk M, van der Wall EE, van Veldhuisen DJ, Jager PL.
Comparison of 99mTc-sestamibi/18FDG DISA SPECT with PET for the detection of viability in patients with
coronary artery disease and left ventricular dysfunction. Eur J Nucl Med Mol Imaging 2005; 32(8):972-9.
188. Wahba FF, Dibbets-Schneider P, Bax JJ, Bavelaar-Croon CD, Zwinderman AH, Pauwels EK, van der Wall EE.
Detection of residual wall motion after myocardial infarction by gated technetium-99m tetrofosmin SPET: a
comparison with contrast ventriculography. Eur J Nucl Med 2001; 28(4):514-21.
189. Rizzello V, Poldermans D, Schinkel AF, Biagini E, Boersma E, Elhendy A, Sozzi FB, Maat A, Crea F, Roelandt JR,
Bax JJ. Long term prognostic value of myocardial viability and ischaemia during dobutamine stress
echocardiography in patients with ischaemic cardiomyopathy undergoing coronary revascularisation. Heart
2006; 92(2):239-44.
190. Kim RJ, Albert TS, Wible JH, Elliott MD, Allen JC, Lee JC, Parker M, Napoli A, Judd RM. Performance of delayedenhancement magnetic resonance imaging with gadoversetamide contrast for the detection and assessment
of myocardial infarction: an international, multicenter, double-blinded, randomized trial. Circulation 2008;
117(5):629-37.
191. D'Egidio G, Nichol G, Williams KA, Guo A, Garrard L, deKemp R, Ruddy TD, DaSilva J, Humen D, Gulenchyn KY,
Freeman M, Racine N, Benard F, Hendry P, Beanlands RS. Increasing benefit from revascularization is
associated with increasing amounts of myocardial hibernation: a substudy of the PARR-2 trial. JACC
Cardiovasc Imaging 2009; 2(9):1060-8.
192. Desideri A, Cortigiani L, Christen AI, Coscarelli S, Gregori D, Zanco P, Komorovsky R, Bax JJ. The extent of
perfusion-F18-fluorodeoxyglucose positron emission tomography mismatch determines mortality in
medically treated patients with chronic ischemic left ventricular dysfunction. J Am Coll Cardiol 2005;
46(7):1264-9.
193. Gerber BL, Ordoubadi FF, Wijns W, Vanoverschelde JL, Knuuti MJ, Janier M, Melon P, Blanksma PK, Bol A, Bax
JJ, Melin JA, Camici PG. Positron emission tomography using(18)F-fluoro-deoxyglucose and euglycaemic
hyperinsulinaemic glucose clamp: optimal criteria for the prediction of recovery of post-ischaemic left
ventricular dysfunction. Results from the European Community Concerted Action Multicenter study on use
of(18)F-fluoro-deoxyglucose Positron Emission Tomography for the Detection of Myocardial Viability. Eur
Heart J 2001; 22(18):1691-701.
194. Zaglavara T, Pillay T, Karvounis H, Haaverstad R, Parharidis G, Louridas G, Kenny A. Detection of myocardial
viability by dobutamine stress echocardiography: incremental value of diastolic wall thickness measurement.
Heart 2005; 91(5):613-7.
195. Choi KM, Kim RJ, Gubernikoff G, Vargas JD, Parker M, Judd RM. Transmural extent of acute myocardial
infarction predicts long-term improvement in contractile function. Circulation 2001; 104(10):1101-7.
81
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Scenario 4 – ICD & CRT
Relevant Imaging Parameters
Anatomy
C. Coronary Vein Variations
Function
G. Global Ventricular Systolic Dysfunction (including reduced ejection fraction)
H. Global Ventricular Diastolic Dysfunction (including reduced early ventricular filling)
I. Valve Dysfunction (stenosis/regurgitation/other abnormalities)
Myocardial Status
K. Fibrosis/Scarring (transmural extent/mural distribution/pattern)
M. Regional Ventricular Systolic Dysfunction (including wall thickening)
N. Myocardial Wall Mechanics (including strain and synchrony analysis)
Miscellaneous
Q1. Thrombus-Atrial
Q2. Thrombus-Ventricular
Imaging
Specific
References
Clinical Indications
Modality Major Points
Parameter
Insights
cited
Post-ICD placement survival
does not differ according to
Echo
modality of pre-placement
[112]
LVEF assessment by Echo vs.
contrast left ventriculography.
Global
CMR
none
LVEF <
Ventricular
CCT
none
35% is
Systolic and
prerequisi SPECT
none
Diastolic
te
PET
none
Dysfunction
Post-ICD placement survival
1. Initial evaluation to
does not differ according to
determine patient
Cath
modality of pre-placement
[196]
candidacy
LVEF assessment by contrast
left ventriculography vs. Echo.
Echo
None
Source of
LV midwall fibrosis in nonventricula
ischemic HF and
Myocardial
r
subendocardial scar in
Fibrosis /
tachyarrh
CMR
ischemic HF detected by CMR
[126,127]
Scarring
ythmias in
in is predictive of ventricular
HF[197arrhythmia and/or sudden
199]
cardiac death.
Based on fibrosis/scar extent,
Source of
pre-ICD placement CMR
ventricula
predicts adverse cardiac
r
outcomes (i.e. HF
1. Initial evaluation to Myocardial
determine patient
Fibrosis /
tachyarrh
CMR
hospitalizations, appropriate
[200]
candidacy
Scarring
ythmias in
ICD firings, cardiac death) in
HF[197non-ischemic HF post-ICD
199]
placement for primary
prevention.
82
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
1. Initial evaluation to Myocardial
determine patient
Fibrosis /
candidacy
Scarring
2. Follow-up
evaluation to
determine patient
candidacy
a. After a course of
maximal medical
therapy
OR
b. Coronary
revascularization
3. Follow-up 3 months
after placement
a. No deterioration
in clinical status
AND
b. No change in
arrhythmia
status
4. Follow-up 3 months
after placement
a. Deterioration in
clinical status
OR
b. Change in
arrhythmia
status (i.e. ICD
discharge)
4. Follow-up 3 months
after placement
a. Deterioration in
clinical status
OR
b. Change in
arrhythmia
status (i.e. ICD
discharge)
Global
Ventricular
Systolic and
Diastolic
Dysfunction
Global
Ventricular
Systolic and
Diastolic
Dysfunction
Specific
Insights
Source of
ventricula
r
tachyarrh
ythmias in
HF[197199]
Monitorin
g of LV
function
Monitorin
g of LV
function
Modality Major Points
CMR
Of CMR (e.g. total infarct size,
LVEF) or clinical variables,
infarct tissue heterogeneity on
pre-ICD placement CMR is the
strongest predictor of
ventricular arrhythmia in
ischemic HF post-ICD
placement for primary
prevention.
References
cited
[201,202]
CCT
SPECT
PET
Cath
Echo
none
none
none
none
none
CMR
none
CCT
none
SPECT
none
PET
none
Cath
none
Echo
CMR
CCT
SPECT
PET
none
none
none
none
none
Cath
none
Echo
At 2-14 months post-ICD
placement, only 12% of nonischemic HF patients
demonstrate improved LVEF
>35% on Echo.
Echo
Restrictive LV filling pattern on
pre-ICD placement Echo is
strongly related to adverse
[204,205]
cardiac events (e.g. death from
pump failure) in the first year
post-ICD placement.
CMR
[203]
none
83
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
4. Follow-up 3 months
after placement
a. Deterioration in
clinical status
OR
b. Change in
arrhythmia
status (i.e. ICD
discharge)
Imaging
Parameter
Global
Ventricular
Systolic and
Diastolic
Dysfunction
Specific
Insights
Monitorin
g of LV
function
Modality Major Points
CCT
SPECT
PET
Cath
Echo
5. Initial evaluation to
determine patient
candidacy
a. NYHA class III
despite optimum
medical therapy
AND
b. Left bundle
branch block on
ECG
Global
Ventricular
Systolic and
Diastolic
Dysfunction
LVEF <
35% is
prerequisi
te
[10,98,13
2]
Regional
Ventricular
Systolic
Dysfunction
and
Myocardial
Wall
Mechanics
LV
mechani
cal
dyssync
hrony
[10,98,1
32,208210]
Echo
[197]
none
none
none
Compared to pre-CRT
measures of LV dysfunction
on Echo, post-CRT measures
indicate improved overall LV
systolic function (e.g.
increased LVEF).
Relative to pre-CRT measures
of LV dilation on Echo,
reversed LV remodeling
(typically 10-15% decrease in
end-systolic volume) is found
post-CRT in 44-65% of HF
patients.
CMR
CCT
SPECT
PET
Cath
5. Initial evaluation to
determine patient
candidacy
a. NYHA class III
despite optimum
medical therapy
AND
b. Left bundle
branch block on
ECG
Asymptomatic perforations by
leads are common on CCT,
especially with RA (vs. RV)
leads and ventricular ICD (vs.
ventricular pacemaker) leads,
but rarely result in
electrophysiologic
consequences.
References
cited
[107,113]
[107,113,2
06,207]
none
none
none
none
Compared to Cath-derived
measures of baseline LV
dilation and dysfunction,
post-CRT measures
demonstrate reversal of LV
remodeling (e.g. decreasing
end-systolic volumes) and/or
improved overall LV systolic
function (e.g. increased LVEF)
within the first month.
CRT candidates with more
QRS prolongation have a
higher likelihood of LV
dyssynchrony on Echo, but
approximately 30% with very
wide QRS complexes (i.e. >
0.15 seconds) lack inter- or
intra-ventricular
dyssynchrony.
[200]
[211,212]
84
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
5. Initial evaluation
to determine
patient candidacy
a. NYHA class III
despite
optimum
medical
therapy
AND
b. Left bundle
branch block
on ECG
Imaging
Parameter
Regional
Ventricular
Systolic
Dysfunction
and
Myocardial
Wall
Mechanics
Specific
Insights
Modality Major Points
LV
mechanic
al
dyssynchr
Echo
ony
[10,98,13
2,208210]
If HF patients with severe LV
dysfunction have Echo
evidence of dyssynchrony,
approximately 50% may not
have significant QRS
prolongation.
In patients with severe HF
and narrow QRS complexes,
LV dyssynchrony can be
detected by Echo in 27-72%.
The utility of LV
dyssynchrony evaluation by
Echo to guide CRT
implantation when the QRS is
not prolonged has not been
consistently confirmed.
Concordance between QRS
duration and LV
dyssynchrony in severe HF is
not strong, and influenced by
the type of dilated
cardiomyopathy
There are predictive clinical
benefits of Echo inter- or
intra-ventricular
dyssynchrony detection using
various forms of tissue
doppler imaging in HF
patients undergoing CRT
evaluation.
The technical challenges in
Echo dyssynchrony analysis
in mainstream clinical
practice are highlighted in a
large multicenter trial which
stresses ongoing reliance on
current guidelines.
Despite considerable
variability in techniques, Echo
can reliably identify the latest
mechanically contracting
region of the LV in CRT
candidates for optimal device
implantation, almost always
with improved response.
References
cited
[124]
[125,211,2
13]
[121,214]
[201,205,2
07,215]
[115,117,2
09,216]
[116]
[118,127,2
07,210,21
2,217,218]
85
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Specific
Insights
Modality Major Points
Echo
5. Initial evaluation to
determine patient
candidacy
a. NYHA class III
despite optimum
medical therapy
AND
b. Left bundle
branch block on
ECG
CMR
Regional
Ventricular
Systolic
Dysfunction
and Myocardial
Wall Mechanics
LV
mechanical
dyssynchr
ony
[10,98,132,
208-210]
CCT
SPECT
Low-dose dobutamine stress
Echo may accentuate LBBBinduced dyssynchrony which
indicates a higher likelihood
of response to CRT.
CMR can be used to assess LV
mechanical dyssynchrony in
CRT candidates with results
comparable to those derived
by Echo.
CMR assessment of LV
dyssynchrony may help
predict outcome from CRT.
CCT may be used to assess LV
dyssynchrony in CRT
evaluation.
Various SPECT measures of
LV dyssynchrony in HF
patients undergoing CRT
evaluation correlate well with
those derived using Echo.
SPECT measures of LV
dyssynchrony in patients
undergoing CRT can be used
to predict response to
therapy.
PET
Cath
5. Initial evaluation to
determine patient
candidacy
a. NYHA class III
despite optimum Valve
medical therapy Dysfunction
AND
b. Left bundle
branch block on
ECG
Function
al mitral
regurgit
ation
from
mitral
apparatu
s
abnorma
lities due
to LV
dilatatio
n and
dysfunct
ion.
Echo
References
cited
[219]
[128,220]
[121,206,2
13,221]
[214]
[218,222224]
[115,117,1
29,225]
none
none
CRT immediately decreases
mitral regurgitation possibly
from improved strain on the
papillary muscles or adjacent
LV wall.
[116,226]
86
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
5. Initial evaluation to
determine patient
candidacy
a. NYHA class III
despite optimum Valve
medical therapy Dysfunction
AND
b. Left bundle
branch block on
ECG
6. Procedure
Planning:
Considerations
Myocardial
Fibrosis/Sca
rring
Specific
References
Modality Major Points
Insights
cited
Function
CMR
none
al mitral
CCT
none
regurgit
SPECT
none
ation
PET
none
from
mitral
apparatu
s
abnorma
lities due
Cath
none
to LV
dilatatio
n and
dysfunct
ion.
In ischemic HF, Echo
assessment of global LV scar
area (based on segmental
end-diastolic wall thinning)
[118,227]
correlates directly with lack
of long-term LV reverse
Amount/
remodeling with CRT.
Echo
distribut
Indirect Echo measurement of
ion of
myocardial fibrosis/scarring
myocard
(based on absent myocardial
ial
[217,228]
contractile reserve) predicts
fibrosis
lack of LV reverse remodeling
and
with CRT.
scarring
may
Percentage scarring of total
limit:
LV myocardial volume on
 Contra
CMR predicts a lack of
[219,220,2
ctile
response to CRT, presumably
29,230]
respon
due to inadequate contractile
se to
reserve.
CRT
CMR
The presence of potentially
 Captur
unstimulated posterolateral
e in
wall transmural (> 50%)
[128,206,2
region
scarring on CMR, near the
31,232]
of
CRT LV lead placement,
latest
indicates poor response rate
activati
and/or increased risk.
on by
CCT has untested potential to
LV lead
delineate myocardial scar
location, in combination with
CCT
coronary vein mapping and
[221,233]
LV dyssynchrony assessment,
as part of CRT planning in
ischemic HF.
87
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Myocardial
Fibrosis/Sca
rring
6. Procedure
Planning:
Considerations
Coronary
Vein
Variations
Specific
References
Modality Major Points
Insights
cited
Amount/
Based on SPECT delineation
distribut
of extent and location of LV
ion of
myocardial scarring, both
[66,224,23
myocard
overall scar burden and scar
5,236]
ial
density near the LV lead
fibrosis
portend an unfavorable
and
response to CRT.
SPECT
scarring
Compared to CMR, SPECT
may
overestimates scar tissue in
limit:
non-ischemic HF (due to
[66,222]
 Contra
attenuation artifact) and
ctile
identifies CRT nonrespon
responders less reliably.
se to
Indirect assessments of
CRT
myocardial fibrosis/scarring
[234]
PET
by PET, can be used to predict [129,237]
 Captur
lack of improvement in LVEF
e in
after CRT.
region
of
latest
activati
Cath
none
on by
LV
lead[9
8]
Echo
none
CMR
none
CCT has been used to direct
ventricular lead placement for [225,226,2
optimal CRT as effectively as
42,243]
Segment
retrograde angiographic
al
venography.
CCT
descripti
In ischemic HF, the left
on of
marginal vein is often absent
coronary
on CCT, potentially interfering [234,244]
venous
with optimal lead positioning
anatomy
for CRT.
for
SPECT
none
optimal
PET
none
LV lead
Advances
in
catheter-based
placeme
lead delivery systems,
nt[209,2
possibly including venoplasty
38-241]
and stenting, have improved
[227,228,2
Cath
the success rates of CRT LV
45,246]
lead implantation by
retrograde angiographic
venography.
88
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
Coronary
Vein
Variations
6. Procedure
Planning:
Considerations
IntraCavitary
Thrombus
7. Follow-up early (<
6 months) after
implantation
a. No
improvement
in symptoms
OR
b. No
improvement
functional
capacity
Global
Ventricular
Systolic and
Diastolic
Dysfunction
Specific
Modality Major Points
Insights
Segment
al
descripti
When the LV lead of a CRT
on of
system is placed under Cath
coronary
guidance into a posterovenous
lateral, rather than anterior,
anatomy
Cath
coronary sinus tributary,
for
there are significant 6-month
optimal
benefits (e.g. increase in
LV lead
LVEF).
placeme
nt[209,2
38-241]
Echo
Potential
CMR
embolis
CCT
m with
SPECT
CRT[248
PET
]
Cath
Lack of
Poorer early post-CRT
early
response on Echo may reflect
response
an ischemic etiology for HF.
may
reflect:
 Poor
candid
ate
selecti
on[249
,250]
The severity of mitral
 Inadeq
Echo
regurgitation on Echo is an
uate
independent predictor of
lead
poor response to CRT by 6
placem
months.
ent
[251,2
52]
 Subopt
imal
device
setting
s [253]
References
cited
[230,247]
none
none
none
none
none
none
[229,232,2
54,255]
[231,233,2
56,257]
89
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging
Parameter
7. Follow-up early (<
6 months) after
implantation
a. No
improvement
in symptoms
OR
b. No
improvement
functional
capacity
Global
Ventricular
Systolic and
Diastolic
Dysfunction
8. Follow-up later (>6
months) after
implantation
a. Improved
symptoms (i.e.,
from class III,
IV to Class I, II)
OR
b. Improved
functional
capacity
Global
Ventricular
Systolic and
Diastolic
Dysfunction
Specific
References
Modality Major Points
Insights
cited
Lack of
An Echo-dependent approach
early
to optimization of CRT
[122,123,2
response
Echo
settings has immediate
36,258]
may
beneficial effects on early
reflect:
clinical response
 Poor
CMR
none
candid
CCT
none
ate
Despite clinical improvement,
selecti
patients with severe resting
on[249
perfusion defects on pre-CRT
,250]
SPECT
SPECT do not show significant
[66,259]
 Inadeq
improvement in LVEF or LV
uate
volume reduction on SPECT at
lead
3-month post-CRT.
placem
PET
none
ent
[251,2
52]
 Subopt
Cath
none
imal
device
setting
s [253]
In general, Echo
demonstrates at 6 months
post-CRT:
- Improved LV function (e.g. [237,240,2
increased LVEF or stroke
60,261]
volume with sensitivities:
76-96% and specificities:
71-100%)
- Increase cardiac output
[119,239,2
and systolic strain
41,262]
- Increased diastolic
Echo
[238,263]
performance
- Reverse remodeling (e.g.
decreasing end-diastolic
[120,242,2
and end-systolic volumes
43,264]
with sensitivities: 87-97%
and specificities: 55-92%)
- Decreased LV
[217,244,2
dyssynchrony
46,265]
- Decreased mitral
[244,246]
regurgitation.
90
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
8. Follow-up later (>6
months) after
implantation
c. Improved
symptoms (i.e.,
from class III,
IV to Class I, II)
OR
d. Improved
functional
capacity
Imaging
Parameter
Specific
Insights
Modality Major Points
Echo
Global
Ventricular
Systolic and
Diastolic
Dysfunction
At 6 months, the benefits of
CRT on Echo assessments of
LV function (i.e. increased
LVEF) and reverse
remodeling (i.e. decreased LV
EDV) are significantly better
with non-ischemic HF.
CRT induces sustained LV
reverse remodeling on Echo
with progressive
improvement during the first
3-9 months, with extent of
remodeling primarily related
to HF etiology and less to
baseline interventricular
mechanical delay.
At 6 months there may be
slight benefit (e.g. increased
LVEF) from early
optimization of CRT device
programming under Echo
monitoring.
Despite LV reverse
remodeling, interruption of
CRT at 6 months results in
worsening LV function and
dyssynchrony on Echo,
indicating the need for longterm CRT
CMR
CCT
SPECT
PET
Cath
References
cited
[229,237,2
54,261]
[8,245]
[247,266]
[12,248]
none
none
none
By 6 months, PET
demonstrates that CRT makes
resting myocardial blood flow
more homogenous and results
in improved myocardial
efficiency.
[14,249,25
0,267]
none
91
AUI Heart Failure Imaging Parameters Document – October 2010
Section References- Clinical Scenario 4 Imaging Parameters– ICD & CRT
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10.
12.
14.
66.
98.
107.
112.
113.
115.
116.
117.
118.
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244. Van de Veire NR, Schuijf JD, De Sutter J, Devos D, Bleeker GB, de Roos A, van der Wall EE, Schalij MJ,
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Clinical Scenario 5 – Repeat Imaging Evaluation of HF
Relevant Imaging Parameters
The following imaging-based parameters were identified as potentially useful for the repeat imaging in heart failure.
The performance of these parameters per imaging modality is presented in the previously presented tables. Specific
literature references for repeat imaging in heart failure are presented in the brief table.
Anatomy
A. Chamber Anatomy Abnormalities (Geometry/Dimension/Wall Thickness)
B. Coronary Artery Abnormalities (Including atherosclerotic disease, anomalies)
C. Pericardial Abnormalities (Including calcification / fluid / constriction)
Function
G. Global Ventricular Systolic Dysfunction (Including reduced ejection fraction)
H. Global Ventricular Diastolic Dysfunction (Including reduced ventricular relaxation/filling)
I. Valve Dysfunction (Stenosis/Regurgitation/Other Abnormalities)
Myocardial Status
J. Fibrosis/Scarring (Transmural Extent/Mural Distribution/Pattern)
M. Regional Ventricular Systolic Dysfunction (Including wall thickening)
O1. Inducible Ischemia-Decreased Perfusion
O2. Inducible Ischemia-Decreased Contraction
P1. Hibernating State- Positive Contractile Reserve
P2. Hibernating State-Anaerobic Metabolism/Glucose Utilization
P3. Hibernating State-Resting Dysfunction/Minimal Scarring
Clinical Indications
Imaging Parameter Modality
Major Points
References
cited
Please
refer to the
literature
review
from
Section
Table 1
Please
B. Coronary Artery refer to the
Abnormalities
1. New or increasing
literature
orthopnea or
review
(Including
exertional dyspenea atherosclerotic
from
disease, anomalies) Section
Table 1
Please
C. Pericardial
refer to the
Abnormalities
literature
review
(Including
calcification / fluid / from
Section
constriction)
Table 1
A. Chamber
Anatomy
Abnormalities
(Geometry /
Dimension / Wall
Thickness)
99
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging Parameter Modality
G. Global
Ventricular Systolic
Dysfunction
(Including reduced
ejection fraction)
Please
refer to the
literature
review
from
Section
Table 1
H. Global
Ventricular
Diastolic
Dysfunction
(Including reduced
ventricular
relaxation / filling)
Please
refer to the
literature
review
from
Section
Table 1
I. Valve Dysfunction
(Stenosis /
Regurgitation /
Other
Abnormalities)
1. New or increasing
orthopnea or
exertional dyspnea
J. Fibrosis/Scarring
(Transmural Extent
/ Mural
Distribution /
Pattern)
M. Regional
Ventricular Systolic
Dysfunction
(Including wall
thickening)
O1. Inducible
IschemiaDecreased
Perfusion
O2. Inducible
IschemiaDecreased
Contraction
Major Points
References
cited
Please
refer to the
literature
review
from
Section
Table 1
Please
refer to the
literature
review
from
Section
Table 1
Please
refer to the
literature
review
from
Section
Table 1
Please
refer to the
literature
review
from
Section
Table 1
Please
refer to the
literature
review
from
Section
Table 1
100
AUI Heart Failure Imaging Parameters Document – October 2010
Clinical Indications
Imaging Parameter Modality
P1. Hibernating
State- Positive
Contractile Reserve
1. New or increasing
orthopnea or
exertional dyspnea
P2. Hibernating
State-Anaerobic
Metabolism /
Glucose Utilization
P3. Hibernating
State-Resting
Dysfunction /
Minimal Scarring
G. Global
Ventricular Systolic
Dysfunction
(Including reduced
ejection fraction)
References
cited
Please
refer to the
literature
review
from
Section
Table 1
Please
refer to the
literature
review
from
Section
Table 1
Please
refer to the
literature
review
from
Section
Table 1
Echo
2. No new symptoms
AND no other
change in clinical
status
Routine Monitoring
Major Points
CMR
Serial Echo studies show patients
with HF getting medical therapy
can have improved LVEF
Serial CMR studies – nuclear cine
CMR and routine cine CMR in
patients with HF undergoing
medical therapy – ACE-I or
Spironolactone can identify
improved function
CCT
SPECT
PET
Cath
[137,268]
[133,268,26
9]
none
none
none
none
Section References - Clinical Scenario 5: Repeat Imaging Evaluation of HF
133. Doherty NE, 3rd, Seelos KC, Suzuki J, Caputo GR, O'Sullivan M, Sobol SM, Cavero P, Chatterjee K,
Parmley WW, Higgins CB. Application of cine nuclear magnetic resonance imaging for sequential
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cardiomyopathy. J Am Coll Cardiol 1992; 19(6):1294-302.
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S, Kinan D, et al. Effects of the angiotensin converting enzyme inhibitor enalapril on the long-term
progression of left ventricular dysfunction in patients with heart failure. SOLVD Investigators.
Circulation 1992; 86(2):431-8.
268. Chan AK, Sanderson JE, Wang T, Lam W, Yip G, Wang M, Lam YY, Zhang Y, Yeung L, Wu EB, Chan WW,
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269. Johnson DB, Foster RE, Barilla F, Blackwell GG, Roney M, Stanley AW, Jr., Kirk K, Orr RA, van der Geest
RJ, Reiber JH, Dell'Italia LJ. Angiotensin-converting enzyme inhibitor therapy affects left ventricular
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AUI Heart Failure Imaging Parameters Document – October 2010
mass in patients with ejection fraction > 40% after acute myocardial infarction. J Am Coll Cardiol
1997; 29(1):49-54.
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4.
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7.
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10.
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12.
13.
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15.
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