ACC Issues Multisociety Appropriate Use Criteria for Peripheral Vascular Ultrasound

June 11, 2012—The American College of Cardiology (ACC) announced the publication of a new report on the appropriate use of certain noninvasive vascular tests when caring for patients with suspected or known noncoronary arterial disorders.

Available online ahead of print in the Journal of the American College of Cardiology, “Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part I: Arterial Ultrasound and Physiological Testing” provides detailed criteria to help clinicians maximize appropriate testing. The report was issued by the ACC and developed in collaboration with 10 other leading professional societies, including the Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society of Interventional Radiology, Society for Vascular Medicine, and the Society for Vascular Surgery.

Emile R. Mohler III, MD, Director of Vascular Medicine for the University of Pennsylvania Health System, served as Chair of the writing committee. “This is the first systematic and comprehensive evaluation looking at appropriate indications for vascular testing, such as ultrasound or functional testing,” said Dr. Mohler in an ACC press release. “We hope this document will help clinicians determine whether or not and when to refer individual patients for testing.”

The document addresses ultrasound and other noninvasive laboratory tests for (1) the evaluation of vascular blockages and disease in the peripheral arteries and the aorta; (2) the surveillance of the vascular system to help inform treatment decisions and prevent serious problems; and (3) follow-up after peripheral vascular procedures, such as arterial bypass, endarterectomy, or stenting.

A 19-member panel identified common clinical scenarios when noninvasive vascular testing might be considered in patients with suspected or known noncoronary arterial disorders. Each indication was then assessed for appropriateness and often at different time intervals (3–5, 6–8, and 9–12 months).

The group found arterial vascular testing to be appropriate in approximately half of the evaluated clinical situations. Vascular studies were deemed appropriate overall when clinical signs and symptoms were the main reason for testing. Tests that were conducted in patients with existing atherosclerotic disease, or to establish a baseline after a revascularization procedure, were also considered appropriate. One-third of the indications were rated as uncertain.

In the ACC press release, Dr. Mohler noted that these indications represent variations in practice and reveal important gaps in the evidence that prompted the panel to call for clinical and cost-effectiveness studies on noninvasive vascular testing.

The panel determined one in five uses of vascular testing to be inappropriate—although doing the test does not cause harm, the gathered information would not further inform clinical judgment. Examples of inappropriate testing include: ordering an ultrasound of the carotid arteries in someone at low risk for heart attack or stroke; screening for kidney artery disease in someone with peripheral artery disease with well controlled hypertension on one medication; choosing to perform an abdominal ultrasound in a patient with nonspecific lower extremity discomfort; ordering a mesenteric artery ultrasound as an initial test to evaluate the patient with chronic constipation or diarrhea; and performing a follow-up study for a patient with a normal baseline study who has no new symptoms.

Dr. Mohler, who advised that these guidelines should not supersede sound clinical judgment for individual patients, added, “As imaging technology and clinical applications continue to advance, the health care community needs to understand how to best incorporate these technologies into daily clinical care. These appropriate use criteria should guide clinicians as to what is an appropriate and inappropriate test so that we can rationally decide when testing is the best next step, especially in this time of cost-effectiveness in medicine.”

The group also sought to determine how frequently repeat testing is needed in clinical practice in light of the need for ongoing surveillance in some patients. The guidelines also outline key research areas for the future. A related report of appropriate use criteria for vascular laboratory testing to evaluate venous circulation is expected to be released in late fall of this year, according to the ACC.