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National Imaging Associates, Inc. Clinical Guidelines MYOCARDIAL PERFUSION IMAGING (Aka NUCLEAR CARDIAC IMAGING STUDY) Original

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National Imaging Associates, Inc. Clinical Guidelines MYOCARDIAL PERFUSION IMAGING (Aka NUCLEAR CARDIAC IMAGING STUDY) Original National Imaging Associates, Inc. Clinical guidelines Original Date: October 2009 MYOCARDIAL PERFUSION IMAGING Page 1 of 13 (aka NUCLEAR CARDIAC IMAGING STUDY) CPT Code: 78451, 78452, 78453, 78454, 78466, Last Reviewed Date: September 2014 78468, 78469, 78481, 78483, 78499 Guideline Number: NIA_CG_024 Last Revised Date: August 2011 Responsible Department: Implementation Date: January 2015 Clinical Operations INTRODUCTION: Stress tests are done to assess cardiac function in terms of the heart’s ability to respond to increased work. Stress testing can be done without imaging including Standard Exercise Treadmill Testing (ETT) or with imaging including Stress Echocardiography (SE) and nuclear myocardial perfusion imaging (MPI). Exercise Treadmill Testing (ETT) is often an appropriate first line test in many patients with suspected Coronary Artery Disease (CAD). However, there are patients in whom the test is not the best choice, for example those with resting ECG abnormalities, inability to exercise, and perimenopausal women. Stress Echocardiography is an initial imaging modality for the evaluation of coronary artery disease/ischemic heart disease when stress testing with imaging is indicated. It has similar sensitivity and superior specificity to MPI for evaluation of ischemic heart disease and avoids radiation. In addition to diagnostic capabilities stress echocardiography is useful in risk stratification and efficacy of therapy. Myocardial perfusion imaging is also often used as an initial test to evaluate the presence, and extent of coronary disease. Like stress echocardiography it is also used to stratify the risk for patients with and without significant disease. Similar to all stress testing MPI can be used for monitoring the efficacy of therapy and may have a more powerful role in the assessment of myocardial viability in patients who have had a myocardial infarction in whom interventions are contemplated. Perhaps it’s most important distinction lies in the tests ability to obtain useful information in patients who are unable to exercise. In such cases drugs such as, dipyridamole, dobutamine, or adenosine, are administered to mimic the physiological effects of exercise. The common approach for stress testing by American College of Cardiology and American Heart Association indicates the following: Treadmill test: sensitivity 68%, specificity 77% Stress Echocardiogram: sensitivity 76%, specificity 88% Nuclear test: sensitivity 88%, specificity 77% Stress echo and MPI have been evaluated by the American College of Cardiology (ACC) and found to be similar in rating across a number of indicators for cardiac stress testing. As part of NIA efforts to curb unneeded radiation exposure whenever possible, this guideline emphasizes the use of stress echocardiography for cardiac evaluation whenever the two 1— Myocardial Perfusion Imaging - 2015 Proprietary modalities are found to be equivalent in “Acceptable” and “Uncertain” ranking status. Where the indicator shows a difference in ranking between MPI and Echocardiographic Stress testing, the MPI will be allowed as the preferential test. All pertinent indicators are marked with a large check mark in the table below. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 APPROPRIATE USE CRITERIA: ACCF et INDICATIONS APPROPRIATE al. USE SCORE Criteria # (*Refer to Additional Information section) (4-9); MPI / Not subject to Stress Echocardiogram contraindications A= Appropriate; Stress as noted in section “Indications for a Nuclear Cardiac U=Uncertain (MPI Echo Imaging / Myocardial Perfusion Study”. Please see / Stress Echo) explanation in Introduction, paragraph “6” Detection of CAD/Risk Assessment: Symptomatic Evaluation of Ischemic Equivalent (Non-Acute) Low pretest probability of CAD* A(7) / A(7) 2 / 115 ECG uninterpretable OR unable to exercise Intermediate pretest probability of CAD* A(7) / A(7) 3 / 116 ECG interpretable AND able to exercise Intermediate pretest probability of CAD* A(9) / A(9) 4 / 117 ECG uninterpretable OR unable to exercise High pretest probability of CAD* A(8) / A(7) 5 / 118 Regardless of ECG interpretability and ability to exercise Detection of CAD: Asymptomatic (Without Ischemic Equivalent) Asymptomatic Intermediate CHD risk (ATP III risk criteria)*** U(5) / U(5) 14 / 126 ECG uninterpretable 15 /127 High CHD risk (ATP III risk criteria)*** A(8) / U(5) New-Onset or Newly Diagnosed Heart Failure With LV Systolic Dysfunction Without Ischemic Equivalent No prior CAD evaluation AND no planned A(8) / A(7) 16 /128 coronary angiography New-Onset Atrial Fibrillation ♦ 17 / 132 Part of evaluation when etiology unclear U(6) / U(6) Ventricular Tachycardia ♦ 18 / NA Low CHD risk (ATP III risk criteria)*** A(7) / NA 19 / NA Intermediate or high CHD risk (ATP III risk A(8) / NA criteria)*** 2—Myocardial Perfusion Imaging - 2015 Proprietary ACCF et INDICATIONS APPROPRIATE al. USE SCORE Criteria # (*Refer to Additional Information section) (4-9); MPI / Not subject to Stress Echocardiogram contraindications A= Appropriate; Stress as noted in section “Indications for a Nuclear Cardiac U=Uncertain (MPI Echo Imaging / Myocardial Perfusion Study”. Please see / Stress Echo) explanation in Introduction, paragraph “6” Syncope 21 / 134 Intermediate or high CHD risk (ATP III risk A(7) / A(7) criteria)*** Elevated Troponin 22 / 135 Troponin elevation without additional evidence of A(7) / A(7) acute coronary syndrome (with ischemia present patient is not subject to Stress Echocardiogram contraindications) Risk Assessment With Prior Test Results and/or Known Chronic Stable CAD Asymptomatic OR Stable Symptoms Normal Prior Stress Imaging Study 26 / 145 Intermediate to high CHD risk (ATP III risk U(6) / U(4) criteria)*** Last stress imaging study done more than or equal to 2 years ago If known CAD, not subject to Stress Echo contraindications Asymptomatic OR Stable Symptoms Abnormal Coronary Angiography OR Abnormal Prior Stress Imaging Study, No Prior Revascularization 28 / 147 Known CAD on coronary angiography OR prior U(5) / U(5) abnormal stress imaging study Last stress imaging study done more than or equal to 2 years ago Prior Noninvasive Evaluation 29 / 153 Equivocal, borderline, or discordant stress testing A(8) / A(8) where obstructive CAD remains a concern New or Worsening Symptoms 30 / 151 Abnormal coronary angiography OR abnormal A(9) / A(7) prior stress imaging study 31 / 152 Normal coronary angiography OR normal prior U(6) / U(5) stress imaging study Coronary Angiography (Invasive or Noninvasive) 32 / 141 Coronary stenosis or anatomic abnormality of A(9) / A(8) uncertain significance 3—Myocardial Perfusion Imaging - 2015 Proprietary ACCF et INDICATIONS APPROPRIATE al. USE SCORE Criteria # (*Refer to Additional Information section) (4-9); MPI / Not subject to Stress Echocardiogram contraindications A= Appropriate; Stress as noted in section “Indications for a Nuclear Cardiac U=Uncertain (MPI Echo Imaging / Myocardial Perfusion Study”. Please see / Stress Echo) explanation in Introduction, paragraph “6” Asymptomatic Prior Coronary Calcium Agatston Score 34 / 137 Low to intermediate CHD risk*** U(5) / U(5) Agatston score between 100 and 400 35 / 138 High CHD risk*** A(7) / U(6) Agatston score between 100 and 400 36 / 139 Agatston score greater than 400 A(7) / A(7) Duke Treadmill Score 38 / 149 Intermediate-risk Duke treadmill score**** A(7) / A(7) 39 / 150 High-risk Duke treadmill score**** A(8) / A(7) Risk Assessment: Preoperative Evaluation for Noncardiac Surgery Without Active Cardiac Conditions Intermediate-Risk Surgery 43 / 157 Greater than or equal to 1 clinical risk factor A(7) / U(6) Poor or unknown functional capacity (less than 4 METs) Vascular Surgery 47 / 161 Greater than or equal to 1 clinical risk factor A(8) / A(7) Poor or unknown functional capacity (less than 4 METS) Risk Assessment: Within 3 Months of an Acute Coronary Syndrome STEMI 50 / 164 Hemodynamically stable, no recurrent chest pain A(8) / A(7) symptoms or no signs of HF To evaluate for inducible ischemia No prior coronary angiography UA/NSTEMI 52 / 166 Minor perioperative risk predictor A(9) / A(8) Normal exercise tolerance (greater than or equal to 4 METS) Hemodynamically stable, no recurrent chest pain symptoms or no signs of HF To evaluate for inducible ischemia No prior coronary angiography 4—Myocardial Perfusion Imaging - 2015 Proprietary ACCF et INDICATIONS APPROPRIATE al. USE SCORE Criteria # (*Refer to Additional Information section) (4-9); MPI / Not subject to Stress Echocardiogram contraindications A= Appropriate; Stress as noted in section “Indications for a Nuclear Cardiac U=Uncertain (MPI Echo Imaging / Myocardial Perfusion Study”. Please see / Stress Echo) explanation in Introduction, paragraph “6” Risk Assessment: Postrevascularization (Percutaneous Coronary Intervention or Coronary Artery Bypass Graft) Symptomatic 55 / 169 Evaluation of ischemic equivalent A(8) / A(8) Asymptomatic 56 / 170 Incomplete revascularization A(7) / A(7) Additional revascularization feasible 57 Less than 5 years after CABG AND U(5) No MPI for 2 years or more unless most recent MPI showed reversible ischemia 58 / 172 Greater than or equal to 5 years after CABG A(7) / U(6) AND No MPI for 2 years or more unless most recent MPI showed reversible ischemia 60 /174 Greater than or equal to 2 years after PCI U(6) / U(5) Assessment of Viability/Ischemia Ischemic Cardiomyopathy/Assessment of Viability 62 /176 Known severe LV dysfunction A(9) / A(8) Patient
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