Appropriate use criteria (AUC) have been released by the American College of Cardiology since 2005 to help cardiologists decide on the risks and benefits of various cardiac procedures. The process has evolved greatly since when I was a member of an AUC cardiac imaging writing group in 20061; our instructions were to put ourselves in the position of the practicing physician in deciding what would be reasonable without any review of the literature.
Today, AUC incorporate published evidence to guide clinicians in the labyrinth of clinical choices presented by individual patients. For each scenario, the procedure is rated as appropriate, may be appropriate, or rarely appropriate.
Of course, the benefits of including the published literature in AUC development depends on the availability of useful data . This is well illustrated by an article by Cremer et al2 in this issue. For example, myocardial perfusion imaging (MPI), a commonly used cardiac stress test, is rated as appropriate or may be appropriate for asymptomatic patients with atrial fibrillation to identify silent ischemia. Cremer et al2 analyzed 8 years of experience of performing MPI at the Cleveland Clinic in asymptomatic patients with atrial fibrillation. They found that the yield for detecting cardiac ischemia was low; even in patients with atrial fibrillation with high global cardiovascular risk, the yield for detecting ischemia was 5.2%, and ischemia was not associated with increased mortality in this population. These findings suggest that these asymptomatic patients do not benefit from MPI. Harms of MPI include increased cancer risk from the high radiation burden (6-37 mSv depending on protocol, which is equivalent to hundreds or thousands of chest radiographs). These findings support a change in the AUC rating to the rarely appropriate category for this indication, and because MPI has definite harms without benefits for asymptomatic patients with atrial fibrillation this Research Letter merits the Less is More designation.
Conflict of Interest Disclosures: None reported.
Redberg RF. Appropriate Use Criteria Require Data. JAMA Intern Med. 2015;175(11):1855-1856. doi:10.1001/jamainternmed.2015.5050