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B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06

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B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06

  1. 1. B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06
  2. 2. B. C. Kansupada, MD HeartCare Assoc ACC chapter talk 4/28/06
  3. 3. Nuclear Imaging 2006 <ul><li>Bindu Kansupada, MD, MBA, FACC </li></ul><ul><li>HeartCare Associates </li></ul><ul><li>Member Payors Committee PACC </li></ul>
  4. 4. Disclosure <ul><li>Consultant/speaker bureau for: </li></ul><ul><ul><ul><li>Medtronics </li></ul></ul></ul><ul><ul><ul><li>Guident </li></ul></ul></ul><ul><ul><ul><li>St. Judes </li></ul></ul></ul><ul><ul><ul><li>Merck </li></ul></ul></ul><ul><ul><ul><li>Bristol Myers Squib </li></ul></ul></ul>
  5. 5. <ul><li>Special Thanks: </li></ul><ul><li>Dr. Polk </li></ul><ul><li>Dr. Ronald Schwartz </li></ul><ul><li>Dr. Braunwald </li></ul>
  6. 6. Nuclear Cardiac Imaging (Myocardial Perfusion Imaging ) <ul><li>Myocardial Perfusion Imaging – What is it? </li></ul><ul><li>MPI Images – What does it look like? </li></ul><ul><li>Clinical Value – What good is it? </li></ul><ul><li>Comparison with other modalities </li></ul><ul><ul><ul><li>– Why MPI? </li></ul></ul></ul>
  7. 7. What is Myocardial Perfusion Imaging? <ul><li>In the U.S., nuclear cardiology (MPI) procedures have overtaken non-cardiology procedures in procedural volume. </li></ul>
  8. 8. <ul><li>MPI is a non-invasive nuclear imaging technique that uses radioactive imaging agents to image the heart. </li></ul><ul><li>Thallium - 201 </li></ul><ul><li>Technetium-99 m Sestamibi </li></ul><ul><li>Technetium-99 m Tetrofosmin </li></ul>What is Myocardial Perfusion Imaging?
  9. 9. What do MPI images look like? <ul><li>In a typical nuclear cardiac imaging exam, the physician reviews: </li></ul><ul><ul><li>Static “Summed Perfusion Images” </li></ul></ul><ul><ul><li>Dynamic “Gated Images” </li></ul></ul>Perfusion Images are viewed in three orientations: SA – Short Axis VLA – Vertical Long Axis HLA - Horizontal Long Axis
  10. 10. What do MPI images look like? - Summed Perfusion Images Stress Rest Stress Rest Stress Rest Stress Rest SA SA VLA HLA
  11. 11. What do MPI images look like? - Summed Perfusion Images Stress Rest <ul><li>Summed images are used to assess cardiac perfusion . Rest and Stress images are compared to determine if a region of the heart is “ischemic” – starved of oxygen </li></ul><ul><li>In the study below, the rest image indicates normal blood flow, but the stress image indicates abnormal blood flow in the Inferior-lateral region. </li></ul><ul><li>This may indicate “ischemia” in this region of the heart – which is supplied by the LCX (left circumflex artery). There may be stenosis in that coronary artery. </li></ul>
  12. 12. What do MPI images look like? Gated Images SA HLA VLA <ul><li>Gated images are made possible by ECG-gated SPECT </li></ul><ul><li>Physicians can now access cardiac function : </li></ul><ul><ul><li>Wall motion – does the LV contract uniformly? </li></ul></ul><ul><ul><li>Ejection Fraction – does the LV pump out enough blood to the body? </li></ul></ul>
  13. 13. What Good is MPI? – Clinical Value <ul><li>A nuclear stress test provides excellent negative predictive value </li></ul><ul><ul><li>Patients from the general population with normal MPI scans have <1% annual risk of cardiac events </li></ul></ul>
  14. 14. What Good is MPI? – Clinical Value <ul><li>A gated nuclear stress test is a powerful tool to risk stratify patients for optimal management. </li></ul><ul><li>It is in effect a “gate-keeper” to the cardiac cath lab </li></ul>
  15. 15. Coronary Distribution (Left Ventricle) Remember This The 3 coronary arteries are: LAD - left anterior descending artery RCA - right coronary artery LCX - left circumflex coronary artery
  16. 17. Normal Myocardial Perfusion
  17. 18. Myocardial Ischemia
  18. 19. Myocardial Infarction
  19. 20. Type of Nuclear Imaging
  20. 21. Gated Study <ul><li>Gating process-Functional assessment </li></ul><ul><ul><li>ventricular wall motion </li></ul></ul><ul><ul><li>ES and ED ventricular volumes </li></ul></ul><ul><ul><li>LV ejection fraction </li></ul></ul><ul><ul><ul><li>normal = 64% +/- 12% </li></ul></ul></ul>
  21. 22. Gated Study <ul><li>Radiopharmaceutical </li></ul><ul><ul><li>Tc-99m labeled red blood cells </li></ul></ul><ul><ul><li>in-vitro and in-vivo labeling </li></ul></ul><ul><li>Images </li></ul><ul><ul><li>anterior </li></ul></ul><ul><ul><li>left lateral </li></ul></ul><ul><ul><li>left anterior oblique (best LV separation) </li></ul></ul>
  22. 23. Gated Study <ul><li>Exercise assessment </li></ul><ul><ul><li>stress done with bicycle </li></ul></ul><ul><ul><li>rest EF to compare stress EF </li></ul></ul><ul><li>Primary uses of test </li></ul><ul><ul><li>congestive heart failure </li></ul></ul><ul><ul><li>cardiomyopathy </li></ul></ul><ul><ul><li>chemo cardiotoxicity </li></ul></ul>
  23. 24. First Pass Cardiac Study <ul><li>What’s ‘first pass’? </li></ul><ul><ul><li>temporal separation of chambers </li></ul></ul><ul><li>Functional assessment </li></ul><ul><ul><li>ventricular wall motion </li></ul></ul><ul><ul><li>ES and ED ventricular volumes </li></ul></ul><ul><ul><li>LV and RV ejection fractions </li></ul></ul><ul><ul><li>pulmonary transit time </li></ul></ul>
  24. 25. First Pass Cardiac Study <ul><li>Can be performed with exercise </li></ul><ul><ul><li>stress done with bicycle </li></ul></ul><ul><ul><li>rest EF to compare to stress EF </li></ul></ul><ul><li>Primary uses of test </li></ul><ul><ul><li>same as gated cardiac study </li></ul></ul><ul><ul><li>better than gated at right ventricle assessment and cardiac shunts </li></ul></ul>
  25. 26. Myocardial Perfusion Study Assess coronary blood flow Demonstrate blood perfusion of the LV myocardium Software allows gating for EF 3D reconstruction of heart
  26. 27. Myocardial Perfusion <ul><li>Radiopharmaceuticals </li></ul><ul><ul><li>Thallium-201 chloride </li></ul></ul><ul><ul><li>Tc-99m Sestamibi </li></ul></ul><ul><ul><li>Tc-99m Tetrofosmin </li></ul></ul><ul><li>SPECT acquisition </li></ul><ul><ul><li>provides cross-sectional images of the myocardium in the short axis, horizontal long axis and vertical long axis planes </li></ul></ul>
  27. 28. Myocardial Perfusion <ul><li>Performed at rest & stress </li></ul><ul><li>Stress study options </li></ul><ul><ul><li>treadmill exercise </li></ul></ul><ul><ul><li>pharmacologic stress agents </li></ul></ul><ul><ul><ul><li>adenosine </li></ul></ul></ul><ul><ul><ul><li>persantine (dipyridamole) </li></ul></ul></ul><ul><ul><ul><li>dobutamine </li></ul></ul></ul>
  28. 29. Myocardial Perfusion -Percentage of LV myocardium receiving decreased perfusion -Differentiate ischemia from MI -24 hour delayed images demonstrate myocardial viability (hibernating) -Rest-only studies can provide information on acute MI’s
  29. 30. Exam Results <ul><li>Myocardial Infarction </li></ul><ul><ul><li>perfusion defect on rest & stress </li></ul></ul><ul><li>Myocardial Ischemia </li></ul><ul><ul><li>perfusion defect on stress only </li></ul></ul>
  30. 31. Diagnostic Approach
  31. 32. Exercise Protocol <ul><li>Exercise preferred modality </li></ul><ul><li>Radiopharmaceutical injected at peak and continued exercise for another 1-2 minutes. </li></ul><ul><li>If unable to exercise, unable to attain target heart rate, or contraindications pharmacologic testing should be performed. </li></ul><ul><li>B-blockers should be held for 48 hours </li></ul><ul><li>No caffeine for 24 hours. </li></ul>
  32. 33. Exercise Testing - Contra Indications <ul><li>Unstable Angina </li></ul><ul><li>Decompensated CHF </li></ul><ul><li>Uncontrolled hypertension (blood pressure > 200/115 mm of Hg) </li></ul><ul><li>Acute myocardial infarction within last 2 to 3 days </li></ul><ul><li>Severe pulmonary hypertension </li></ul><ul><li>Relative contraindication AS, HCM </li></ul>
  33. 34. Exercise Testing <ul><li>Each of the protocols has advantages and disadvantages. </li></ul><ul><li>Quality control from preparation, acquisition to reading assure the best data. </li></ul>
  34. 35. Myocardial PerfusionScintigraphy: Assessment of Diagnosis, Prognosis, and Treatment Response of Cardiovascular Risk. <ul><li>Diagnosis, Prognosis, and Response to Therapy </li></ul><ul><li>Suspected Coronary artery disease </li></ul><ul><li>Known stable coronary artery disease </li></ul><ul><li>Prior to non-cardiac surgery </li></ul><ul><li>Before and after cardiac revascularization </li></ul>
  35. 36. Myocardial PerfusionScintigraphy: Assessment of Diagnosis, Prognosis, and Treatment Response of Cardiovascular Risk <ul><li>Diagnosis, Prognosis, and Response to Therapy Special populations (women, diabetics) </li></ul><ul><li>Evaluation of acute chest pain syndromes </li></ul><ul><li>Myocardial infarction </li></ul><ul><li>Screening: Multiple risk factors, Family history </li></ul><ul><li>Response to medical therapy </li></ul>
  36. 37. Populations Who Benefit from SPECT MPI <ul><li>Diagnostic and prognostic chest pain evaluation </li></ul><ul><li>Angina </li></ul><ul><li>Atypical Angina </li></ul><ul><li>Atypical Chest Pain </li></ul><ul><li>Non-cardiac Chest Pain </li></ul><ul><li>Peri-operative risk of non-cardiac surgery </li></ul><ul><li>Diagnostic and prognostic evaluation of ACS </li></ul><ul><li>Emergency Department </li></ul><ul><li>In Hospital </li></ul>
  37. 38. Populations Who Benefit from SPECT MPI <ul><li>Hemodynamic/prognostic assessment of known CAD </li></ul><ul><li>High risk asymptomatic populatios </li></ul><ul><li>Diabetes, Metabolic syndrome, insulin resistance syndrome </li></ul><ul><li>Family history of sibling with coronary event </li></ul><ul><li>Mediastinal radiation </li></ul><ul><li>Multiple coronary risk factor </li></ul><ul><li>Monitoring effectiveness of surgical and percutaneous revascularization </li></ul><ul><li>Monitoring effectiveness of “ medical revascularization” </li></ul>
  38. 39. 2742 Men 1394 Women + MPI + EXERCISE CLINICAL Incremental Prognostic Value of MPI Testing: Men vs. Women 120
  39. 40. Specificity of MPI with SPECT Procedures in Women P =.0004
  40. 41. Heart Disease in Women: Lessons From The Past Decade <ul><li>The importance of studying gender specific aspects of CAD have helped in the following clinical dilemmas: </li></ul><ul><li>Presentation of CAD: women are older than men </li></ul><ul><li>Less Specific clinical manifestations of CAD in women </li></ul><ul><li>Greater Difficulty in Diagnosis: women>men </li></ul><ul><li>More sever consequences of MI when it occurs in women </li></ul>
  41. 42. Detecting CAD in Women <ul><li>Evidence from numerous medical societies uniformly supports association of exercise ECG has lower diagnostic accuracy in women (more false positive) </li></ul><ul><li>Critical Factors Affects Accuracy: Functional Capacity, Rest ST-T changes, Hormonal Factors </li></ul><ul><li>SPECT was better able to identify and satisfy women at high risk for future events. </li></ul><ul><li>Extent of total perfusion abnormality, extent of reversible perfusion abnormality, multivessel abnormality, & large perfusion abnormality are all strong predictors of future cardiac events. </li></ul><ul><li>Await RCT data from the WOMEN study to provide further detail as to the value of SPECt in accessing risk in women. </li></ul>
  42. 43. Long –Term outcome of Patients With Intermediate-Risk Exercise Electrocardiograms who Do Not Have Myocardial Perfision Defects on Radionuclide Imaging <ul><li>Results </li></ul><ul><li>Cardiovascular survival was 99.8% at 1 year, 99.0% at 5 years and 98.5% at 7 years. </li></ul><ul><li>Near-normal scans and cardiac enlargement were independent predictors of time to cardiac death. </li></ul><ul><li>Cardiac survival time free of myocardial infarction or revascularization was 87.1% at 7 years. </li></ul>
  43. 44. Summary: Acute Rest Imaging in 2005 <ul><li>Strong predictor of short-term cardiac events </li></ul><ul><li>Very high negative predictive value for acute MI </li></ul><ul><li>Interpretative differences between acute and stress imaging requires experience. </li></ul><ul><li>Use in clinical decision-making and other acute situations </li></ul><ul><li>Consider as a gateway of opportunity to assess intermediate to long term risk of patient -> value of stress imaging following acute resting evauation. </li></ul>
  44. 45. DIAD: Detection of Ischemia is Asymptomatic Diabetes <ul><li>Abnormalities were observed in: </li></ul><ul><li>- 22 % of patients with > 2 risk factors (66 of 306) </li></ul><ul><li>- 22 % of patients with < 2 risk factors (45 of 204) </li></ul><ul><li>Greater than one in five diabetic patients without symptoms have an abnormal gated SPECT MPI </li></ul><ul><li>Selecting only patients who meet ADA guidelines would have failed to identify 41 % of patients with ischemia </li></ul>
  45. 46. Radionuclide MPS in Pre-operative Risk Assessment <ul><li>Perfusion imaging works so well in predicting outcome, we tend to overuse it </li></ul><ul><li>For patients with positive perfusion study, try to avoid revascularization unless the patient needs it regardless of upcoming surgery. </li></ul><ul><li>Recent study demonstrates no benefit compared to beta blockade peri-operatively. </li></ul><ul><li>High risk subsets will benefit long term. </li></ul><ul><li>Treat patients with mild reversible defects medically </li></ul><ul><li>Avoid noncardiac surgery within 6 weeks of bare metal stenting </li></ul><ul><li>Among patients who have CAD, or who are at risk of CAD, consider preoperative beta blockade and statins. </li></ul><ul><li>Several studies in clinical settings in which the ACC/AHA guidelines were followed have demonstarted their effectiveness. </li></ul>
  46. 47. Shortcut to indications for noninvasive testing- Perform if any 2 of 3 factors are present. <ul><li>High surgical risk operations </li></ul><ul><li>- AAA & PVD </li></ul><ul><li>- Long procedures with lg fluid shifts or blood loss </li></ul><ul><li>Poor functional capacity ( < 4 METs) </li></ul><ul><li>Intermediate clinical predictors presents </li></ul><ul><li>- CAD </li></ul><ul><li>>> Angina ( CCS I & II) </li></ul><ul><li>>> Prior MI </li></ul><ul><li>- CHF </li></ul><ul><li>- Diabetes or renal insufficiency. </li></ul>
  47. 48. Coronary Blood Flow <ul><li>Myocardial blood flow reduction correlates with degree of stenosis </li></ul><ul><li>Flow reserve reduces with coronary stenoses of 45-50 % </li></ul><ul><li>Able to maintain resting flow untill stenosis is 80-90 % </li></ul>
  48. 49. Coronary Blood Flow Rates
  49. 50. Prognostic Variables of Gated SPECT
  50. 51. Value of Stress MPI in the general population: Stress MPI: Prognostic Significance
  51. 56. Prognosis • Prognostic data are incremental • Normal scans: <1% cardiac event rate per year • Mildly abnormal scans: – <1% cardiac death rate – MI rate not affected by revascularization – Treatment may be medical (catheterization reserved for refractory symptoms)
  52. 59. Risk Stratification: Prognosis <ul><li>Risk of cardiac Death: </li></ul><ul><li>* Low </li></ul><ul><li>< 1 % per year </li></ul><ul><li>* Intermediate </li></ul><ul><li>1 – 3 % per year </li></ul><ul><li>* High </li></ul><ul><li>> 3 % per year </li></ul>
  53. 60. Risk Stratification: Noninvasive Testing Markers <ul><li>Amount of infarcted myocardium </li></ul><ul><li>Amount of jeopardized myocardium </li></ul><ul><li>Degree of jeopardy </li></ul><ul><li>Left vanticular systolic function </li></ul><ul><li>All can be assessed by measurements of perfusion or function </li></ul>
  54. 61. TID: transit Ischemic Dilation (Stress induced LV Cavity Dilation) <ul><li>Severe, extensive CAD (usually with classic ischemic defect) </li></ul><ul><li>Left Main </li></ul><ul><li>Prox LAD </li></ul><ul><li>MVD </li></ul><ul><li>Microvascular disease (no stress defect; atypical defects) </li></ul><ul><ul><ul><li>HTN </li></ul></ul></ul><ul><ul><ul><li>LVH </li></ul></ul></ul><ul><ul><ul><li>DCM </li></ul></ul></ul>
  55. 62. Prognostic implications of myocardial perfusion imaging.
  56. 63. Single-photon emission computed tomography perfusion images in two patients with stable anginal symptoms.
  57. 64. Incremental value Of SPECT
  58. 65. Evaluation of CAD: A Prognostic Approach Patients with suspected CAD referred to SPECT Normal Study Mildly Abnormal Study Mod-Severely Abnormal Study RISK OF ADVERSE EVENT LOW INTERMEDIATE HIGH Reassurance/Risk factor modification Aggressive risk factor modification Revascularization Myocardial Perfusion Imaging with Gated SPECT
  59. 66. Evaluation of CAD: A Diagnostic Approach Patients with possible CAD Normal DIAGNOSTIC TES Abnormal Intermediate to high likelihood of CAD Low likelihood of CAD Revascularization Risk factor modification
  60. 67. Cost Effective Approach
  61. 68. Myocardial perfusion imaging • Cost effectiveness • MPI as gatekeeper • Incremental information
  62. 69. • High sensitivity • Exclude disease • Fewer false negatives • Higher downstream costs in undiagnosed pts • No need for 2 nd test vs. low sensitivity low cost • High specificity • Reduces number of false positive tests • Reduced downstream testing Principles of Cost-Effective Diagnosis and Management of CAD using MPS
  63. 70. END Study: Financial Analysis of Treatment Strategies • 11,249 consecutive stable angina patients • Two treatment groups –Direct catheterization –Stress MPI followed by selective catheterization • Cohorts matched by pretest probability of CAD • Strategy: cost minimization at equal mortality risk • Cost evaluation –Diagnostic ( early ): SPECT, catheterization–Follow-up ( late ): includes costs of PTCA, CABG Adapted from Shaw LJ, et al. J Am CollCardiol. 1999;33:661-669. Cost-effectiveness: Assessing the Prognostic Approach
  64. 71. END: Angiographic findings
  65. 72. END Study: Outcome by Screening Strategy
  66. 73. Pretest Clinical Risk (n=5,423) Pretest Clinical Risk (n=5,826)* P <.01 vs catheterization.
  67. 74. Cost Effectiveness in Clinical Practice • Patient risk assessed? • Low risk, negative testing • Intermediate risk, further testing • If risk < 1% then no further testing needed
  68. 75. Why to Practice Appropriateness Criteria based Practice? One may not get reimbursed. Inappropriate test could increase financial burden to society. Possible increased radiation
  69. 76. Appropriateness Criteria: SPECT MPI <ul><li>Tables 1 through 9 sequentially list the 52 indications by purpose, clinical scenario, and their ratings, as obtained from the second-round rating sheets. In addition, Tables 10 through 12 arrange the indications into three main scoring categories—those that were rated as inappropriate (I, me­dian score of 1 to 3), uncertain or possibly appropriate (U, median score of 4 to 6), and appropriate (A, median score of 7 to 9), respectively. </li></ul>
  70. 77. Appropriateness Criteria: SPECT MPI <ul><li>Table 10 lists the 13 indications that were rated as inappropriate (i.e., the imaging test is not generally accept-able and is not a reasonable approach for the indication). This does not preclude, however, the performance of the test if justifiable because of special clinical and patient circumstances. It is likely that reimbursement for the test will require a documented exception from the physician. </li></ul>
  71. 78. Table 10. Inappropriate Indications (Median Rating of 1 to 3) Table 10. Inappropriate Indications (Median Rating of 1 to 3) I (1.0) ~ Low CHD risk (Framingham) 17. Risk Assessment: General and Specific Patient Populations— Asymptomatic I (1.0) ~ Low CHD risk (Framingham risk criteria) 10 . Detection of CAD: Asymptomatic (Without Chest Pain Syndrome ) I (1.0) ~ High pre-test probability of CAD ~ ECG: ST elevation 8. Detection of CAD Symptomatic—Acute Chest Pain (in Reference to Rest Perfusion Imaging) I (2.0) ~ Low pre-test probability of CAD ~ ECG interpretable AND able to exercise 1. Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome Appropriateness Criteria (Median Score) Indication
  72. 79. Table 10. Inappropriate Indications (Median Rating of 1 to 3) I (1.0) ~ Preoperative evaluation for non-cardiac surgery risk assessment 31. Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— Low-Risk Surgery I (1.5) ~ Agatston score less than 100 28. Risk Assessment With Prior Test Results: Asymptomatic— Prior Coronary Calcium Agatston Score I (2.5) ~ Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure ~ Asymptomatic OR stable symptoms ~ Less than 1 year to evaluate worsening disease 23. Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Abnormal Catheterization OR Prior SPECT MPI Study I (3.0) ~ Normal initial RNI study ~ High CHD risk (Framingham) ~ Annual SPECT MPI study 21. Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Normal Prior SPECT MPI Study
  73. 80. Table 10. Inappropriate Indications (Median Rating of 1 to 3) ~ Less than 1 year after PCI I (3.0) ~ Symptomatic prior to previous revascularization 47. Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic I (1.0) ~ Routine evaluation prior to hospital discharge 40. Risk Assessment: Following Acute Coronary Syndrome— Asymptomatic Post-Revascularization (PCI or CABG) I (1.0) ~ Thrombolytic therapy administered 38. Unstable, Risk Assessment: Following Acute Coronary Syndrome STEMI—Hemodynamically Signs of Cardiogenic Shock, or Mechanical Complications I (3.0) ~ Asymptomatic up to 1 year post normal catheterization, non-invasive test, or previous revascularization 36. Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—High Risk Surgery I (3.0) ~ Minor to intermediate perioperative risk predictor ~ Normal exercise tolerance (greater than or equal to 4 METS) 32. Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— Intermediate-Risk Surgery
  74. 81. Table 11. Appropriate Indications (Median Rating of 7 to 9) A (9.0) ~ Intermediate pre-test probability of CAD ~ ECG: no ST elevation AND initial cardiac enzymes negative 7. Detection of CAD: Symptomatic— Acute Chest Pain (in Reference to Rest Perfusion Imaging) ~ ECG uninterpretable OR unable to exercise A (9.0) High pre-test probability of CAD ~ 6. ~ ECG interpretable AND able to exercise A (8.0) High pre-test probability of CAD ~ 5. ~ ECG uninterpretable OR unable to exercise A (9.0) Intermediate pre-test probability of CAD ~ 4. ~ ECG interpretable AND able to exercise A (7.0) Intermediate pre-test probability of CAD ~ 3. Detection of CAD: Symptomatic— Evaluation of Chest Pain Syndrome Appropriateness Criteria (Median Score) Indication
  75. 82. Table 11. Appropriate Indications (Median Rating of 7 to 9) A (9.0) ~ Moderate to high CHD risk (Framingham) 16. Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— Ventricular Tachycardia ~ Part of the evaluation A (8.0) ~ High CHD Risk (Framingham) 15. Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— New-Onset Atrial Fibrillation ~ No prior CAD evaluation AND no planned cardiac catheterization A (7.5) ~ Moderate CHD risk (Framingham) 12. Detection of CAD: Asymptomatic— New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction Without Chest Pain Syndrome A (8.0) ~ Intermediate pre-test probability of CAD 9. Detection of CAD: Symptomatic— New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome
  76. 83. Table 11. Appropriate Indications (Median Rating of 7 to 9) ~ High CHD risk (Framingham) ~ Repeat SPECT MPI study after 2 years or greater A (7.0) ~ Normal initial RNI study 22. Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Normal Prior SPECT MPI Study A (7.5) ~ High CHD risk (Framingham) 20. ~ High-risk occupation (e.g., airline pilot) A (8.0) ~ Moderate to high CHD risk (Framingham) 19. Risk Assessment: General and Specific Patient Populations— Asymptomatic
  77. 84. Table 11. Appropriate Indications (Median Rating of 7 to 9) A (9.0) ~ Known CAD on catheterization OR prior SPECT MPI study 25. Risk Assessment With Prior Test Results: Worsening Symptoms— Abnormal Catheterization OR Prior SPECT MPI Study ~ Greater than or equal to 2 years to evaluate worsening disease A (7.5) ~ Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure 24. Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms— Abnormal Catheterization or Prior SPECT MPI Study
  78. 85. Table 11. Appropriate Indications (Median Rating of 7 to 9) A (8.0) ~ Intermediate perioperative risk predictor OR Poor exercise tolerance (less than 4 METS) 33. Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— Intermediate-Risk Surgery A (9.0) ~ Intermediate Duke treadmill score ~ Intermediate CHD risk (Framingham) 30. Risk Assessment With Prior Test Results— Duke Treadmill Score A (9.0) ~ Stenosis of unclear significance 29. Risk Assessment With Prior Test Results: UA/NSTEMI, STEMI, or Chest Pain Syndrome—Coronary Angiogram A (7.5) ~ Agatston score greater than or equal to 400 27. Risk Assessment With Prior Test Results: Asymptomatic— Prior Coronary Calcium Agatston Score Appropriateness Criteria (Median Score) Indication
  79. 86. Table 11. Appropriate Indications (Median Rating of 7 to 9) A (8.0) ~ Evaluation of chest pain syndrome 41. Risk Assessment: Post-Revascularization (PCI or CABG)— Symptomatic A (8.5) ~ Not planning to undergo early catheterization 39. Risk Assessment: Following Acute Coronary Syndrome— UA/NSTEMI—No Recurrent Ischemia OR No Signs of HF A (8.0) ~ Thrombolytic therapy administered ~ Not planning to undergo catheterization 37. Risk Assessment: Following Acute Coronary Syndrome— STEMI-Hemodynamically Stable ~ Poor exercise tolerance (less than 4 METS) A (8.0) ~ Minor perioperative risk predictor AND 35. Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— High-Risk Surgery
  80. 87. Table 11. Appropriate Indications (Median Rating of 7 to 9) A (9.0) ~ Baseline and serial measurements 52. Evaluation of Ventricular Function: Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin) A (9.0) ~ Non-diagnostic echocardiogram 51. Evaluation of Left Ventricular Function A (8.5) ~ Known CAD on catheterization ~ Patient eligible for revascularization 50. Assessment of Viability/Ischemia: Ischemic Cardiomyopathy (Includes SPECT Imaging for Wall Motion and Ventricular Function) ~ Greater than or equal to 5 years after CABG A (7.5) ~ Symptomatic prior to previous revascularization 45. ~ Greater than or equal to 5 years after CABG A (7.5) ~ Asymptomatic prior to previous revascularization 44. Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic
  81. 88. Table 12. Uncertain Indications (Median Rating of 4 to 6) U (5.5) ~ Moderate CHD risk (Framingham) ~ To help guide decision for invasive studies 13. Detection of CAD: Asymptomatic— Valvular Heart Disease Without Chest Pain Syndrome U (5.5) ~ Moderate CHD risk (Framingham) 11. Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) U * (6.5) ~ Low pre-test probability of CAD ~ ECG uninterpretable OR unable to exercise 2. Detection of CAD: Symptomatic— Evaluation of Chest Pain Syndrome Appropriateness Criteria (Median Score) Indication
  82. 89. Table 12. Uncertain Indications (Median Rating of 4 to 6) U (4.0) ~ Minor perioperative risk predictor ~ Normal exercise tolerance (greater than or equal to 4 METS) 34. Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery— High-Risk Surgery U * (6.5) ~ Stenosis of unclear significance 26. Risk Assessment With Prior Test Results: Asymptomatic— CT Coronary Angiography U (4.0) ~ Moderate CHD risk (Framingham) 18. Risk Assessment: General and Specific Patient Populations— Asymptomatic U * (3.5) ~ Low CHD risk (Framingham) ~ Part of the evaluation 14. Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)— New-Onset Atrial Fibrillation
  83. 90. Table 12. Uncertain Indications (Median Rating of 4 to 6) U (5.5) ~ Symptomatic prior to previous revascularization ~ Greater than or equal to 2 years after PCI 49. U * (6.5) ~ Asymptomatic prior to previous revascularization ~ Greater than or equal to 2 years after PCI 48. U * (6.5) ~ Asymptomatic prior to previous revascularization ~ Less than 1 year after PCI 46. Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic U (4.5) ~ Symptomatic prior to previous revascularization ~ Less than 5 years after CABG 43. U (6.0) ~ Asymptomatic prior to previous revascularization ~ Less than 5 years after CABG 42. Risk Assessment: Post-Revascularization (PCI or CABG)— Asymptomatic
  84. 91. Appropriateness Criteria: SPECT MPI <ul><li>Summary: </li></ul><ul><li>Median Score 7 to 9 ---- Appropriate </li></ul><ul><li>Median Score 1 to 3 ---- Inappropriate </li></ul><ul><li>Median Score 4 to 6 ---- Uncertain </li></ul>
  85. 92. Pre-Cert Requirements in SE-PA <ul><li>IMPORTANT INFORMATION REGARDING DIAGNOSTIC IMAGING SERVICES— NUCLEAR CARDIOLOGY STUDIES  </li></ul><ul><li>INDEPENDENT BLUE CROSS HAS CONTRACTED WITH AMERICAN IMAGING MANAGEMENT, INC (AIM) TO IMPLEMENT A NEW RADIOLOGY QUALITY INITIATIVE FOR OUTPATEINT NON-EMERGENT DIAGNOSTIC IMAGING SERVICES FOR NUCLEAR CARDIOLOGY.(KEYSTONE HPE, PERSONAL CHOICE, AMERIHEALTH NJ, PPO HMO) </li></ul>
  86. 93. Pre-Cert Requirements in SE-PA <ul><li>THE ORDERING PHYSICIAN IS TO CONTACT AIM VIA NAVINET, PHONE OR FAX, WHETHER THE ORDERING PHYSICIAN IS A PCP OR A SPECIALIST. </li></ul><ul><li>CALL CENTER TEL NUMBER IS—800-227-3116 </li></ul><ul><li>FAX NUMBER IS—800-610-0050 </li></ul><ul><li>PROVIDERS MAY ACCESS AIM’S CLINICAL GUIDELINES AND OTHER EDUCATIONAL RESOURCES BY SELECTING THE AIM LINK ON NAVINET OR BY ACCESSING AI’S WEBSITE AT WWW.AMERICANIMAGING.NET </li></ul>
  87. 94. Pre-Cert Requirements in SE-PA <ul><li>FOR QUESTIONS REGARDING AIM PROGRAM CALL CUSTOMER SERVICE DEPARTMETN AT 800-252-2021(AIM). </li></ul><ul><li>  </li></ul><ul><li>FOR CLAIM RELATED QUESTIONS PLEASE CONTACT IBC PROVIDER SERVICES DEPARTMENT –HMO CALL 215-567-3590 OR 800-227-3119/ FOR PPO CALL 800-332-2566 OR YOUR NETWORK COORDINATOR. </li></ul>
  88. 95. Pre-Cert Requirements in SE-PA <ul><li>KEYSTONE MERCY—AETNA </li></ul><ul><li>THE ABOVE PLANS HAVE ENTERED INTO AN ARRANGEMENT WITH </li></ul><ul><li>NATIONAL IMAGING ASSOCIATES (NIA) FOR OUT PATEINT IMAGING MANAGEMENT SERVICES.  </li></ul><ul><li>CALL 800-642-7597—FOR AETNA PRECERTIFICATON FOR NIA  </li></ul><ul><li>CALL 866-642-9700—FOR MERCY PRECERTIFICATION FOR NIA </li></ul>
  89. 96. Pre-Cert Requirements in SE-PA <ul><li>OXFORD HEALTH PLAN AND HEALTHNET HAVE AN AGREEMENT WITH CARECORE </li></ul><ul><li>NEW JERSY BLUES(ONLY IF DONE IN NJ)  </li></ul><ul><li>CALL (866) 496-6200-FOR PRECERTIFICATION-REMEMBER YOU HAVE TO HAVE ANY OF THE FOLLOWING CERTIFICATES ON FILE WITH CARECORE Nuclear Certificates valid from ONE OF the following (any one): </li></ul>
  90. 97. Pre-Cert Requirements in SE-PA <ul><li>CBNC---Certification Board of Nuclear Cardiology </li></ul><ul><li>CCNC---Certification Council of Nuclear Cardiology </li></ul><ul><li>ABNM-American Board of Nuclear Medicine </li></ul><ul><li>ABR—American Board of Radiology </li></ul><ul><li>  </li></ul><ul><li>ALSO THE NUCLEAR FACILITY HAS TO BE CERTIFIED BY CARECORE GUIDELINES. </li></ul>
  91. 98. Thank You

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