Professional Statements and Societal Positions Guidelines
Practice Guidelines and Position Statements
American College of Cardiology et al
The American College of Cardiology, American Heart Association, and American Society for Nuclear Cardiology (2003) updated their joint guidelines for cardiac radionuclide imaging, including cardiac applications of PET. Table 6 summarizes the guidelines for PET and SPECT imaging in individuals with an intermediate risk of coronary artery disease (CAD).
Table 6. Guidelines for PET and SPECT in Individuals at Intermediate Risk of Coronary Artery Disease
Indication
|
Classa
|
|
SPECT
|
PET
|
Identify extent, severity, and location of ischemia (SPECT protocols vary according to whether individual can exercise)
|
I
|
IIa
|
Repeat test after 3-5 y after revascularization in selected high-risk asymptomatic individuals (SPECT protocols vary according to whether individuals can exercise)
|
IIa
|
-
|
As initial test in individuals who are considered to be at high-risk (i.e., individuals with diabetes or those with a >20% 10-y risk of a coronary disease event) (SPECT protocols vary according to whether individuals can exercise)
|
IIa
|
-
|
Myocardial perfusion PET when prior SPECT study has been found to be equivocal for diagnostic or risk stratification purposes
|
Not appropriate
|
I
|
Adapted from Klocke et al (2003).
PET: positron emission tomography; SPECT: single-photon emission computed tomography.
a Class I is defined as conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class IIa is defined as conditions for which there is conflicting evidence or a divergence of opinion, but the weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb is similar to class II except that the usefulness/efficacy is less well-established by evidence/opinion.
These guidelines concluded that PET "appears to have slightly better overall accuracy for predicting recovery of regional function after revascularization in individuals with left ventricular dysfunction than single-photon techniques (i.e., SPECT scans)." However, the guidelines indicated that both PET and SPECT scans are class I indications for predicting improvement in regional and global left ventricular function and natural history after revascularization; therefore, the guidelines did not indicate a clear preference for PET or SPECT scans in this situation.
The American College of Cardiology Foundation and American Heart Association (2009) collaborated with 6 other imaging societies to develop Appropriate Use Criteria for cardiac radionuclide imaging. Their report stated:
"...use of cardiac RNI for diagnosis and risk assessment in intermediate- and high-risk individuals with coronary artery disease (CAD) was viewed favorably, while testing in low-risk individuals, routine repeat testing, and general screenings in certain clinical scenarios were viewed less favorably. Additionally, use for perioperative testing was found to be inappropriate except for high selected groups of individuals."
American College of Radiology
The ACR Appropriateness Criteria (2011) considered both SPECT and PET to be appropriate for the evaluation of individuals with a high probability of CAD. The ACR indicated that PET perfusion imaging has advantages over SPECT, including higher spatial and temporal resolution. Routine performance of both PET and SPECT are unnecessary. The 2017 update stated:
"Hybrid PET scanners use CT [computed tomography] for attenuation correction (PET/CT) following completion of the PET study. By coupling the PET perfusion examination findings to a CCTA [coronary computed tomographic angiography], PET/CT permits the fusion of anatomic coronary arterial and functional (perfusion) myocardial information and enhances diagnostic accuracy. The fused examinations can accurately measure the atherosclerotic burden and identify the hemodynamic functional significance of coronary stenosis. The results of the combined examinations can more accurately identify individuals for revascularization."
The ACR Appropriateness Criteria (2012) also recommended PET for the evaluation of individuals with chronic chest pain and the low-to-intermediate probability of CAD.
The ACR does not recommend PET for individuals with acute nonspecific chest pain who have a low probability of CAD or for asymptomatic individuals at risk for CAD.
