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Original Articles

Applicability of Appropriateness Criteria for Stress Imaging

Similarities and Differences Between Stress Echocardiography and Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging Criteria

Robert B. McCully, MD; Patricia A. Pellikka, MD; David O. Hodge, MSc; Philip A. Araoz, MD; Todd D. Miller, MD and Raymond J. Gibbons, MD

From the Divisions of Cardiovascular Diseases (R.B.M., P.A.P., T.D.M., R.J.G.) and Biostatistics (D.O.H.), and the Department of Radiology (P.A.A.), Mayo Clinic, Rochester, Minn.

Correspondence to Robert B. McCully, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail mccully.robert{at}mayo.edu

Received June 10, 2008; accepted January 26, 2009.

Background— Appropriateness criteria for stress imaging have been published to promote the effective use of stress nuclear scintigraphy and stress echocardiography. We sought to evaluate the application of the stress echocardiography appropriateness criteria to patients undergoing stress echocardiography in an academic medical center.

Methods and Results— The stress echocardiography criteria were applied to 298 consecutive patients who underwent stress echocardiography. Patients were rated as appropriate, uncertain, inappropriate, or not classifiable. Results were compared with those of a previous analysis in the same patients using the single-photon computed tomography myocardial perfusion imaging (SPECT MPI) criteria. The level of agreement between 2 cardiac nurse abstractors for categorizing appropriateness by the stress echocardiography criteria was good (=0.72). Overall, 54% of patients were classified as appropriate, 8% as uncertain, and 19% as inappropriate; 19% were not classifiable. By the SPECT MPI criteria, 64% of patients were classified as appropriate, 9% as uncertain, and 18% as inappropriate; 9% were not classifiable (P<0.001 compared with stress echocardiography criteria). By the stress echocardiography criteria, 6 clinical situations or indications accounted for more than 90% of the inappropriate tests; most of these involved asymptomatic patients.

Conclusions— Applying stress echocardiography appropriateness criteria to a patient population is feasible, although 1 in 5 of our patients was not classifiable. Overall, the stress echocardiography criteria classified patients differently compared with the SPECT MPI criteria. Future refinements of the appropriateness criteria for stress imaging should address gaps in the criteria and disparities between the stress echocardiography and SPECT MPI criteria.

Key Words: coronary heart disease • echocardiography • imaging • scintigraphy • stress • tomography

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CLINICAL PERSPECTIVE

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