Concerns regarding “2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS: Appropriate utilization of cardiovascular imaging in emergency department patients with chest Pain”

The American College of Cardiology (ACC) and the American College of Radiology (ACR) recently published appropriate use criteria (AUC) directed at patients presenting to the emergency department with chest pain, providing guidance regarding the first imaging test to be ordered [1]. This AUC document addresses use of echocardiographic, nuclear, computed tomography, magnetic resonance, and invasive angiography imaging. The Society for Cardiovascular for Angiography and Interventions (SCAI) and the American Society of Echocardiography (ASE) have declined to endorse the document due to concerns that it would adversely impact the care of patients both by suggesting that entirely guideline-based care is “less than appropriate” and by inviting payers to limit patient access to tests that are labeled M (for “May be appropriate”) in clinical scenarios where other tests are labeled A (for “Appropriate”). The editor of the Journal of the American College of Cardiology (JACC) has declined to publish our concerns, stating that letters to the editor are instead referred to the AUC writing committee for consideration in the next version of the AUC document. Thus SCAI and ASE have taken the unusual step of publishing this joint statement detailing our concerns. First, a word about the generation of AUC. The modified Delphi method has been described in many situations and is the method used for generating the criteria. Initially, a writing panel composes a group of clinical scenarios, thought to cover most of the common presentations for the issue at hand. Members of a separate ranking panel individually vote on the indications, then meet to discuss the votes, and subsequently individually re-rank the indications. The appropriateness rankings reported in the final document are the medians of individual members’ rankings. There are a number of steps where the process can go awry, as we believe happened with this AUC document. First and perhaps most importantly, many common clinical scenarios are not included in this AUC document. As a result, the scenarios that are included have ratings that are inappropriate for significant numbers of patients. For several scenarios involving patients with significant likelihood of active coronary artery disease, coronary angiography is rated as “rarely appropriate” and instead a non-invasive study is recommended. However,