ACC Corner | Imagings Journey to the High Road

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 - John J. Mahmarian, MD, FACC, FASNC
John J. Mahmarian, MD, FACC, FASNC

Over the past several years, the practice of medicine has faced considerable headwinds. Likewise, cardiovascular imaging has been challenged on a number of different fronts, ranging from growing public concern over radiation exposure, reductions in reimbursement and increased denials by third-party payors.  

We now stand at the crossroads where moving our field forward will require us to capitalize on our strengths, clearly define the value of cardiovascular imaging and decrease variation in practice.

In 2011, the American Society of Nuclear Cardiology (ASNC) embarked on a campaign to raise the bar for nuclear cardiac imaging to realize the true potential of myocardial perfusion imaging (MPI) in optimizing patient care in a safe and efficient manner.

The Excellence in Imaging Campaign, conceived by ASNC’s immediate Past-President Leslee J. Shaw, PhD, embodies these principles. The campaign emphasizes application of appropriate use criteria (AUC) to identify patients most likely to benefit from an imaging strategy (J Am Coll Cardiol 2009;53:2201-2229). It also focuses on choosing the proper imaging protocol for an individual patient to provide accurate and clinically meaningful information to the referring physician. Equally important, tailoring imaging protocols also will help ensure that every patient’s radiation exposure is limited to the lowest dose required to obtain a diagnostic study.  

Numerous clinical documents and evidence-based imaging guidelines published by ASNC also lay important foundations for performing MPI procedures and complement the American College of Cardiology’s (ACC) appropriate use criteria publications. Recently, ASNC published its first patient-centered imaging document that is meant to assist the technologist and imaging physician in choosing the proper test for the proper patient (J Nucl Cardiol 2012;19:185-215). Unlike previous guidelines, this document specifically outlines the pros and cons of all current imaging procedures, stressor modalities and radiotracers, while presenting a framework for estimating patient radiation exposure based on administration of typical radiotracer doses. The paper takes into account four important principles when tailoring imaging protocols to individual patients:

  1. Patient safety;
  2. Optimizing clinical benefit to the patient;
  3. Patient convenience and satisfaction; and
  4. Cost considerations.

Using these criteria as a guide, the document provides evidence-based roadmaps for matching patients to imaging protocols. A section also utilizes a case-based approach to summarize the choice of MPI procedure under varying clinical conditions and describes how best to cope with specific imaging challenges in individual patients. For cost strategies, the paper recommends streamlining procedures and establishing protocols that maximize efficiencies.

Recently, ACC and ASNC supported these patient-centered principles as part of the Choosing Wisely campaign organized by the ABIM (American Board of Internal Medicine) Foundation. With seven other medical societies in an April press conference, ACC and ASNC discussed the appropriate use of healthcare procedures in the U.S. The campaign aims to strengthen the physician-patient relationship in making healthcare decisions to ensure that patients receive the right test at the right time. It complements efforts underway by organizations like ACC, ASNC and others to demonstrate providers’ commitment to optimal patient care. 

Appropriate Use in Imaging
The 2009 report on the appropriate use criteria for nuclear radionuclide imaging in patients with coronary artery disease concluded that:
  • Testing in low-risk patients, routine repeat testing and general screening in certain clinical scenarios was viewed less favorably.
  • Use for perioperative testing was found to be inappropriate except in selected groups of patients.

Taking the high road is an important and necessary challenge. Through a vision of patient-centered imaging and a concerted effort by providers, the cardiovascular field will continue to grow and be recognized as providing value and quality to our patients.  

Dr. Mahmarian is president of the American Society of Nuclear Cardiology.