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Editor's Note
November 2015

Appropriate Use Criteria Require Data

JAMA Intern Med. 2015;175(11):1855-1856. doi:10.1001/jamainternmed.2015.5050

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.

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Article Information

Conflict of Interest Disclosures: None reported.

References
1.
Hendel  RC, Patel  MR, Kramer  CM,  et al; American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group; American College of Radiology; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; American Society of Nuclear Cardiology; North American Society for Cardiac Imaging; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology.  ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48(7):1475-1497. doi:10.1016/j.jacc.2006.07.003.PubMedArticle
2.
Cremer  PC, Mentias  A, Newton  D,  et al.  Low yield of myocardial perfusion imaging in asymptomatic patients with atrial fibrillation [published online September 14, 2015]. JAMA Intern Med. doi:10.1001/jamainternmed.2015.4802.
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