JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. - ,NO.- ,2014 ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00 PUBLISHED BY ELSEVIER INC. http://dx.doi.org/10.1016/j.jacc.2014.08.003 1 APPROPRIATE USE CRITERIA 55 2 56 3 57 4 ACC/AAP/AHA/ASE/HRS/ 58 5 59 6 SCAI/SCCT/SCMR/SOPE 60 7 61 8 2014 Appropriate Use Criteria for 62 9 63 10 Initial Transthoracic Echocardiography 64 11 65 12 in Outpatient Pediatric Cardiology 66 13 67 14 A Report of the American College of Cardiology Appropriate Use Criteria Task Force, 68 15 American Academy of Pediatrics, American Heart Association, American Society of 69 16 Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and 70 17 Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular 71 18 Magnetic Resonance, and Society of Pediatric Echocardiography 72 19 73 20 74 21 75 22 76 Q1 Writing Group for Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS, Wyman W. Lai, MD, MPH, FACC, FASE 23 77 Echocardiography Chair Leo Lopez, MD, FACC, FAAP, FASE 24 78 in Outpatient Ritu Sachdeva, MD, FACC, FAAP, FASE 25 79 Pediatric Pamela S. Douglas, MD, MACC, FAHA, FASE 26 80 Cardiology Benjamin W. Eidem, MD, FACC, FASE 27 81 28 82 29 83 30 Rating Panel Robert M. Campbell, MD, FACC, FAHA, FAAP, FHRS, Richard Lockwood, MD** 84 yy 31 Chair* G. Paul Matherne, MD, MBA, FACC, FAHA 85 zz 32 Pamela S. Douglas, MD, MACC, FAHA, FASE, Moderator* David Nykanen, MD, FACC 86 yy 33 Catherine L. Webb, MD, FACC, FAHA, FASE 87 y 34 Louis I. Bezold, MD, FACC, FAAP, FASE Robert Wiskind, MD, FAAP* 88 35 William B. Blanchard, MD, FACC, FAHA, FAAP* 89 36 Jeffrey R. Boris, MD, FACC* 90 z *American College of Cardiology representative. yAmerican Academy of 37 Bryan Cannon, MD Pediatrics representative. zHeart Rhythm Society representative. 91 Gregory J. Ensing, MD, FACC, FASEx 38 xAmerican Society of Echocardiography representative. jjSociety of 92 jj 39 Craig E. Fleishman, MD, FACC, FASE Pediatric Echocardiography representative. {Society for Cardiovascular 93 { Magnetic Resonance representative. #Society of Cardiovascular Computed 40 Mark A. Fogel, MD, FACC, FAHA, FAAP 94 yy B. Kelly Han, MD, FACC# Tomography representative. **Health Plan representative. American 41 Heart Association representative. zzSociety for Cardiovascular 95 42 Shabnam Jain, MD, MPH, FAAP* Angiography and Interventions representative. 96 jj 43 Mark B. Lewin, MD 97 44 98 45 99 This document was approved by the American College of Cardiology Board of Trustees in June 2014. 46 The American College of Cardiology requests that this document be cited as follows: 100 47 Campbell RM, Douglas PS, Eidem BW, Lai WW, Lopez L, Sachdeva R. ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria 101 48 for initial transthoracic echocardiography in outpatient pediatric cardiology: a report of the American College of Cardiology Appropriate Use Criteria 102 Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for 49 Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and 103 50 Society of Pediatric Echocardiography. J Am Coll Cardiol 2014;XX:xxx-xx. 104 51 This document is copublished in the Journal of the American Society of Echocardiography. 105 52 Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, 106 please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected]. 53 Permissions: Modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the 107 54 American College of Cardiology. 108 PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce 2 Campbell et al. JACC VOL. - ,NO.- ,2014 AUC for Pediatric Echocardiography - ,2014:- – - 109 Appropriate Manesh R. Patel, MD, FACC, Chair Pamela S. Douglas, MD, MACC, FAHA, FASE 163 110 Use Criteria Christopher M. Kramer, MD, FACC, FAHA, Co-Chair Robert C. Hendel, MD, FACC, FAHA, FASNC 164 111 Task Force Bruce D. Lindsay, MD, FACC 165 112 Steven R. Bailey, MD, FACC, FAHA, FSCAI Leslee J. Shaw, PhD, FACC, FASNC, FAHA 166 113 Alan S. Brown, MD, FACC L. Samuel Wann, MD, MACC 167 114 John U. Doherty, MD, FACC, FAHA Joseph M. Allen, MA 168 115 169 116 170 117 TABLE OF CONTENTS 171 118 172 119 173 ABSTRACT ..................................... XX Figure 5. Palpitaions and Arrhythmias .............xx 120 174 121 Figure 6. Murmur ..............................xx 175 PREFACE ...................................... XX 122 176 9. DISCUSSION ................................ XX 123 177 1. INTRODUCTION ............................. XX 124 Assumptions and Definitions ....................xx 178 125 Indications and Ratings .........................xx 179 2. METHODS .................................. XX 126 180 Comparison with the Adult Cardiology AUC ........xx 127 Figure 1. AUC Development Process ...............xx 181 128 Limitations ...................................xx 182 129 3. GENERAL ASSUMPTIONS ..................... XX 183 Use of AUC to Improve Care .....................xx 130 184 Figure 2. Factors Influencing Outcomes 131 ............................ 185 of an Imaging Study xx 10. CONCLUSIONS .............................. XX 132 186 133 187 4. DEFINITIONS ............................... XX APPENDIX A 134 188 Appropriate Use Criteria for Initial Transthoracic 135 5. ABBREVIATIONS ............................ XX 189 Echocardiography in Outpatient Pediatric Cardiology: 136 190 Participants ...................................xx 137 6. RESULTS ................................... XX 191 138 192 APPENDIX B 139 7. TRANSTHORACIC ECHOCARDIOGRAPHY IN 193 140 OUTPATIENT PEDIATRIC CARDIOLOGY: Relationships With Industry (RWI) and 194 Other Entities .................................xx 141 APPROPRIATE USE CRITERIA (BY INDICATION) ..... XX 195 142 196 Table 1. Palpitations and Arrhythmias .............xx 143 ABSTRACT 197 144 Table 2. Syncope ..............................xx 198 145 The American College of Cardiology (ACC) participated in 199 Table 3. Chest Pain .............................xx 146 a joint project with the American Society of Echocardi- 200 .............................. 147 Table 4. Murmur xx ography, the Society of Pediatric Echocardiography, and 201 148 Table 5. Other Symptoms and Signs ...............xx several other subspecialty societies and organizations to 202 149 establish and evaluate Appropriate Use Criteria (AUC) for 203 Table 6. Prior Test Results .......................xx 150 the initial use of outpatient pediatric echocardiography. 204 151 Table 7. Systemic Disorders ......................xx Assumptions for the AUC were identified, including the 205 152 fi 206 Table 8. Family History of Cardiovascular Disease in fact that all indications assumed a rst-time transthoracic 153 Patients Without Signs or Symptoms and Without echocardiographic study in an outpatient setting for pa- 207 154 Confirmed Cardiac Diagnosis .....................xx tients without previously known heart disease. The defi- 208 155 nitions for frequently used terminology in outpatient 209 Table 9. Outpatient Neonates Without Post-Natal 156 Cardiology Evaluation ..........................xx pediatric cardiology were established using published 210 157 guidelines and standards and expert opinion. These AUC 211 158 8. FLOW DIAGRAMS FOR COMMON serve as a guide to help clinicians in the care of children 212 fi 159 PATIENT SYMPTOMS ......................... XX with possible heart disease, speci cally in terms of when 213 160 a transthoracic echocardiogram is warranted as an initial 214 Figure 3. Chest Pain ............................xx 161 diagnostic modality in the outpatient setting. They are 215 162 Figure 4. Syncope .............................xx alsoausefultoolforeducationandprovidethe 216 PGL 5.2.0 DTD JAC20491_proof 12 September 2014 3:25 pm ce JACC VOL. - ,NO.- ,2014 Campbell et al. 3 - ,2014:- – - AUC for Pediatric Echocardiography 217 infrastructure for future quality improvement initiatives increase in the utilization of such technologies. As these 271 218 as well as research in healthcare delivery, outcomes, and imaging technologies and clinical applications continue to 272 219 resource utilization. advance, the healthcare community needs to understand 273 220 To complete the AUC process, the writing group iden- how best to incorporate these options into daily clinical 274 221 tified 113 indications based on common clinical scenarios care and how to choose between new and long-standing, 275 222 and/or published clinical practice guidelines, and each established imaging technologies. In an effort to res- 276 223 indication was classified into 1 of 9 categories of common pond to this need and to ensure the effective use of 277 224 clinical presentations, including palpitations, syncope, advanced diagnostic imaging tools and procedures, the 278 225 chest pain, and murmur. A separate, independent rating AUC project was initiated. The AUC in this document have 279 226 panel evaluated each indication using a scoring scale of 1 been developed in order to promote effective patient 280 227 to 9, thereby designating each indication as “Appropriate” care, better clinical outcomes, and improved resource 281 228 (median score 7 to 9), “May Be Appropriate” (median utilization. This set of AUC should be