B.%20C.%20Kansupada,%20MD,%20HeartCare%20Assoc.%20ACC%20chapter%20talk%20%204/28/06

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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
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Nuclear Imaging 2006

• Bindu Kansupada, MD, MBA, FACC
• HeartCare Associates
• Member Payors Committee PACC

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Disclosure

• Consultant/speaker bureau for
• Medtronics
• Guident
• St. Judes
• Merck
• Bristol Myers Squib

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• Special Thanks
• Dr. Polk
• Dr. Ronald Schwartz
• Dr. Braunwald

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Nuclear Cardiac Imaging (Myocardial Perfusion
Imaging)

• Myocardial Perfusion Imaging What is it?
• MPI Images What does it look like?
• Clinical Value What good is it?
• Comparison with other modalities
• Why MPI?

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What is Myocardial Perfusion Imaging?

• In the U.S., nuclear cardiology (MPI) procedures
  have overtaken non-cardiology procedures in
  procedural volume.

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What is Myocardial Perfusion Imaging?

• MPI is a non-invasive nuclear imaging technique
  that uses radioactive imaging agents to image the
  heart.
• Thallium - 201
• Technetium-99 m Sestamibi
• Technetium-99 m Tetrofosmin

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What do MPI images look like?

• In a typical nuclear cardiac imaging exam, the
  physician reviews
• Static Summed Perfusion Images
• Dynamic Gated Images

Perfusion Images are viewed in three
orientations SA Short Axis VLA Vertical Long
Axis HLA - Horizontal Long Axis
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What do MPI images look like? - Summed Perfusion
Images
Stress
SA
Rest
Stress
SA
Rest
Stress
VLA
Rest
Stress
HLA
Rest
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What do MPI images look like? - Summed Perfusion
Images
Stress
Rest
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What do MPI images look like? Gated Images
SA
HLA
VLA
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What Good is MPI? Clinical Value
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What Good is MPI? Clinical Value
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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
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Normal Myocardial Perfusion
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Myocardial Ischemia
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Myocardial Infarction
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Type of Nuclear Imaging
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Gated Study
Gating process-Functional assessment ventricular
wall motion ES and ED ventricular volumes LV
ejection fraction normal 64 /- 12
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Gated Study
Radiopharmaceutical Tc-99m labeled red blood
cells in-vitro and in-vivo labeling
Images anterior left lateral left anterior
oblique (best LV separation)
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Gated Study
Exercise assessment stress done with
bicycle rest EF to compare stress EF Primary
uses of test congestive heart failure cardiomyopat
hy chemo cardiotoxicity
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First Pass Cardiac Study
Whats first pass? temporal separation of
chambers Functional assessment ventricular wall
motion ES and ED ventricular volumes LV and RV
ejection fractions pulmonary transit time
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First Pass Cardiac Study
Can be performed with exercise stress done with
bicycle rest EF to compare to stress EF Primary
uses of test same as gated cardiac study better
than gated at right ventricle assessment and
cardiac shunts
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Myocardial Perfusion Study
Assess coronary blood flow Demonstrate blood
perfusion of the LV myocardium Software allows
gating for EF 3D reconstruction of heart
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Myocardial Perfusion
Radiopharmaceuticals Thallium-201 chloride Tc-99m
Sestamibi Tc-99m Tetrofosmin SPECT
acquisition provides cross-sectional images of
the myocardium in the short axis, horizontal long
axis and vertical long axis planes
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Myocardial Perfusion
Performed at rest stress Stress study
options treadmill exercise pharmacologic stress
agents adenosine persantine (dipyridamole) dobutam
ine
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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 MIs
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Exam Results
Myocardial Infarction perfusion defect on rest
stress Myocardial Ischemia perfusion defect
on stress only
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Diagnostic Approach
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Exercise Protocol

• Exercise preferred modality
• Radiopharmaceutical injected at peak and
  continued exercise for another 1-2 minutes.
• If unable to exercise, unable to attain target
  heart rate, or contraindications pharmacologic
  testing should be performed.
• B-blockers should be held for 48 hours
• No caffeine for 24 hours.

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Exercise Testing- Contra Indications

• Unstable Angina
• Decompensated CHF
• Uncontrolled hypertension (blood pressure gt
  200/115 mm of Hg)
• Acute myocardial infarction within last 2 to 3
  days
• Severe pulmonary hypertension
• Relative contraindication AS, HCM

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Exercise Testing

• Each of the protocols has advantages and
  disadvantages.
• Quality control from preparation, acquisition to
  reading assure the best data.

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Myocardial PerfusionScintigraphy Assessment of
Diagnosis, Prognosis, and Treatment Response of
Cardiovascular Risk.

• Diagnosis, Prognosis, and Response to Therapy
• Suspected Coronary artery disease
• Known stable coronary artery disease
• Prior to non-cardiac surgery
• Before and after cardiac revascularization

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Myocardial PerfusionScintigraphy Assessment of
Diagnosis, Prognosis, and Treatment Response of
Cardiovascular Risk

• Diagnosis, Prognosis, and Response to Therapy
  Special populations (women, diabetics)
• Evaluation of acute chest pain syndromes
• Myocardial infarction
• Screening Multiple risk factors, Family history
• Response to medical therapy

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Populations Who Benefit from SPECT MPI

• Diagnostic and prognostic chest pain evaluation
• Angina
• Atypical Angina
• Atypical Chest Pain
• Non-cardiac Chest Pain
• Peri-operative risk of non-cardiac surgery
• Diagnostic and prognostic evaluation of ACS
• Emergency Department
• In Hospital

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Populations Who Benefit from SPECT MPI

• Hemodynamic/prognostic assessment of known CAD
• High risk asymptomatic populatios
• Diabetes, Metabolic syndrome, insulin resistance
  syndrome
• Family history of sibling with coronary event
• Mediastinal radiation
• Multiple coronary risk factor
• Monitoring effectiveness of surgical and
  percutaneous revascularization
• Monitoring effectiveness of medical
  revascularization

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Incremental Prognostic Value of MPI Testing Men
vs. Women

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CLINICAL
EXERCISE
MPI
2742 Men 1394 Women
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Specificity of MPI with SPECT Procedures in
Women P.0004
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Heart Disease in Women Lessons From The Past
Decade

• The importance of studying gender specific
  aspects of CAD have helped in the following
  clinical dilemmas
• Presentation of CAD women are older than men
• Less Specific clinical manifestations of CAD in
  women
• Greater Difficulty in Diagnosis womengtmen
• More sever consequences of MI when it occurs in
  women

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Detecting CAD in Women

• Evidence from numerous medical societies
  uniformly supports association of exercise ECG
  has lower diagnostic accuracy in women (more
  false positive)
• Critical Factors Affects Accuracy Functional
  Capacity, Rest ST-T changes, Hormonal Factors
• SPECT was better able to identify and satisfy
  women at high risk for future events.
• Extent of total perfusion abnormality, extent of
  reversible perfusion abnormality, multivessel
  abnormality, large perfusion abnormality are
  all strong predictors of future cardiac events.
• Await RCT data from the WOMEN study to provide
  further detail as to the value of SPECt in
  accessing risk in women.

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Long Term outcome of Patients With
Intermediate-Risk Exercise Electrocardiograms who
Do Not Have Myocardial Perfision Defects on
Radionuclide Imaging

• Results
• Cardiovascular survival was 99.8 at 1 year,
  99.0 at 5 years and 98.5 at 7 years.
• Near-normal scans and cardiac enlargement were
  independent predictors of time to cardiac death.
• Cardiac survival time free of myocardial
  infarction or revascularization was 87.1 at 7
  years.

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Summary Acute Rest Imaging in 2005

• Strong predictor of short-term cardiac events
• Very high negative predictive value for acute MI
• Interpretative differences between acute and
  stress imaging requires experience.
• Use in clinical decision-making and other acute
  situations
• Consider as a gateway of opportunity to assess
  intermediate to long term risk of patient -gt
  value of stress imaging following acute resting
  evauation.

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DIAD Detection of Ischemia is Asymptomatic
Diabetes

• Abnormalities were observed in
• - 22 of patients with gt 2 risk factors (66 of
  306)
• - 22 of patients with lt 2 risk factors (45 of
  204)
• Greater than one in five diabetic patients
  without symptoms have an abnormal gated SPECT MPI
• Selecting only patients who meet ADA guidelines
  would have failed to identify 41 of patients
  with ischemia

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Radionuclide MPS in Pre-operative Risk Assessment

• Perfusion imaging works so well in predicting
  outcome, we tend to overuse it
• For patients with positive perfusion study, try
  to avoid revascularization unless the patient
  needs it regardless of upcoming surgery.
• Recent study demonstrates no benefit compared to
  beta blockade peri-operatively.
• High risk subsets will benefit long term.
• Treat patients with mild reversible defects
  medically
• Avoid noncardiac surgery within 6 weeks of bare
  metal stenting
• Among patients who have CAD, or who are at risk
  of CAD, consider preoperative beta blockade and
  statins.
• Several studies in clinical settings in which the
  ACC/AHA guidelines were followed have
  demonstarted their effectiveness.

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Shortcut to indications for noninvasive testing-
Perform if any 2 of 3 factors are present.

• High surgical risk operations
• - AAA PVD
• - Long procedures with lg fluid shifts or blood
  loss
• Poor functional capacity ( lt 4 METs)
• Intermediate clinical predictors presents
• - CAD
• gtgt Angina ( CCS I II)
• gtgt Prior MI
• - CHF
• - Diabetes or renal insufficiency.

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Coronary Blood Flow

• Myocardial blood flow reduction correlates with
  degree of stenosis
• Flow reserve reduces with coronary stenoses of
  45-50
• Able to maintain resting flow untill stenosis is
  80-90

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Coronary Blood Flow Rates
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Prognostic Variables of Gated SPECT
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Value of Stress MPI in the general population
Stress MPI Prognostic Significance
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Prognosis
Prognostic data are incremental Normal scans
lt1 cardiac event rate per year Mildly abnormal
scans lt1 cardiac death rate MI rate not
affected by revascularization Treatment may be
medical (catheterization reserved for refractory
symptoms)
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Risk Stratification Prognosis

• Risk of cardiac Death
• Low
• lt 1 per year
• Intermediate
• 1 3 per year
• High
• gt 3 per year

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Risk Stratification Noninvasive Testing Markers

• Amount of infarcted myocardium
• Amount of jeopardized myocardium
• Degree of jeopardy
• Left vanticular systolic function
• All can be assessed by measurements of perfusion
  or function

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TID transit Ischemic Dilation (Stress induced LV
Cavity Dilation)

• Severe, extensive CAD (usually with classic
  ischemic defect)
• Left Main
• Prox LAD
• MVD
• Microvascular disease (no stress defect atypical
  defects)
• HTN
• LVH
• DCM

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Prognostic implications of myocardial perfusion
imaging.
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Single-photon emission computed tomography
perfusion images in two patients with stable
anginal symptoms.
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Incremental value Of SPECT
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Evaluation of CAD A Prognostic Approach
Patients with suspected CAD referred to SPECT
Myocardial Perfusion Imaging with Gated 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
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Evaluation of CAD
A Diagnostic Approach
Patients with possible CAD
Normal DIAGNOSTIC TES
Abnormal
Low likelihood of CAD Intermediate to high likelihood of CAD
Risk factor modification Revascularization
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Cost Effective Approach
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Myocardial perfusion imaging Cost
effectiveness MPI as gatekeeper Incremental
information
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Principles of Cost-Effective Diagnosis and
Management of CAD using MPS
High sensitivity Exclude disease Fewer false
negatives Higher downstream costs in
undiagnosed pts No need for 2nd test vs. low
sensitivity low cost High specificity Reduces
number of false positive tests Reduced
downstream testing
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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, catheterizationFollow
-up (late) includes costs of PTCA, CABG Adapted
from Shaw LJ, et al.J Am CollCardiol.
199933661-669. Cost-effectiveness Assessing
the Prognostic Approach
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END Angiographic findings
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END Study Outcome by Screening Strategy
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Pretest Clinical Risk
(n5,423) Pretest Clinical Risk
(n5,826)
P lt.01 vs catheterization.
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Cost Effectiveness in Clinical Practice
Patient risk assessed? Low risk, negative
testing Intermediate risk, further testing If
risk lt 1 then no further testing needed
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Why to Practice Appropriateness Criteria based
Practice?One may not get reimbursed.Inappropriat
e test could increase financial burden to
society.Possible increased radiation
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Appropriateness Criteria SPECT MPI

• 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
  categoriesthose 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.

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Appropriateness Criteria SPECT MPI

• 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.

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Table 10. Inappropriate Indications (Median
Rating of 1 to 3)
Indication Indication Appropriateness Criteria (Median Score) Appropriateness Criteria (Median Score)
Detection of CAD SymptomaticEvaluation of Chest Pain Syndrome Detection of CAD SymptomaticEvaluation of Chest Pain Syndrome Detection of CAD SymptomaticEvaluation of Chest Pain Syndrome Detection of CAD SymptomaticEvaluation of Chest Pain Syndrome
1. Low pre-test probability of CAD ECG interpretable AND able to exercise I (2.0) I (2.0)
Detection of CAD SymptomaticAcute Chest Pain (in Reference to Rest Perfusion Imaging) Detection of CAD SymptomaticAcute Chest Pain (in Reference to Rest Perfusion Imaging) Detection of CAD SymptomaticAcute Chest Pain (in Reference to Rest Perfusion Imaging) Detection of CAD SymptomaticAcute Chest Pain (in Reference to Rest Perfusion Imaging)
8. High pre-test probability of CAD ECG ST elevation I (1.0)
Detection of CAD Asymptomatic (Without Chest Pain Syndrome) Detection of CAD Asymptomatic (Without Chest Pain Syndrome) Detection of CAD Asymptomatic (Without Chest Pain Syndrome)
10. Low CHD risk (Framingham risk criteria) I (1.0)
Risk Assessment General and Specific Patient Populations Asymptomatic Risk Assessment General and Specific Patient Populations Asymptomatic Risk Assessment General and Specific Patient Populations Asymptomatic
17. Low CHD risk (Framingham) I (1.0)
Table 10. Inappropriate Indications (Median
Rating of 1 to 3)
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Table 10. Inappropriate Indications (Median
Rating of 1 to 3)
Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study
21. Normal initial RNI study High CHD risk (Framingham) Annual SPECT MPI study I (3.0)
Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization OR Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization OR Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization OR Prior SPECT MPI Study
23. 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 I (2.5)
Risk Assessment With Prior Test Results Asymptomatic Prior Coronary Calcium Agatston Score Risk Assessment With Prior Test Results Asymptomatic Prior Coronary Calcium Agatston Score Risk Assessment With Prior Test Results Asymptomatic Prior Coronary Calcium Agatston Score
28. Agatston score less than 100 I (1.5)
Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Low-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Low-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Low-Risk Surgery
31. Preoperative evaluation for non-cardiac surgery risk assessment I (1.0)
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Table 10. Inappropriate Indications (Median
Rating of 1 to 3)
Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Intermediate-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Intermediate-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Intermediate-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Intermediate-Risk Surgery
32. 32. Minor to intermediate perioperative risk predictor Normal exercise tolerance (greater than or equal to 4 METS) I (3.0)
Risk Assessment Preoperative Evaluation for Non-Cardiac SurgeryHigh Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac SurgeryHigh Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac SurgeryHigh Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac SurgeryHigh Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac SurgeryHigh Risk Surgery
36. Asymptomatic up to 1 year post normal catheterization, non-invasive test, or previous revascularization I (3.0)
Risk Assessment Following Acute Coronary Syndrome STEMIHemodynamically Signs of Cardiogenic Shock, or Mechanical Complications Risk Assessment Following Acute Coronary Syndrome STEMIHemodynamically Signs of Cardiogenic Shock, or Mechanical Complications Risk Assessment Following Acute Coronary Syndrome STEMIHemodynamically Signs of Cardiogenic Shock, or Mechanical Complications Unstable,
38. 38. Thrombolytic therapy administered I (1.0)
Risk Assessment Following Acute Coronary Syndrome Asymptomatic Post-Revascularization (PCI or CABG) Risk Assessment Following Acute Coronary Syndrome Asymptomatic Post-Revascularization (PCI or CABG) Risk Assessment Following Acute Coronary Syndrome Asymptomatic Post-Revascularization (PCI or CABG) Risk Assessment Following Acute Coronary Syndrome Asymptomatic Post-Revascularization (PCI or CABG)
40. 40. Routine evaluation prior to hospital discharge I (1.0)
Risk Assessment Post-Revascularization (PCI or CABG)Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG)Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG)Asymptomatic
47. Symptomatic prior to previous revascularization I (3.0)
Less than 1 year after PCI
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Indication Indication Indication Appropriateness Criteria (Median Score)
Detection of CAD Symptomatic Evaluation of Chest Pain Syndrome
3. Intermediate pre-test probability of CAD A (7.0)
ECG interpretable AND able to exercise ECG interpretable AND able to exercise A (7.0)
4. Intermediate pre-test probability of CAD A (9.0)
ECG uninterpretable OR unable to exercise ECG uninterpretable OR unable to exercise A (9.0)
5. High pre-test probability of CAD A (8.0)
ECG interpretable AND able to exercise ECG interpretable AND able to exercise A (8.0)
6. High pre-test probability of CAD A (9.0)
ECG uninterpretable OR unable to exercise ECG uninterpretable OR unable to exercise A (9.0)
Detection of CAD Symptomatic Acute Chest Pain (in Reference to Rest Perfusion Imaging) Detection of CAD Symptomatic Acute Chest Pain (in Reference to Rest Perfusion Imaging) Detection of CAD Symptomatic Acute Chest Pain (in Reference to Rest Perfusion Imaging)
7. 7. Intermediate pre-test probability of CAD ECG no ST elevation AND initial cardiac enzymes negative Intermediate pre-test probability of CAD ECG no ST elevation AND initial cardiac enzymes negative A (9.0)
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Detection of CAD Symptomatic New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome Detection of CAD Symptomatic New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome Detection of CAD Symptomatic New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome
9. 9. Intermediate pre-test probability of CAD A (8.0)
Detection of CAD Asymptomatic New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction Without Chest Pain Syndrome Detection of CAD Asymptomatic New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction Without Chest Pain Syndrome
12. Moderate CHD risk (Framingham) A (7.5)
No prior CAD evaluation AND no planned cardiac catheterization A (7.5)
Detection of CAD Asymptomatic (Without Chest Pain Syndrome) New-Onset Atrial Fibrillation Detection of CAD Asymptomatic (Without Chest Pain Syndrome) New-Onset Atrial Fibrillation
15. High CHD Risk (Framingham) A (8.0)
Part of the evaluation A (8.0)
Detection of CAD Asymptomatic (Without Chest Pain Syndrome) Ventricular Tachycardia Detection of CAD Asymptomatic (Without Chest Pain Syndrome) Ventricular Tachycardia
16. Moderate to high CHD risk (Framingham) A (9.0)
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Risk Assessment General and Specific Patient Populations Asymptomatic Risk Assessment General and Specific Patient Populations Asymptomatic
19. Moderate to high CHD risk (Framingham) A (8.0)
High-risk occupation (e.g., airline pilot) A (8.0)
20. High CHD risk (Framingham) A (7.5)
Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Normal Prior SPECT MPI Study
22. Normal initial RNI study A (7.0)
High CHD risk (Framingham) Repeat SPECT MPI study after 2 years or greater A (7.0)
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization or Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization or Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization or Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization or Prior SPECT MPI Study Risk Assessment With Prior Test Results Asymptomatic OR Stable Symptoms Abnormal Catheterization or Prior SPECT MPI Study
24. Known CAD on catheterization OR prior SPECT MPI study in patients who have not had revascularization procedure A (7.5)
Greater than or equal to 2 years to evaluate worsening disease A (7.5)
Risk Assessment With Prior Test Results Worsening Symptoms Abnormal Catheterization OR Prior SPECT MPI Study Risk Assessment With Prior Test Results Worsening Symptoms Abnormal Catheterization OR Prior SPECT MPI Study Risk Assessment With Prior Test Results Worsening Symptoms Abnormal Catheterization OR Prior SPECT MPI Study Risk Assessment With Prior Test Results Worsening Symptoms Abnormal Catheterization OR Prior SPECT MPI Study
25. 25. Known CAD on catheterization OR prior SPECT MPI study A (9.0)
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Indication Indication Indication Appropriateness Criteria (Median Score)
Risk Assessment With Prior Test Results Asymptomatic Prior Coronary Calcium Agatston Score Risk Assessment With Prior Test Results Asymptomatic Prior Coronary Calcium Agatston Score Risk Assessment With Prior Test Results Asymptomatic Prior Coronary Calcium Agatston Score
27. 27. Agatston score greater than or equal to 400 A (7.5)
Risk Assessment With Prior Test Results UA/NSTEMI, STEMI, or Chest Pain SyndromeCoronary Angiogram Risk Assessment With Prior Test Results UA/NSTEMI, STEMI, or Chest Pain SyndromeCoronary Angiogram
29. Stenosis of unclear significance A (9.0)
Risk Assessment With Prior Test Results Duke Treadmill Score Risk Assessment With Prior Test Results Duke Treadmill Score
30. Intermediate Duke treadmill score Intermediate CHD risk (Framingham) A (9.0)
Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Intermediate-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery Intermediate-Risk Surgery
33. Intermediate perioperative risk predictor OR Poor exercise tolerance (less than 4 METS) A (8.0)
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery High-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery High-Risk Surgery
35. Minor perioperative risk predictor AND A (8.0)
Poor exercise tolerance (less than 4 METS) A (8.0)
Risk Assessment Following Acute Coronary Syndrome STEMI-Hemodynamically Stable Risk Assessment Following Acute Coronary Syndrome STEMI-Hemodynamically Stable
37. Thrombolytic therapy administered Not planning to undergo catheterization A (8.0)
Risk Assessment Following Acute Coronary Syndrome UA/NSTEMINo Recurrent Ischemia OR No Signs of HF Risk Assessment Following Acute Coronary Syndrome UA/NSTEMINo Recurrent Ischemia OR No Signs of HF
39. Not planning to undergo early catheterization A (8.5)
Risk Assessment Post-Revascularization (PCI or CABG) Symptomatic Risk Assessment Post-Revascularization (PCI or CABG) Symptomatic
41. Evaluation of chest pain syndrome A (8.0)
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Table 11. Appropriate Indications (Median Rating
of 7 to 9)
Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic
44. Asymptomatic prior to previous revascularization A (7.5)
Greater than or equal to 5 years after CABG A (7.5)
45. Symptomatic prior to previous revascularization A (7.5)
Greater than or equal to 5 years after CABG A (7.5)
Assessment of Viability/Ischemia Ischemic Cardiomyopathy (Includes SPECT Imaging for Wall Motion and Ventricular Function) Assessment of Viability/Ischemia Ischemic Cardiomyopathy (Includes SPECT Imaging for Wall Motion and Ventricular Function) Assessment of Viability/Ischemia Ischemic Cardiomyopathy (Includes SPECT Imaging for Wall Motion and Ventricular Function)
50. Known CAD on catheterization Patient eligible for revascularization A (8.5)
Evaluation of Left Ventricular Function Evaluation of Left Ventricular Function
51. Non-diagnostic echocardiogram A (9.0)
Evaluation of Ventricular Function Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin) Evaluation of Ventricular Function Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)
52. Baseline and serial measurements A (9.0)
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Table 12. Uncertain Indications (Median Rating of
4 to 6)
Indication Indication Appropriateness Criteria (Median Score) Appropriateness Criteria (Median Score)
Detection of CAD Symptomatic Evaluation of Chest Pain Syndrome Detection of CAD Symptomatic Evaluation of Chest Pain Syndrome Detection of CAD Symptomatic Evaluation of Chest Pain Syndrome
2. Low pre-test probability of CAD ECG uninterpretable OR unable to exercise U (6.5)
Detection of CAD Asymptomatic (Without Chest Pain Syndrome) Detection of CAD Asymptomatic (Without Chest Pain Syndrome) Detection of CAD Asymptomatic (Without Chest Pain Syndrome)
11. Moderate CHD risk (Framingham) U (5.5)
Detection of CAD Asymptomatic Valvular Heart Disease Without Chest Pain Syndrome Detection of CAD Asymptomatic Valvular Heart Disease Without Chest Pain Syndrome Detection of CAD Asymptomatic Valvular Heart Disease Without Chest Pain Syndrome
13. Moderate CHD risk (Framingham) To help guide decision for invasive studies U (5.5)
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Table 12. Uncertain Indications (Median Rating of
4 to 6)
Detection of CAD Asymptomatic (Without Chest Pain Syndrome) New-Onset Atrial Fibrillation Detection of CAD Asymptomatic (Without Chest Pain Syndrome) New-Onset Atrial Fibrillation Detection of CAD Asymptomatic (Without Chest Pain Syndrome) New-Onset Atrial Fibrillation
14. Low CHD risk (Framingham) Part of the evaluation U (3.5)
Risk Assessment General and Specific Patient Populations Asymptomatic Risk Assessment General and Specific Patient Populations Asymptomatic Risk Assessment General and Specific Patient Populations Asymptomatic
18. Moderate CHD risk (Framingham) U (4.0)
Risk Assessment With Prior Test Results Asymptomatic CT Coronary Angiography Risk Assessment With Prior Test Results Asymptomatic CT Coronary Angiography Risk Assessment With Prior Test Results Asymptomatic CT Coronary Angiography
26. Stenosis of unclear significance U (6.5)
Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery High-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery High-Risk Surgery Risk Assessment Preoperative Evaluation for Non-Cardiac Surgery High-Risk Surgery
34. Minor perioperative risk predictor Normal exercise tolerance (greater than or equal to 4 METS) U (4.0)
90
Table 12. Uncertain Indications (Median Rating of
4 to 6)
Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic
42. Asymptomatic prior to previous revascularization Less than 5 years after CABG U (6.0)
43. Symptomatic prior to previous revascularization Less than 5 years after CABG U (4.5)
Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic Risk Assessment Post-Revascularization (PCI or CABG) Asymptomatic
46. Asymptomatic prior to previous revascularization Less than 1 year after PCI U (6.5)
48. Asymptomatic prior to previous revascularization Greater than or equal to 2 years after PCI U (6.5)
49. Symptomatic prior to previous revascularization Greater than or equal to 2 years after PCI U (5.5)
91
Appropriateness Criteria SPECT MPI

• Summary
• Median Score 7 to 9 ---- Appropriate
• Median Score 1 to 3 ---- Inappropriate
• Median Score 4 to 6 ---- Uncertain

92
Pre-Cert Requirements in SE-PA

• IMPORTANT INFORMATION REGARDING DIAGNOSTIC
  IMAGING SERVICESNUCLEAR CARDIOLOGY STUDIES 
• 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)

93
Pre-Cert Requirements in SE-PA

• THE ORDERING PHYSICIAN IS TO CONTACT AIM VIA
  NAVINET, PHONE OR FAX, WHETHER THE ORDERING
  PHYSICIAN IS A PCP OR A SPECIALIST.
• CALL CENTER TEL NUMBER IS800-227-3116
• FAX NUMBER IS800-610-0050
• PROVIDERS MAY ACCESS AIMS CLINICAL GUIDELINES
  AND OTHER EDUCATIONAL RESOURCES BY SELECTING THE
  AIM LINK ON NAVINET OR BY ACCESSING AIS WEBSITE
  AT WWW.AMERICANIMAGING.NET

94
Pre-Cert Requirements in SE-PA

• FOR QUESTIONS REGARDING AIM PROGRAM CALL CUSTOMER
  SERVICE DEPARTMETN AT 800-252-2021(AIM).
•  
• 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.

95
Pre-Cert Requirements in SE-PA

• KEYSTONE MERCYAETNA
• THE ABOVE PLANS HAVE ENTERED INTO AN ARRANGEMENT
  WITH
• NATIONAL IMAGING ASSOCIATES (NIA) FOR OUT PATEINT
  IMAGING MANAGEMENT SERVICES. 
• CALL 800-642-7597FOR AETNA PRECERTIFICATON FOR
  NIA 
• CALL 866-642-9700FOR MERCY PRECERTIFICATION FOR
  NIA

96
Pre-Cert Requirements in SE-PA

• OXFORD HEALTH PLAN AND HEALTHNET HAVE AN
  AGREEMENT WITH CARECORE
• NEW JERSY BLUES(ONLY IF DONE IN NJ) 
• CALL [phone]-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)

97
Pre-Cert Requirements in SE-PA

• CBNC---Certification Board of Nuclear Cardiology
• CCNC---Certification Council of Nuclear
  Cardiology
• ABNM-American Board of Nuclear Medicine
• ABRAmerican Board of Radiology
•  
• ALSO THE NUCLEAR FACILITY HAS TO BE CERTIFIED BY
  CARECORE GUIDELINES.

98
Thank You