Chronic Cough

Variant: 1 Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 2 Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
MRI chest without and with IV contrast	Usually Not Appropriate	O
MRI chest without IV contrast	Usually Not Appropriate	O
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 3 Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
CT chest with IV contrast	Usually Appropriate	☢☢☢
CT chest without IV contrast	Usually Appropriate	☢☢☢
CT maxillofacial without IV contrast	May Be Appropriate	☢☢
Fluoroscopy biphasic esophagram	Usually Not Appropriate	☢☢☢
MRI heart function and morphology without and with IV contrast	Usually Not Appropriate	O
CT maxillofacial with IV contrast	Usually Not Appropriate	☢☢
CT chest without and with IV contrast	Usually Not Appropriate	☢☢☢
CT maxillofacial without and with IV contrast	Usually Not Appropriate	☢☢☢
V/Q scan lung	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.

Variant 1: Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.
A. Radiography Chest

Variant 1: Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.
B. CT Chest

Variant 1: Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.
C. FDG-PET/CT Skull Base to Mid-Thigh

Variant 1: Chronic cough lasting more than 8 weeks. No known risk factors for lung cancer. Initial imaging.
D. MRI Chest

Variant 2: Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.

Variant 2: Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.
A. Radiography Chest

Variant 2: Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.
B. CT Chest

Variant 2: Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.
C. FDG-PET/CT Skull Base to Mid-Thigh

Variant 2: Chronic cough lasting more than 8 weeks. Increased risk for lung cancer. Initial imaging.
D. MRI Chest

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
A. Radiography Chest

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
B. CT Chest

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
C. CT Maxillofacial

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
D. FDG-PET/CT Skull Base to Mid-Thigh

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
E. Fluoroscopy Biphasic Esophagram

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
F. MRI Heart Function and Morphology Without and With IV Contrast

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
G. SPECT or SPECT/CT MPI Rest and Stress

Variant 3: Chronic cough lasting more than 8 weeks. Persistent symptoms despite initial clinical evaluation and empiric treatment. Initial imaging.
H. V/Q Scan Lung

Summary of Recommendations

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.

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.”

References

1.	Irwin RS, French CL, Chang AB, Altman KW, Panel* CEC. Classification of Cough as a Symptom in Adults and Management Algorithms: CHEST Guideline and Expert Panel Report. Chest 2018;153:196-209.
2.	Kuzniar TJ, Morgenthaler TI, Afessa B, Lim KG. Chronic cough from the patient's perspective. Mayo Clin Proc. 82(1):56-60, 2007 Jan.
3.	Truba O, Rybka A, Klimowicz K, et al. Is a normal chest radiograph sufficient to exclude pulmonary abnormalities potentially associated with chronic cough?. Advances in Respiratory Medicine. 86(3), 2018.
4.	Kwak HJ, Moon JY, Choi YW, et al. High prevalence of bronchiectasis in adults: analysis of CT findings in a health screening program. Tohoku J Exp Med. 222(4):237-42, 2010 Dec.
5.	Martin MJ, Harrison TW. Causes of chronic productive cough: An approach to management. [Review]. Respir Med. 109(9):1105-13, 2015 Sep.
6.	Ooi GC, Khong PL, Chan-Yeung M, et al. High-resolution CT quantification of bronchiectasis: clinical and functional correlation. Radiology. 225(3):663-72, 2002 Dec.
7.	Kastelik JA, Aziz I, Ojoo JC, Thompson RH, Redington AE, Morice AH. Investigation and management of chronic cough using a probability-based algorithm. Eur Respir J 2005;25:235-43.
8.	McGarvey L, Gibson PG. What Is Chronic Cough? Terminology. J Allergy Clin Immunol Pract. 7(6):1711-1714, 2019 Jul - Aug.
9.	McCallion P, De Soyza A. Cough and bronchiectasis. [Review]. Pulmonary Pharmacology & Therapeutics. 47:77-83, 2017 Dec.
10.	Pacheco A, de Diego A, Domingo C, et al. Chronic Cough. Archivos de Bronconeumologia. 51(11):579-89, 2015 Nov.
11.	Song WJ, Chang YS, Morice AH. Changing the paradigm for cough: does 'cough hypersensitivity' aid our understanding?. [Review]. Asia Pac Allergy. 4(1):3-13, 2014 Jan.
12.	Tan BK, Chandra RK, Conley DB, Tudor RS, Kern RC. A randomized trial examining the effect of pretreatment point-of-care computed tomography imaging on the management of patients with chronic rhinosinusitis symptoms. Int Forum Allergy Rhinol. 1(3):229-34, 2011 May-Jun.
13.	Michaudet C, Malaty J. Chronic Cough: Evaluation and Management. [Review]. Am Fam Physician. 96(9):575-580, 2017 Nov 01.
14.	Ando A, Smallwood D, McMahon M, Irving L, Mazzone SB, Farrell MJ. Neural correlates of cough hypersensitivity in humans: evidence for central sensitisation and dysfunctional inhibitory control. Thorax. 71(4):323-9, 2016 Apr.
15.	Tran BB, Ditto AM. Cough: A Practical and Multifaceted Approach to Diagnosis and Management. [Review]. Med Clin North Am. 104(1):45-59, 2020 Jan.
16.	Turner RD, Bothamley GH. Chronic cough and a normal chest X-ray - a simple systematic approach to exclude common causes before referral to secondary care: a retrospective cohort study. NPJ Primary Care Respiratory Medicine. 26:15081, 2016 Mar 03.
17.	Ojoo JC, Everett CF, Mulrennan SA, Faruqi S, Kastelik JA, Morice AH. Management of patients with chronic cough using a clinical protocol: a prospective observational study. Cough 2013;9:2.
18.	Touw HR, Parlevliet KL, Beerepoot M, et al. Lung ultrasound compared with chest X-ray in diagnosing postoperative pulmonary complications following cardiothoracic surgery: a prospective observational study. Anaesthesia. 73(8):946-954, 2018 Aug.
19.	Tasci O, Hatipoglu ON, Cagli B, Ermis V. Sonography of the chest using linear-array versus sector transducers: Correlation with auscultation, chest radiography, and computed tomography. J Clin Ultrasound. 44(6):383-9, 2016 Jul 08.
20.	Dogan C, Comert SS, Caglayan B, et al. A New Modality for the Diagnosis of Bleomycin-induced Toxicity: Ultrasonography. Arch Bronconeumol. 54(12):619-624, 2018 12.
21.	Buda N, Piskunowicz M, Porzezinska M, Kosiak W, Zdrojewski Z. Lung Ultrasonography in the Evaluation of Interstitial Lung Disease in Systemic Connective Tissue Diseases: Criteria and Severity of Pulmonary Fibrosis - Analysis of 52 Patients. Ultraschall Med. 37(4):379-85, 2016 Aug.
22.	Mohammadi A, Oshnoei S, Ghasemi-rad M. Comparison of a new, modified lung ultrasonography technique with high-resolution CT in the diagnosis of the alveolo-interstitial syndrome of systemic scleroderma. Med. ultrasonography. 16(1):27-31, 2014 Mar.
23.	Tardella M, Di Carlo M, Carotti M, Filippucci E, Grassi W, Salaffi F. Ultrasound B-lines in the evaluation of interstitial lung disease in patients with systemic sclerosis: Cut-off point definition for the presence of significant pulmonary fibrosis. Medicine (Baltimore). 97(18):e0566, 2018 May.
24.	Moazedi-Fuerst FC, Kielhauser S, Brickmann K, et al. Sonographic assessment of interstitial lung disease in patients with rheumatoid arthritis, systemic sclerosis and systemic lupus erythematosus. Clin Exp Rheumatol. 33(4 Suppl 91):S87-91, 2015 Jul-Aug.
25.	National Lung Screening Trial Research Team, Aberle DR, Adams AM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 365(5):395-409, 2011 Aug 04.
26.	Park JE, Kim Y, Lee SW, Shim SS, Lee JK, Lee JH. The usefulness of low-dose CT scan in elderly patients with suspected acute lower respiratory infection in the emergency room. Br J Radiol. 89(1060):20150654, 2016.
27.	Christe A, Charimo-Torrente J, Roychoudhury K, Vock P, Roos JE. Accuracy of low-dose computed tomography (CT) for detecting and characterizing the most common CT-patterns of pulmonary disease. Eur J Radiol. 82(3):e142-50, 2013 Mar.
28.	Schaal M, Severac F, Labani A, Jeung MY, Roy C, Ohana M. Diagnostic Performance of Ultra-Low-Dose Computed Tomography for Detecting Asbestos-Related Pleuropulmonary Diseases: Prospective Study in a Screening Setting. PLoS ONE. 11(12):e0168979, 2016.
29.	Kardos P, Berck H, Fuchs KH, et al. Guidelines of the German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough. Pneumologie. 64(11):701-11, 2010 Nov.
30.	Piccazzo R, Paparo F, Garlaschi G. Diagnostic accuracy of chest radiography for the diagnosis of tuberculosis (TB) and its role in the detection of latent TB infection: a systematic review. [Review]. J Rheumatol Suppl. 91:32-40, 2014 May.
31.	Colaci M, Sebastiani M, Manfredi A, et al. Lung involvement in systemic sclerosis: role of high resolution computed tomography and its relationship with other pulmonary and clinico-serological features. J Biol Regul Homeost Agents. 28(3):481-8, 2014 Jul-Sep.
32.	Altenburg J, Wortel K, van der Werf TS, Boersma WG. Non-cystic fibrosis bronchiectasis: clinical presentation, diagnosis and treatment, illustrated by data from a Dutch Teaching Hospital. [Review]. Neth J Med. 73(4):147-54, 2015 May.
33.	Choo JY, Lee KY, Yu A, et al. A comparison of digital tomosynthesis and chest radiography in evaluating airway lesions using computed tomography as a reference. Eur Radiol. 26(9):3147-54, 2016 Sep.
34.	Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA. High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med. 2013;31(2):401-405.
35.	Wielputz MO, Heusel CP, Herth FJ, Kauczor HU. Radiological diagnosis in lung disease: factoring treatment options into the choice of diagnostic modality. [Review]. Dtsch. Arztebl. int.. 111(11):181-7, 2014 Mar 14.
36.	Youssef AA, Machaly SA, El-Dosoky ME, El-Maghraby NM. Respiratory symptoms in rheumatoid arthritis: relation to pulmonary abnormalities detected by high-resolution CT and pulmonary functional testing. Rheumatology International. 32(7):1985-95, 2012 Jul.
37.	de Brito MC, Ota MK, Leitao Filho FS, Meirelles GS. Radiologist agreement on the quantification of bronchiectasis by high-resolution computed tomography. Radiol. Bras.. 50(1):26-31, 2017 Jan-Feb.
38.	Hochhegger B, Alves GR, Irion KL, et al. Computed tomographic pulmonary changes in patients with chronic rhinosinusitis. Br J Radiol. 88(1054):20150273, 2015 Oct.
39.	Grydeland TB, Dirksen A, Coxson HO, et al. Quantitative computed tomography measures of emphysema and airway wall thickness are related to respiratory symptoms. American Journal of Respiratory & Critical Care Medicine. 181(4):353-9, 2010 Feb 15.
40.	Wilsher M, Voight L, Milne D, et al. Prevalence of airway and parenchymal abnormalities in newly diagnosed rheumatoid arthritis. Respiratory Medicine. 106(10):1441-6, 2012 Oct.
41.	Morris MJ, Dodson DW, Lucero PF, et al. Study of active duty military for pulmonary disease related to environmental deployment exposures (STAMPEDE). Am J Respir Crit Care Med. 190(1):77-84, 2014 Jul 01.
42.	Winter DH, Manzini M, Salge JM, et al. Aging of the lungs in asymptomatic lifelong nonsmokers: findings on HRCT. Lung. 193(2):283-90, 2015 Apr.
43.	Wachsmann JW, Gerbaudo VH. Thorax: normal and benign pathologic patterns in FDG-PET/CT imaging. [Review]. Pet Clinics. 9(2):147-68, 2014 Apr.
44.	Ackman JB, Wu CC, Halpern EF, Abbott GF, Shepard JA. Nonvascular thoracic magnetic resonance imaging: the current state of training, utilization, and perceived value: survey of the Society of Thoracic Radiology membership. J Thorac Imaging. 29(4):252-7, 2014 Jul.
45.	Theilmann RJ, Darquenne C, Elliott AR, Bailey BA, Conrad DJ. Characterizing Lung Disease in Cystic Fibrosis with Magnetic Resonance Imaging and Airway Physiology. PLoS ONE. 11(6):e0157177, 2016.
46.	Renz DM, Scholz O, Bottcher J, et al. Comparison between magnetic resonance imaging and computed tomography of the lung in patients with cystic fibrosis with regard to clinical, laboratory, and pulmonary functional parameters. Invest Radiol. 50(10):733-42, 2015 Oct.
47.	Ohno Y, Koyama H, Yoshikawa T, et al. Pulmonary high-resolution ultrashort TE MR imaging: Comparison with thin-section standard- and low-dose computed tomography for the assessment of pulmonary parenchyma diseases. J Magn Reson Imaging. 43(2):512-32, 2016 Feb.
48.	Kern AL, Vogel-Claussen J. Hyperpolarized gas MRI in pulmonology. [Review]. Br J Radiol. 91(1084):20170647, 2018 Apr.
49.	Harle ASM, Buffin O, Burnham J, Molassiotis A, Blackhall FH, Smith JA. The prevalence of cough in lung cancer: Its characteristics and predictors. Journal of Clinical Oncology 2014;32:162-62.
50.	Molassiotis A, Smith JA, Mazzone P, Blackhall F, Irwin RS, CHEST Expert Cough Panel. Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report. Chest. 151(4):861-874, 2017 Apr.
51.	Tutkun E, Abusoglu S, Yilmaz H, et al. Farewell to an old friend: chest X-ray vs high-resolution computed tomography in welders' lung disease. Clin Respir J. 8(2):220-4, 2014 Apr.
52.	Akhtar N, Bansal JG. Risk factors of Lung Cancer in nonsmoker. Curr Probl Cancer 2017;41:328-39.
53.	Achilleos A.. Evidence-based Evaluation and Management of Chronic Cough. [Review]. Medical Clinics of North America. 100(5):1033-45, 2016 Sep.
54.	American College of Radiology. ACR–STR Practice Parameter for the Performance of High-Resolution Computed Tomography (HRCT) of the Lungs in Adults. Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=83+&releaseId=2
55.	Abrass LJ, Chandra RK, Conley DB, Tan BK, Kern RC. Factors associated with computed tomography status in patients presenting with a history of chronic rhinosinusitis. Int Forum Allergy Rhinol. 1(3):178-82, 2011 May-Jun.
56.	Conley D, Pearlman A, Zhou K, Chandra R, Kern R. The role of point-of-care CT in the management of chronic rhinosinusitis: a case-control study. Ear Nose Throat J. 90(8):376-81, 2011 Aug.
57.	Moore P, Blakley B, Meen E. Clinical predictors of chronic rhinosinusitis: do the Canadian clinical practice guidelines for acute and chronic rhinosinusitis predict CT-confirmation of disease?. J Otolaryngol Head Neck Surg. 46(1):65, 2017 Dec 04.
58.	Horwitz Berkun R, Polak D, Shapira L, Eliashar R. Association of dental and maxillary sinus pathologies with ear, nose, and throat symptoms. Oral Dis. 24(4):650-656, 2018 May.
59.	Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016;6 Suppl 1:S22-209.
60.	Groves AM, Win T, Screaton NJ, et al. Idiopathic pulmonary fibrosis and diffuse parenchymal lung disease: implications from initial experience with 18F-FDG PET/CT. Journal of Nuclear Medicine. 50(4):538-45, 2009 Apr.
61.	Yadav M, Karkhanis VS, Basu S, Joshi JM. Potential Clinical Utility of FDG-PET in Non-malignant Pulmonary Disorders: A Pilot Study. Indian J Chest Dis Allied Sci. 58(3):165-172, 2016 Jul.
62.	Win T, Thomas BA, Lambrou T, et al. Areas of normal pulmonary parenchyma on HRCT exhibit increased FDG PET signal in IPF patients. European Journal of Nuclear Medicine & Molecular Imaging. 41(2):337-42, 2014 Feb.
63.	Irwin RS, French CL, Curley FJ, Zawacki JK, Bennett FM. Chronic cough due to gastroesophageal reflux. Clinical, diagnostic, and pathogenetic aspects. Chest. 104(5):1511-7, 1993 Nov.
64.	Sidhwa F, Moore A, Alligood E, Fisichella PM. Diagnosis and Treatment of the Extraesophageal Manifestations of Gastroesophageal Reflux Disease. [Review]. Annals of Surgery. 265(1):63-67, 2017 01.
65.	Cardasis JJ, MacMahon H, Husain AN. The spectrum of lung disease due to chronic occult aspiration. Annals of the American Thoracic Society. 11(6):865-73, 2014 Jul.
66.	Aksu O, Songur N, Songur Y, et al. Is gastroesophageal reflux contribute to the development chronic cough by triggering pulmonary fibrosis. Turk J Gastroenterol. 25 Suppl 1:48-53, 2014 Dec.
67.	Kahrilas PJ, Altman KW, Chang AB, et al. Chronic Cough Due to Gastroesophageal Reflux in Adults: CHEST Guideline and Expert Panel Report. Chest. 150(6):1341-1360, 2016 Dec.
68.	Nin CS, Marchiori E, Irion KL, et al. Barium swallow study in routine clinical practice: a prospective study in patients with chronic cough. J Bras Pneumol 2013;39:686-91.
69.	Amalachandran J, Simon S, Elangoven I, Jain A, Sivathapandi T. Scintigraphic Evaluation of Esophageal Motility and Gastroesophageal Reflux in Patients Presenting with Upper Respiratory Tract Symptoms. Indian J. Nucl. Med.. 33(1):25-31, 2018 Jan-Mar.
70.	Akers SR, Panchal V, et al. ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease. J Am Coll Radiol. 2017 May;14(5S):S1546-1440(17)30141-2.
71.	McComb BL, Ravenel JG, Steiner RM, et al. ACR Appropriateness Criteria® Chronic Dyspnea-Noncardiovascular Origin. J Am Coll Radiol 2018;15:S291-S301.
72.	Expert Panel on Cardiac Imaging:, Vogel-Claussen J, Elshafee ASM, et al. ACR Appropriateness Criteria R Dyspnea-Suspected Cardiac Origin. [Review]. J. Am. Coll. Radiol.. 14(5S):S127-S137, 2017 May.
73.	Kirsch J, Brown RKJ, Henry TS, et al. ACR Appropriateness Criteria® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2017;14:S2-S12.
74.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

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.