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Assessment of Cardiac Function and Baseline Cardiac Risk Stratification in Oncology Patients
Variant: 1
Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US echocardiography transthoracic resting | 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 |
| Nuclear medicine ventriculography | Usually Appropriate | ☢☢☢ |
| US echocardiography transesophageal | May Be Appropriate | O |
| US echocardiography transthoracic stress | May Be Appropriate | O |
| MRI heart function with stress without and with IV contrast | May Be Appropriate | O |
| MRI heart function with stress without IV contrast | May Be Appropriate | O |
| CT coronary calcium | May Be Appropriate | ☢☢☢ |
| CTA coronary arteries with IV contrast | May Be Appropriate | ☢☢☢ |
| N-13 ammonia PET/CT MPI rest and stress | May Be Appropriate | ☢☢☢ |
| CT heart function and morphology with IV contrast | May Be Appropriate | ☢☢☢☢ |
| Rb-82 PET/CT MPI rest and stress | May Be Appropriate | ☢☢☢☢ |
| SPECT or SPECT/CT heart | May Be Appropriate | ☢☢☢☢ |
| US duplex Doppler lower extremity | Usually Not Appropriate | O |
| Radiography chest | Usually Not Appropriate | ☢ |
| Arteriography coronary | Usually Not Appropriate | ☢☢☢ |
| Arteriography coronary with ventriculography | Usually Not Appropriate | ☢☢☢ |
| 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 | ☢☢☢ |
| CTA chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA pulmonary arteries with IV contrast | Usually Not Appropriate | ☢☢☢ |
| PYP scan heart | Usually Not Appropriate | ☢☢☢ |
| PYP scan with SPECT or SPECT/CT heart | Usually Not Appropriate | ☢☢☢ |
Variant: 2
Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. 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 | ☢☢☢ |
| Rb-82 PET/CT MPI rest and stress | Usually Appropriate | ☢☢☢☢ |
| SPECT or SPECT/CT heart | Usually Appropriate | ☢☢☢☢ |
| US echocardiography transesophageal | May Be Appropriate | O |
| Radiography chest | May Be Appropriate (Disagreement) | ☢ |
| Arteriography coronary | May Be Appropriate | ☢☢☢ |
| Arteriography coronary with ventriculography | May Be Appropriate | ☢☢☢ |
| MRI heart function with stress without IV contrast | May Be Appropriate (Disagreement) | O |
| CTA pulmonary arteries with IV contrast | May Be Appropriate | ☢☢☢ |
| N-13 ammonia PET/CT MPI rest and stress | May Be Appropriate (Disagreement) | ☢☢☢ |
| Nuclear medicine ventriculography | May Be Appropriate | ☢☢☢ |
| CT heart function and morphology with IV contrast | May Be Appropriate | ☢☢☢☢ |
| US duplex Doppler lower extremity | 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 chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| PYP scan heart | Usually Not Appropriate | ☢☢☢ |
| PYP scan with SPECT or SPECT/CT heart | Usually Not Appropriate | ☢☢☢ |
Panel Members
Nandini M. Meyersohn, MDa; Anushri Parakh, MDb; Brian B. Ghoshhajra, MD, MBAc; Prachi P. Agarwal, MDd; Jamieson M. Bourque, MD, MHSe; Murthy R. Chamarthy, MDf; Carlo N. De Cecco, MD, PhDg; Matthew Ehrhardt, MD, MSh; Cristina Fuss, MDi; Kimberly Kallianos, MDj; Juan C. Lopez-Mattei, MDk; Sachin B. Malik, MDl; Charlotte Manisty, MBBS, PhDm; Christopher D. Maroules, MDn; Alaka Ray, MDo; Marielle Scherrer-Crosbie, MD, PhDp; William Small Jr., MDq; Tina D. Tailor, MDr; Lynne M. Koweek, MDs.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
A. Arteriography coronary
A. Arteriography coronary
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
B. Arteriography coronary with ventriculography
B. Arteriography coronary with ventriculography
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
C. CT chest with IV contrast
C. CT chest with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
D. CT chest without and with IV contrast
D. CT chest without and with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
E. CT chest without IV contrast
E. CT chest without IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
F. CT coronary calcium
F. CT coronary calcium
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
G. CT heart function and morphology with IV contrast
G. CT heart function and morphology with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
H. CTA chest with IV contrast
H. CTA chest with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
I. CTA chest without and with IV contrast
I. CTA chest without and with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
J. CTA coronary arteries with IV contrast
J. CTA coronary arteries with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
K. CTA pulmonary arteries with IV contrast
K. CTA pulmonary arteries with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
L. MRI heart function and morphology without and with IV contrast
L. MRI heart function and morphology without and with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
M. MRI heart function and morphology without IV contrast
M. MRI heart function and morphology without IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
N. MRI heart function with stress without and with IV contrast
N. MRI heart function with stress without and with IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
O. MRI heart function with stress without IV contrast
O. MRI heart function with stress without IV contrast
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
P. N-13 ammonia PET/CT MPI rest and stress
P. N-13 ammonia PET/CT MPI rest and stress
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
Q. Nuclear medicine ventriculography
Q. Nuclear medicine ventriculography
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
R. PYP scan heart
R. PYP scan heart
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
S. PYP scan with SPECT or SPECT/CT heart
S. PYP scan with SPECT or SPECT/CT heart
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
T. Radiography chest
T. Radiography chest
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
U. Rb-82 PET/CT MPI rest and stress
U. Rb-82 PET/CT MPI rest and stress
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
V. SPECT or SPECT/CT heart
V. SPECT or SPECT/CT heart
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
W. US duplex Doppler lower extremity
W. US duplex Doppler lower extremity
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
X. US echocardiography transesophageal
X. US echocardiography transesophageal
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
Y. US echocardiography transthoracic resting
Y. US echocardiography transthoracic resting
Variant 1: Adult. Cardiac risk stratification prior to initiation of oncologic therapy. No cardiac symptoms. Initial imaging.
Z. US echocardiography transthoracic stress
Z. US echocardiography transthoracic stress
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
A. Arteriography coronary
A. Arteriography coronary
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
B. Arteriography coronary with ventriculography
B. Arteriography coronary with ventriculography
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
C. CT chest with IV contrast
C. CT chest with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
D. CT chest without and with IV contrast
D. CT chest without and with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
E. CT chest without IV contrast
E. CT chest without IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
F. CT coronary calcium
F. CT coronary calcium
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
G. CT heart function and morphology with IV contrast
G. CT heart function and morphology with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
H. CTA chest with IV contrast
H. CTA chest with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
I. CTA chest without and with IV contrast
I. CTA chest without and with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
J. CTA coronary arteries with IV contrast
J. CTA coronary arteries with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
K. CTA pulmonary arteries with IV contrast
K. CTA pulmonary arteries with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
L. MRI heart function and morphology without and with IV contrast
L. MRI heart function and morphology without and with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
M. MRI heart function and morphology without IV contrast
M. MRI heart function and morphology without IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
N. MRI heart function with stress without and with IV contrast
N. MRI heart function with stress without and with IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
O. MRI heart function with stress without IV contrast
O. MRI heart function with stress without IV contrast
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
P. N-13 ammonia PET/CT MPI rest and stress
P. N-13 ammonia PET/CT MPI rest and stress
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
Q. Nuclear medicine ventriculography
Q. Nuclear medicine ventriculography
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
R. PYP scan heart
R. PYP scan heart
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
S. PYP scan with SPECT or SPECT/CT heart
S. PYP scan with SPECT or SPECT/CT heart
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
T. Radiography chest
T. Radiography chest
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
U. Rb-82 PET/CT MPI rest and stress
U. Rb-82 PET/CT MPI rest and stress
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
V. SPECT or SPECT/CT heart
V. SPECT or SPECT/CT heart
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
W. US duplex Doppler lower extremity
W. US duplex Doppler lower extremity
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
X. US echocardiography transesophageal
X. US echocardiography transesophageal
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
Y. US echocardiography transthoracic resting
Y. US echocardiography transthoracic resting
Variant 2: Adult. Assessment of cardiac function during oncologic therapy. Cardiac symptoms. Ischemia not excluded. Initial imaging.
Z. US echocardiography transthoracic stress
Z. 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.” |
||
References
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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.