Suspected and Known Heart Failure

Variant: 1 Adult. Suspected heart failure. No history of heart failure. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US echocardiography transthoracic resting	Usually Appropriate	O
Radiography chest	Usually Appropriate	☢
US echocardiography transthoracic stress	May Be Appropriate	O
MRI heart function and morphology without and with IV contrast	May Be Appropriate	O
MRI heart function and morphology without IV contrast	May Be Appropriate	O
Nuclear medicine ventriculography	May Be Appropriate	☢☢☢
CT heart function and morphology with IV contrast	May Be Appropriate	☢☢☢☢
US echocardiography transesophageal	Usually Not Appropriate	O
Arteriography coronary	Usually Not Appropriate	☢☢☢
MRA coronary arteries without and with IV contrast	Usually Not Appropriate	O
MRI heart function with stress without and with IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢
CT coronary calcium	Usually Not Appropriate	☢☢☢
CTA coronary arteries with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT heart	Usually Not Appropriate	☢☢☢☢
Rb-82 PET/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult. Known heart failure. Unknown etiology. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US echocardiography transthoracic resting	Usually Appropriate	O
US echocardiography transthoracic stress	Usually Appropriate	O
MRI heart function and morphology without and with IV contrast	Usually Appropriate	O
MRI heart function and morphology without IV contrast	Usually Appropriate	O
MRI heart function with stress without and with IV contrast	Usually Appropriate	O
CTA coronary arteries with IV contrast	Usually Appropriate	☢☢☢
SPECT or SPECT/CT MPI rest and stress	Usually Appropriate	☢☢☢☢
US echocardiography transesophageal	May Be Appropriate	O
Arteriography coronary	May Be Appropriate	☢☢☢
CT heart function and morphology with IV contrast	May Be Appropriate	☢☢☢☢
FDG-PET/CT heart	May Be Appropriate	☢☢☢☢
Rb-82 PET/CT MPI rest and stress	May Be Appropriate	☢☢☢☢
Radiography chest	Usually Not Appropriate	☢
MRA coronary arteries without and with IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢
CT coronary calcium	Usually Not Appropriate	☢☢☢
Nuclear medicine ventriculography	Usually Not Appropriate	☢☢☢

Variant: 3 Adult. Known heart failure. Follow-up imaging.

Procedure	Appropriateness Category	Relative Radiation Level
US echocardiography transthoracic resting	Usually Appropriate	O
US echocardiography transthoracic stress	Usually Appropriate	O
MRI heart function and morphology without and with IV contrast	Usually Appropriate	O
MRI heart function and morphology without IV contrast	Usually Appropriate	O
MRI heart function with stress without and with IV contrast	Usually Appropriate	O
Radiography chest	May Be Appropriate	☢
Nuclear medicine ventriculography	May Be Appropriate	☢☢☢
CT heart function and morphology with IV contrast	May Be Appropriate	☢☢☢☢
FDG-PET/CT heart	May Be Appropriate	☢☢☢☢
Rb-82 PET/CT MPI rest and stress	May Be Appropriate	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	May Be Appropriate	☢☢☢☢
US echocardiography transesophageal	Usually Not Appropriate	O
Arteriography coronary	Usually Not Appropriate	☢☢☢
MRA coronary arteries without and with IV contrast	Usually Not Appropriate	O
CT chest with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT chest without IV contrast	Usually Not Appropriate	☢☢☢
CT coronary calcium	Usually Not Appropriate	☢☢☢
CTA coronary arteries with IV contrast	Usually Not Appropriate	☢☢☢

Panel Members

Kate Hanneman, MD, MPH^a; James Roberts, MD, MSc^b; Prabhakar Shantha Rajiah, MD^c; Shawn Ahmad, MD, MBA^d; Ryan Avery, MD^e; William M. Brown, MD^f; Ahmed H. El-Sherief, MD^g; Joe Y. Hsu, MD^h; Veronica Lenge de Rosen, MDⁱ; Fay Lin, MD^j; Gurusher Panjrath, MBBS^k; Rahul D. Renapurkar, MD, MBBS^l; James A. White, MD^m; Michael A. Bolen, MDⁿ.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
A. Arteriography coronary

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
B. CT chest with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
C. CT chest without and with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
D. CT chest without IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
E. CT coronary calcium

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
F. CT heart function and morphology with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
G. CTA coronary arteries with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
H. FDG-PET/CT heart

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
I. MRA coronary arteries without and with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
J. MRI heart function and morphology without and with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
K. MRI heart function and morphology without IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
L. MRI heart function with stress without and with IV contrast

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
M. Nuclear medicine ventriculography

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
N. Radiography chest

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
O. Rb-82 PET/CT MPI rest and stress

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
P. SPECT or SPECT/CT MPI rest and stress

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
Q. US echocardiography transesophageal

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
R. US echocardiography transthoracic resting

Variant 1: Adult. Suspected heart failure. No history of heart failure. Initial imaging.
S. US echocardiography transthoracic stress

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
A. Arteriography coronary

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
B. CT chest with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
C. CT chest without and with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
D. CT chest without IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
E. CT coronary calcium

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
F. CT heart function and morphology with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
G. CTA coronary arteries with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
H. FDG-PET/CT heart

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
I. MRA coronary arteries without and with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
J. MRI heart function and morphology without and with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
K. MRI heart function and morphology without IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
L. MRI heart function with stress without and with IV contrast

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
M. Nuclear medicine ventriculography

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
N. Radiography chest

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
O. Rb-82 PET/CT MPI rest and stress

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
P. SPECT or SPECT/CT MPI rest and stress

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
Q. US echocardiography transesophageal

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
R. US echocardiography transthoracic resting

Variant 2: Adult. Known heart failure. Unknown etiology. Initial imaging.
S. US echocardiography transthoracic stress

Variant 3: Adult. Known heart failure. Follow-up imaging.

Variant 3: Adult. Known heart failure. Follow-up imaging.
A. Arteriography coronary

Variant 3: Adult. Known heart failure. Follow-up imaging.
B. CT chest with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
C. CT chest without and with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
D. CT chest without IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
E. CT coronary calcium

Variant 3: Adult. Known heart failure. Follow-up imaging.
F. CT heart function and morphology with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
G. CTA coronary arteries with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
H. FDG-PET/CT heart

Variant 3: Adult. Known heart failure. Follow-up imaging.
I. MRA coronary arteries without and with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
J. MRI heart function and morphology without and with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
K. MRI heart function and morphology without IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
L. MRI heart function with stress without and with IV contrast

Variant 3: Adult. Known heart failure. Follow-up imaging.
M. Nuclear medicine ventriculography

Variant 3: Adult. Known heart failure. Follow-up imaging.
N. Radiography chest

Variant 3: Adult. Known heart failure. Follow-up imaging.
O. Rb-82 PET/CT MPI rest and stress

Variant 3: Adult. Known heart failure. Follow-up imaging.
P. SPECT or SPECT/CT MPI rest and stress

Variant 3: Adult. Known heart failure. Follow-up imaging.
Q. US echocardiography transesophageal

Variant 3: Adult. Known heart failure. Follow-up imaging.
R. US echocardiography transthoracic resting

Variant 3: Adult. Known heart failure. Follow-up imaging.
S. US echocardiography transthoracic stress

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination