Professional Statements and Societal Positions Guidelines
American College of Cardiology et al.
The ACC, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Hearth Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons (2019) published appropriate use criteria for multimodality imaging in the assessment of cardiac structure and function in nonvalvular heart disease (see Table 2).
Using a modified Delphi approach, the panel rated indications as “appropriate”, “may be appropriate”, and “not appropriate” The specific studies that formed the basis of the ACC guidelines are not cited, however, they note that they used ACC/American Heart Association clinical practice guidelines whenever possible.
Of 81 indications considered for strain rate imaging, the panel rated only 4 as “appropriate” (Table 2). Three of the four concerned evaluation (initial or follow-up) in individuals prior to and following exposure to potentially cardiotoxic agents. The other indication was follow-up testing to clarify initial diagnostic testing for individuals with suspected hypertrophic cardiomyopathy. The guidelines did not separate out imaging with speckle tracking and tissue Doppler, and did not make recommendations related to the comparative effectiveness of these imaging modalities.
The panel rated 14 other indications “may be appropriate” (Table 2). According to the panel, interventions in this category should be performed depending on individual clinical individual circumstances and individual and provider preferences, including shared decision making.
Summary of ACC Appropriate Use Criteria for Myocardial Strain Imaging
Clinical Scenario and Indication | Rating |
Initial evaluation in an asymptomatic individual: |
|
- Initial evaluation prior to exposure to medications/radiation that could result in cardiotoxicity/heart failure | Appropriate |
- Initial cardiac evaluation of a known systemic, congenital, or acquired disease that could be associated with structural heart disease | May be appropriate |
- Screening evaluation for structure and function in first-degree relatives of an individual with an inherited cardiomyopathy | May be appropriate |
- Preparticipation assessment of an asymptomatic athlete with one (1) or more of the following: abnormal examination, abnormal ECG, or definite (or high suspicion for) family history of inheritable heart disease) | May be appropriate |
Initial evaluation of a individual with clinical signs and/or symptoms of heart disease: |
|
- Initial evaluation when symptoms or signs suggest heart disease | May be appropriate |
- Arrythmias or conduction disorders - Newly diagnosed LBBB
- Nonsustained VT
| May be appropriate |
- Palpitations/Presyncope/Syncope - Clinical symptoms or signs consistent with a cardiac diagnosis known to cause presyncope/syncope (including but not limited to hypertrophic cardiomyopathy and heart failure)
| May be appropriate |
- Respiratory failure/exertional shortness of breath - Exertional shortness of breath/dyspnea or hypoxemia of uncertain etiology
| May be appropriate |
- Heart failure/cardiomyopathy - Initial evaluation of known or suspected heart failure (systolic or diastolic) based on symptoms, signs, or abnormal test results to assess systolic or diastolic function and to assess for possible etiology (CAD, valvular disease)
- Suspected inherited or acquired cardiomyopathy (e.g., restrictive, infiltrative, dilated, hypertrophic)
| May be appropriate |
- Device therapy - Known implanted pacing/ICD/CRT device with symptoms possibly due to suboptimal device settings
| May be appropriate |
- Cardiac Transplantation - Monitoring for rejection or coronary arteriopathy in a cardiac transplant recipient
| May be appropriate |
- Other - Suspected pericardial diseases
| May be appropriate |
Sequential or follow-up testing to clarify initial diagnostic testing: |
|
- Evaluation of suspected hypertrophic cardiomyopathy | Appropriate |
- Re-evaluation (1 year) in an individual previously or currently undergoing therapy with potentially cardiotoxic agents | Appropriate |
- Periodic reevaluation in an individual undergoing therapy with cardiotoxic agents and worsening symptoms | Appropriate |
- Pulmonary hypertension in the absence of severe valvular disease | May be appropriate |
- Comprehensive further evaluation of undefined cardiomyopathy | May be appropriate |
- Evaluation of suspected cardiac amyloidosis | May be appropriate |
| Sequential or follow-up testing: New or Worsening Symptoms or to Guide Therapy |
|
| Re-evaluation of known structural heart disease with change in clinical status or cardiac examination or to guide therapy | May be appropriate |
| Re-evaluation of known cardiomyopathy with a change in clinical status or cardiac examination or to guide therapy | May be appropriate |
| Re-evaluation of known HF (systolic or diastolic) with a change in clinical status or cardiac examination without a clear precipitating change in medication or diet | May be appropriate |
| Re-evaluation for CRT device optimization in an individual with worsening HF | May be appropriate |
Source: Adapted from Doherty et al 2019
American Society of Clinical Oncology
The American Society of Clinical Oncology (2017) noted that measurement of strain has been demonstrated to have some diagnostic and prognostic use in individuals with cancer receiving cardiotoxic therapies but that there have been no studies demonstrating that early intervention based on changes in strain alone can result in changes in risk and improved outcomes. The American Society of Clinical Oncology also notes that screening for asymptomatic cardiac dysfunction using advanced imaging could lead to added distress in cancer survivors.
