This appropriate use criteria (AUC) document is developed by the American College of Cardiology (ACC), along with key specialty and subspecialty societies. It addresses the use of multimodality imaging in the preoperative evaluation of patients undergoing nonemergent noncardiac surgery. Cardiac imaging is used to stratify risk (and to sometimes result in a modification of the operative plan) and is utilized widely. The vast armamentarium of available tests offers many options that are constantly evolving and being validated. Many clinicians from various specialties and disciplines are involved in the evaluation of such patients. Familiarity of the strengths and limitations of these imaging modalities may vary. Whether imaging needs to be done at all in many scenarios is not universally recognized. The purpose of this document is to provide a framework to identify the value of imaging in subsets of patients stratified by the presence or absence of underlying cardiac disease or altered functional status facing surgical procedure across a continuum of risk. Using standardized methodology, the clinical scenarios were developed by a diverse writing group to represent patient presentations encountered in everyday practice, including common applications and anticipated uses. Where appropriate, the scenarios were developed based on the most current ACC/American Heart Association clinical practice guidelines. A separate, independent rating panel scored the 182 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is rarely considered appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the ACC to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Editorials7 April 2020Combined Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Navigating Between Scylla and CharybdisJohn U. Doherty, MDJohn U. Doherty, MDSidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (J.U.D.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-0572 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In The Odyssey, Ulysses navigates between 2 hazards, a rock shoal commandeered by a 6-headed monster (Scylla) and a whirlpool known for gobbling up ships and claiming their crews (Charybdis). The more he tries to avoid one hazard, the more vulnerable he becomes to the other. We face an analogous situation when caring for patients with atrial fibrillation (AF) after coronary stent placement who require anticoagulation to mitigate stroke risk and antiplatelet therapy to promote stent patency. We want to avoid bleeding events—which are increased with combination therapy—while also avoiding ischemic events, such as stent thrombosis, myocardial infarction, and ischemic ...References1. Hucker WJ, Kanzaria M, Doherty JU. Patients taking oral anticoagulants for atrial fibrillation with concomitant complex disease states. In: Flaker G, eds. Stroke Prevention in Atrial Fibrillation. St. Louis: Elsevier; 2019:149-59. Google Scholar2. Cannon CP, Bhatt DL, Oldgren J, et al; RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med. 2017;377:1513-24. [PMID: 28844193] doi:10.1056/NEJMoa1708454 CrossrefMedlineGoogle Scholar3. Gibson CM, Mehran R, Bode C, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med. 2016;375:2423-34. [PMID: 27959713] doi:10.1056/NEJMoa1611594 CrossrefMedlineGoogle Scholar4. Lopes RD, Heizer G, Aronson R, et al; AUGUSTUS Investigators. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380:1509-24. [PMID: 30883055] doi:10.1056/NEJMoa1817083 CrossrefMedlineGoogle Scholar5. Vranckx P, Valgimigli M, Eckardt L, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet. 2019;394:1335-43. [PMID: 31492505] doi:10.1016/S0140-6736(19)31872-0 CrossrefMedlineGoogle Scholar6. Khan SU, Osman M, Khan MU, et al. Dual versus triple therapy for atrial fibrillation after percutaneous coronary intervention. A systematic review and meta-analysis. Ann Intern Med. 2020;172:474-83. doi:10.7326/M19-3763 LinkGoogle Scholar7. Gargiulo G, Goette A, Tijssen J, et al. Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials. Eur Heart J. 2019;40:3757-67. [PMID: 31651946] doi:10.1093/eurheartj/ehz732 CrossrefMedlineGoogle Scholar8. Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70:3042-67. [PMID: 29203195] doi:10.1016/j.jacc.2017.09.1085 CrossrefMedlineGoogle Scholar9. Steffel J, Verhamme P, Potpara TS, et al; ESC Scientific Document Group. The 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J. 2018;39:1330-93. [PMID: 29562325] doi:10.1093/eurheartj/ehy136 CrossrefMedlineGoogle Scholar10. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74:104-32. [PMID: 30703431] doi:10.1016/j.jacc.2019.01.011 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania (J.U.D.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0572.Corresponding Author: John U. Doherty, MD, Jefferson Heart Institute, 925 Chestnut Street, Mezzanine, Philadelphia, PA 19107; e-mail, john.[email protected]edu.This article was published at Annals.org on 17 March 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoDual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention Safi U. Khan , Mohammed Osman , Muhammad U. Khan , Muhammad Shahzeb Khan , Di Zhao , Mamas A. Mamas , Nazir Savji , Ahmad Al-Abdouh , Rani K. Hasan , and Erin D. Michos Metrics Cited byDual vs triple antiplatelet/anticoagulant therapy after PCI 7 April 2020Volume 172, Issue 7Page: 495-496KeywordsAntiplatelet therapyApixabanAspirinHemorrhageIschemic strokeMyocardial infarctionPercutaneous coronary interventionStent implantationStrokeThrombosis ePublished: 17 March 2020 Issue Published: 7 April 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

The American College of Cardiology ( ACC) collaborated with the American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Pediatric Echocardiography to develop Appropriate Use Criteria ( AUC) for multimodality imaging during the follow- up care of patients with congenital heart disease (CHD). This is the first AUC to address cardiac imaging in adult and pediatric patients with established CHD. A number of common patient scenarios ( also termed "indications") and associated assumptions and definitions were developed using guidelines, clinical trial data, and expert opinion in the field of CHD ( 1). The indications relate primarily to evaluation before and after cardiac Indications related to surveillance are based on a patient's symptoms and the hemodynamic significance of cardiac lesions. Unrepaired VSD with ES is addressed in Table 6 (PH Associated With CHD). In the postprocedural section, evaluation due to change in clinical status and/or new concerning signs or symptoms includes complications such as significant residual shunt, device migration, thrombosis or erosion, valvular lesions, ventricular dysfunction, development of double-chambered RV or subaortic membrane, arrhythmias, and PH. Scenarios related to surveillance imaging of small muscular VSDs (indications 20 to 22) and those following complete repair without sequelae (indications 31 to 33) do not address duration of follow-up. This does not imply indefinite follow-up in such cases, and clinicians should base this decision on available guidelines.

The coronavirus disease 2019 (COVID-19) pandemic due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged health-care systems and physicians worldwide to attempt to provide the best care to their patients with an evolving understanding of this unique pathogen. This disease and its worldwide impact have sparked tremendous interest in the epidemiology, pathogenesis, and clinical consequences of COVID-19. This accumulating body of evidence has centered around case series and often empiric therapies as controlled trials are just getting underway. What is clear is that patients appear to be at higher risk for thrombotic disease states including acute coronary syndrome (ACS), venous thromboembolism (VTE) such as deep vein thrombosis (DVT) or pulmonary embolism (PE), or stroke. Patients with underlying cardiovascular disease are also at higher risk for morbidity and mortality if infected. These patients are commonly treated with anticoagulation and/or antiplatelet medications and less commonly thrombolysis during hospitalization, potentially with great benefit but the management of these medications can be difficult in potentially critically ill patients. In an effort to align practice patterns across a large health system (Jefferson Health 2,622 staffed inpatient beds and 319 intensive care unit (ICU) beds across 14 facilities), a task force was assembled to address the utilization of anti-thrombotic and anti-platelet therapy in COVID-19 positive or suspected patients. The task force incorporated experts in Cardiology, Vascular Medicine, Hematology, Vascular Surgery, Pharmacy, and Vascular Neurology. Current guidelines, consensus documents, and policy documents from specialty organizations were used to formulate health system recommendations. OBJECTIVE:Our goal is to provide guidance to the utilization of antithrombotic and antiplatelet therapies in patients with known or suspected COVID-19.

Ty J. Gluckman, MD, FACC, Chair Niti R. Aggarwal, MD, FACC Nicole M. Bhave, MD, FACC Gregory J. Dehmer, MD, MACC Olivia N. Gilbert, MD, MSc, FACC Chayakrit Krittanawong, MD Dharam J. Kumbhani, MD, SM, FACC Javier A. Sala-Mercado, MD, PhD Andrea L. Price, CPHQ, RCIS, AACC David E.

The American College of Cardiology (ACC) collaborated with the American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine, along with several ACC Councils, to establish and evaluate Appropriate Use Criteria (AUC) for peripheral artery intervention (PAI). Although PAI has been the subject of prior single-society papers, this is the first multisocietal effort on the topic. To initiate the AUC process, patient scenarios that are common in clinical practice were drafted, along with assumptions and definitions for those scenarios. The scenarios were created using published guidelines, trial data, and expert opinions from within the field of peripheral artery disease. The writing group developed 45 clinical scenarios with up to 6 intervention options per scenario and categorized them into 6 general sections. A separate, independent rating panel evaluated each indication using a scoring scale from 1 to 9, thereby designating each indication as "Appropriate" (score of 7 to 9), " May Be Appropriate" (score of 4 to 6), or " Rarely Appropriate" (score of 1 to 3). Throughout the scenarios, emphasis was placed on adhering to and exhausting medical therapy to achieve maximal benefit in those situations in which symptom management was desired or incidental disease was discovered. However, situations arise in which medical therapy is insufficient, and identifying a suitable revascularization strategy is necessary. After considering factors such as symptom burden, anatomic distribution, and ischemic burden, the rating panel determined that both endovascular and surgical approaches are Appropriate in clinical scenarios involving concomitant tissue loss or end organ compromise. There was a tendency to select endovascular approaches in these scenarios, particularly in anatomic distributions below the knee and where prior endovascular or surgical revascularization has been performed. Given the dynamic landscape of cardiovascular medicine, the writing group felt it was necessary to address situations in which adjunct arterial revascularization may be necessary to facilitate other procedures such as percutaneous valve replacement or hemodynamic support. The clinical situations where this occurs often make endovascular interventions more attractive and that was reflected in the ratings. The purpose of this particular AUC is to provide guidance to clinicians who may refer patients for revascularization treatments and to interventionalists and surgeons themselves. With the field of peripheral artery disease constantly evolving, it is imperative to offer tools and resources that physicians can utilize to provide the best care for their patients.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document (J Am Coll Cardiol 2017;70:1647-1672) addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

![Figure][1] ![Figure][1] ![Figure][1] ![Figure][1] As codified in its recent strategic plan, the College envisions a world where innovation and knowledge optimize cardiovascular (CV) care and outcomes. To achieve this, it is critical that the scientific and clinical

The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement and transcatheter aortic valve replacement. A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data and expert opinion in the field of AS. The '2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines' [1] and its 2017 focused update paper [2] were used as the primary guiding references in developing these indications. The Writing Group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent Rating Panel was asked to score each indication from 1 to 9, with 1-3 categorized as 'Rarely Appropriate', 4-6 as 'May Be Appropriate' and 7-9 as 'Appropriate'. After considering factors such as symptom status, left ventricular function, surgical risk, and the presence of concomitant coronary or other valve disease, the Rating Panel determined that either surgical aortic valve replacement or transcatheter aortic valve replacement is appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for surgical aortic valve replacement or transcatheter aortic valve replacement are less clear, including situations in which one form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.

The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement and transcatheter aortic valve replacement. A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data and expert opinion in the field of AS. The '2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines' [1] and its 2017 focused update paper [2] were used as the primary guiding references in developing these indications. The Writing Group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent Rating Panel was asked to score each indication from 1 to 9, with 1-3 categorized as 'Rarely Appropriate', 4-6 as 'May Be Appropriate' and 7-9 as 'Appropriate'. After considering factors such as symptom status, left ventricular function, surgical risk, and the presence of concomitant coronary or other valve disease, the Rating Panel determined that either surgical aortic valve replacement or transcatheter aortic valve replacement is appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for surgical aortic valve replacement or transcatheter aortic valve replacement are less clear, including situations in which one form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.

Appropriate use criteria (AUC) have existed for over 30 years and are being deployed with increasing frequency to study the delivery of healthcare. The goal of AUC is to advise all stakeholders about the reasonable use of testing procedures or therapies to improve symptoms, quality of life, and health outcomes. Numerous studies have shown the favorable effects of AUC to limit the overuse of unnecessary procedures while also promoting high-quality clinical care and cost savings. AUC evaluating only a single imaging modality have been replaced by multimodality documents, making it easier for the clinician to evaluate the appropriateness of multiple imaging methods in various clinical scenarios. The Protecting Access to Medicare Act of 2014 contained language mandating the use of AUC when ordering certain advanced cardiac imaging tests, and this requirement is currently scheduled for implementation in January 2020. Clinicians need to be aware of the increasing use of AUC and the financial implications of the AUC mandate legislation.

James L. Januzzi, Jr, MD, FACC, Chair Luis C. Afonso, MBBS, FACC Brendan Everett, MD, FACC Adrian F. Hernandez, MD, FACC William Hucker, MD, PhD Hani Jneid, MD, FACC Dharam J. Kumbhani, MD, SM, FACC Joseph E. Marine, MD, FACC Pamela Bowe Morris, MD, FACC Robert Piana, MD, FACC Karol E.

This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multi-modality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities.Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines.A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario.The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Periprocedural management of anticoagulation is a common clinical conundrum that involves a multidisciplinary team, cuts across many specialties, and varies greatly between institutions in the way it is practiced. Nowhere is this more evident than in the management of patients with nonvalvular atrial fibrillation. Although they have been found to improve patient outcomes, standardized evidence-based protocols are infrequently in place. The frequency of anticoagulant interruption in preparation for a procedure is high, with an estimated 250,000 patients undergoing temporary interruption annually in North America alone. Knowledge about risk of bleeding and short-term thrombotic risk resides in many specialties, further complicating the issue. Our goal in creating this pathway is to help guide clinicians in the complex decision making in this area. In this document, we aim to: 1) validate the appropriateness of the decision to chronically anticoagulate; 2) guide clinicians in the decision of whether to interrupt anticoagulation; 3) provide direction on how to interrupt anticoagulation with specific guidance for vitamin K antagonists and direct-acting oral anticoagulants; 4) evaluate whether to bridge with a parenteral agent periprocedurally; 5) offer advice on how to bridge; and 6) outline the process of restarting anticoagulation post-procedure.

Interruption of oral anticoagulation (AC) for surgery or an invasive procedure is a complicated process. Practice guidelines provide only general recommendations, and care of such patients occurs across multiple specialties. The availability of direct oral anticoagulants further complicates decision making and guidance here is limited. To evaluate current practice patterns in the United States for bridging AC, a survey was developed by the American College of Cardiology Anticoagulation Work Group. The goal of the survey was to assess how general and subspecialty cardiologists, internists, gastroenterologists, and orthopedic surgeons currently manage patients who receive AC and undergo surgery or an invasive procedure. The survey was completed by 945 physicians involved in the periprocedural management of AC. The results provide a template for educational and research projects geared toward the development of clinical pathways and point-of-care tools to improve this area of health care.

The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-by-side rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting.

The American College of Cardiology (ACC) participated in a joint project with the American Society of Echocardiography, the Society of Pediatric Echocardiography, and several other subspecialty societies and organizations to establish and evaluate Appropriate Use Criteria (AUC) for the initial use of outpatient pediatric echocardiography. Assumptions for the AUC were identified, including the fact that all indications assumed a first-time transthoracic echocardiographic study in an outpatient setting for patients without previously known heart disease. The definitions for frequently used terminology in outpatient pediatric cardiology were established using published guidelines and standards and expert opinion. These AUC serve as a guide to help clinicians in the care of children with possible heart disease, specifically in terms of when a transthoracic echocardiogram is warranted as an initial diagnostic modality in the outpatient setting. They are also a useful tool for education and provide the infrastructure for future quality improvement initiatives as well as research in healthcare delivery, outcomes, and resource utilization.To complete the AUC process, the writing group identified 113 indications based on common clinical scenarios and/or published clinical practice guidelines, and each indication was classified into 1 of 9 categories of common clinical presentations, including palpitations, syncope, chest pain, and murmur. A separate, independent rating panel evaluated each indication using a scoring scale of 1 to 9, thereby designating each indication as "Appropriate" (median score 7 to 9), "May Be Appropriate" (median score 4 to 6), or "Rarely Appropriate" (median score 1 to 3). Fifty-three indications were identified as Appropriate, 28 as May Be Appropriate, and 32 as Rarely Appropriate.