Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. US Pelvis Transrectal TRUS is the primary imaging method for anatomic evaluation of the internal and external anal sphincters and adds to the clinical examination and manometry in patients with fecal incontinence [20,91-93]. It has high correlation with surgical and histologic findings [94]. Interobserver agreement is good when evaluating sphincter defects [95] and is better for internal versus external sphincter when measuring muscle thickness [41]. The thickness of the internal anal sphincter is also slightly greater on TVUS compared with TRUS as the anal canal is collapsed. Three- dimensional US provides multiplanar images allowing visualization of the levator ani muscle and measurement of sphincter tear lengths [96]. However, it is not an established method for assessing external anal sphincter atrophy [97,98]. TRUS may be obtained for anatomic evaluation of patients with high suspicion of anal sphincter defects based on clinical evaluation as a complementary test to fluoroscopic CCP or MR defecography, which are the imaging tests of choice for functional evaluation of patients with defecatory dysfunction.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. US Pelvis Transvaginal TVUS may be an alternative to endoanal US for anatomic evaluation of sphincter defects, albeit with some limitations and challenges [99]. To our knowledge, there is no relevant literature comparing the utility of TVUS to physical examination, fluoroscopic CCP, or MR defecography for assessment of defecatory dysfunction.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Pelvic Floor Dysfunction in Females


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Variant 4: Female. Follow-up imaging after pelvic floor surgery. Subacute or chronic complications other than recurrent pelvic floor dysfunction. Initial imaging. This variant focuses on initial imaging evaluation of patients with subacute or chronic complications of pelvic floor repair, often with biological or synthetic graft materials, rather than acute perioperative complications, recurrent prolapse or other recurrent pelvic floor dysfunction. Imaging for evaluation of recurrent prolapse or other recurrent pelvic floor dysfunction follows the same appropriateness criteria as for primary pelvic floor dysfunction in Variants 1 thru 3 described above.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Imaging can complement clinical evaluation in patients that present with subacute or chronic complications after pelvic floor surgery [100]. Evaluation may be complicated by multiple prior procedures with limited access to previous surgical details. The lifetime risk of undergoing a surgical procedure for POP or UI in the US is 11%, and the reoperation rate is as high as 29% [7]. Reconstructive surgical treatments for POP or UI include primary surgical repair of native tissues, repair with biologic or absorbable grafts, placement of synthetic implants such as urethral slings, vaginal mesh or bulking agents, and vaginal wall or bladder-neck suspension procedures. Potential subacute or chronic complications of POP repair with mesh material include contraction or shrinkage, mesh exposure through a mucosal surface, or mesh extrusion out of the body cavity [101-104]. Patients may thus present with pelvic or groin pain, infection, voiding dysfunction, or pain/dyspareunia due to improper positioning or migration of synthetic materials or from excessive scarring. Functional complications of pelvic floor surgery include devascularization and denervation leading to voiding dysfunction, persistent pain, and dyspareunia [105,106].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. CT Pelvis Although CT may be used for the evaluation of patients that present with acute complications after surgical repair, to our knowledge, there is no relevant literature that supports use of CT for routine assessment or initial imaging of patients with subacute or chronic complications of pelvic floor repair. CT can demonstrate certain urethral bulking agents (when calcified), retropubic arms and bone anchors of urethral slings, and sacrocolpopexy mesh as it courses from the vaginal apex to the sacral promontory [100,107]; however, the poor inherent soft-tissue resolution of CT makes visualization of synthetic materials challenging compared with MRI. The synthetic materials along the anterior and posterior vaginal walls are also not depicted well on CT.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Fluoroscopy Voiding Cystourethrography VCUG can be used as an objective measure of change in cystocele height and urethral angle after surgical repair [14]. Although VCUG can be used to assess for urinary dysfunction in the postoperative setting, it is not able to directly depict pelvic floor musculofascial structures. Patients that present with new voiding dysfunction or chronic urinary tract infections after surgery may be assessed with VCUG. In the setting of severe voiding dysfunction, the urethra may not opacify, thus limiting evaluation. In other cases, there may be narrowing of the voiding urethra, a secondary sign to suggest urethral obstruction due to implanted sling or other material. Indirect findings of voiding dysfunction, such as a trabeculated bladder, and large postvoid bladder residual may be seen. In most cases, other anatomic changes after surgery, including implanted surgical material, may not be directly visible on fluoroscopy.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MRI Defecography MR defecography includes both an anatomic and functional evaluation of the pelvic floor. It is used to evaluate patients with suspected postsurgical complications if there is concomitant concern for persistent recurrent POP or other pelvic floor dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs and structural changes after surgery [37,40,108]. In addition to changes in native anatomy, MRI is able to visualize implanted synthetic material including urethral bulking agents, midurethral slings, and different types of vaginal mesh and their complications, although scar tissue may appear similar to sling and mesh components and can confound evaluation [107]. Although there are no studies evaluating the utility of gadolinium IV contrast after surgical repair in the pelvic floor, certain complications such as collections or fistula may be better depicted with contrast as is the case in other parts of the body. MR defecography is generally performed without IV contrast may thus be limited compared with MRI pelvis with IV contrast for this indication.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Furthermore, functional evaluation with the defecography component of the examination would only be indicated if there is concern for recurrent prolapse, urinary incontinence, or defecatory dysfunction.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MRI Pelvis Dynamic Maneuvers without Defecation MRI pelvis with dynamic maneuvers (dynamic pelvic floor MRI) includes both anatomic and functional evaluation of the pelvic floor and, similar to MR defecography, can be performed in postsurgical patients with subacute or chronic complications only if there is suspicion for persistent or recurrent prolapse or other pelvic floor dysfunction. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs and structural changes after surgery [37,40,108].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. In addition to changes in native anatomy, MRI is able to visualize implanted synthetic material including urethral bulking agents, midurethral slings, and different types of vaginal mesh and their complications, although scar tissue may appear similar to sling and mesh components and can confound evaluation [107]. Although there are no studies evaluating the utility of gadolinium IV contrast after surgical repair in the pelvic floor, certain complications such as collections or fistula are better depicted after contrast, as is the case in other parts of the body. Dynamic pelvic floor MRI is generally performed without gadolinium IV contrast, which may be limited compared with MRI pelvis with IV contrast for this indication. Furthermore, functional evaluation with dynamic maneuvers would only be indicated if there is concern for recurrent prolapse, urinary incontinence, or defecatory dysfunction


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MRI Pelvis MRI of the pelvis with gadolinium IV contrast is often used as an initial test for patients with subacute or chronic complications after pelvic floor repair. The inherent high soft-tissue contrast resolution of MRI allows for anatomic evaluation of the pelvic organs and structural changes after surgery [37,40,108].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. In addition to changes in native anatomy, MRI depicts implanted synthetic material including urethral bulking agents, midurethral slings, and different types of vaginal mesh and their complications, although scar tissue may appear similar to sling and mesh components and can confound evaluation [107]. MRI can depict volume and configuration of urethral bulking agent; however, it may not be predictive of clinical outcome [109]. MRI allows for evaluation of urethral slings in the retropubic space better than US, whereas US allows for evaluation in the sub/peri-urethral space [110]. Components of routinely available polypropylene vaginal mesh can typically be seen on T2-weighted MRI.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. MRI can also assess the integrity of sacrocolpopexy mesh and associated complications such as presacral hematomas, bowel or bladder injury, peritoneal inclusion cyst formation, mesh infection, or discitis/osteomyelitis at the sacral promontory [100,111]. Finally, anatomic evaluation of the peripheral nerves with MR neurography may play a role in assessment of chronic or recurrent pain in patients after surgery. Although there are no studies evaluating the utility of gadolinium IV contrast after surgical repair in the pelvic floor, certain complications such as collections or fistula may be better depicted after contrast as is the case in other parts of the body. Thus, MRI of the pelvis with gadolinium IV contrast is a preferred examination for depiction of the majority of subacute or chronic complications after surgical repair of pelvic floor.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. US Pelvis Transabdominal Postoperative complications such as urinary retention and acute retropubic hematomas can be assessed with US; however, to our knowledge, there is no relevant literature regarding the use of TAUS for subacute or chronic complications of pelvic floor surgical repair.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. US Pelvis Transperineal TPUS images are obtained via cine loops in multiple planes during rest, strain, and Kegel maneuvers with both 2- D and 3-D imaging for anatomic and functional pelvic floor assessment. Patients may be positioned semi-upright or in the dorsal lithotomy position. With regard to anatomic evaluation, TPUS can detect levator muscle avulsion both before and after surgical repair for POP [47]. TPUS can visualize urethral bulking agents, urethral slings, and vaginal mesh [107]. TPUS is more sensitive for locating mesh and sling material compared with physical examination and urethrocystoscopy [112]. TPUS with tomographic reconstructions has been used to assess the location of midurethral slings after surgery [113]. Anterior and posterior components of sacrocolpopexy vaginal mesh can be seen with TPUS; however, evaluation of apical and cranial components of the sacrocolpopexy mesh is limited on TPUS [114].


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. TPUS is not able to visualize retropubic components of urethral slings or extrapelvic components of slings or mesh that traverse the obturator foramen or ischiorectal fossa. Best surgical outcomes after sling placement have been


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Pelvic Floor Dysfunction in Females shown in patients with midurethral location of the slings, concordance of urethral movement with the sling, and with deformability of the sling on dynamic TPUS imaging [115]. Dynamic TPUS is able to predict development of high-pressure voiding after midurethral sling placement based on sling position and changes in morphology during straining [116,117]. Dynamic TPUS demonstrates significant reduction in urethral mobility and kinking in patients after POP repair, largely due to repair of cystoceles [118]. Thus, TPUS may have utility for evaluation of subacute or chronic complications after pelvic floor surgery in specific patients needing assessment of urethral bulking agents or suburethral components of urethral slings and vaginal mesh.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. US Pelvis Transrectal To our knowledge, there is no relevant literature demonstrating the utility of TRUS for assessment of subacute of chronic operative complications.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Pelvic Floor Dysfunction in Females Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females

Pelvic Floor Dysfunction in Females. Pelvic Floor Dysfunction in Females


Infective Endocarditis

Infective Endocarditis. Introduction/Background Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. In recent years, infective endocarditis of normal right-sided valves has become more frequent because of intravenous (IV) injection of illicit drugs, indwelling IV catheters, and implantable cardiac devices [1-3]. In patients with implanted cardiac devices, it has become increasingly important to consider infections of the device leads, device generator, and device pocket [4]. The clinical presentation of endocarditis is heterogeneous, with patients often presenting with acute heart failure due to severe valve destruction, but many presenting insidiously. The physical examination often reveals a new heart murmur, most commonly due to valvular insufficiency, and evidence of heart failure or a myriad of potential embolic and inflammatory/immune-mediated sequelae. At the first clinical suspicion of infective endocarditis, the workup typically includes serial blood cultures and transthoracic echocardiography (TTE) [5,6].


Infective Endocarditis

Infective Endocarditis. Although infective endocarditis is typically diagnosed clinically with persistently positive blood cultures in association with characteristic symptoms and physical findings [5,7], and then further evaluated by echocardiography, blood cultures may be negative in the setting of antibiotic use. Imaging is used to support the diagnosis by demonstrating vegetations of cardiac valves and, in complicated cases, paravalvular abscesses affecting native [8] and prosthetic [9] valves. Imaging is also used to assess the severity of valvular damage, identify complications, recognize the presence and severity of heart failure, and inform the next steps in patient management [7,10].


Infective Endocarditis

Infective Endocarditis. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a


Infective Endocarditis

Infective Endocarditis. aResearch Author, VA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California. bKaiser Permanente, Los Angeles, California. cPanel Chair, Duke University Medical Center, Durham, North Carolina. dPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. eUniversity of Louisville School of Medicine, Louisville, Kentucky. fUniversity of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah. gThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. hQueen's University, Kingston, Ontario, Canada; Cardiology expert. iUniversity of California San Diego, San Diego, California. jHarvard Medical School, Boston, Massachusetts. kCleveland Clinic, Cleveland, Ohio; American College of Emergency Physicians. lNaval Medical Center Portsmouth, Portsmouth, Virginia. mMassachusetts General Hospital, Boston, Massachusetts. nUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. oAscension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert. pMedstar Washington Hospital Center, Georgetown University, Washington, District of Columbia; Society for Cardiovascular Magnetic Resonance. qSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas.


Infective Endocarditis

Infective Endocarditis. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Infective Endocarditis

Infective Endocarditis. Reprint requests to: publications@acr.org


Infective Endocarditis

Infective Endocarditis. Infective Endocarditis required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes.


Infective Endocarditis

Infective Endocarditis. OR Discussion of Procedures by Variant Variant 1: Suspected infective endocarditis. Initial imaging. Arteriography Coronary There is limited evidence in the literature for the use of catheterization for assessing patients with suspected infective endocarditis. The primary indication is for presurgical evaluation of the coronary arteries [12].


Infective Endocarditis

Infective Endocarditis. CT Chest There is limited evidence in the literature for the use of CT chest to assess patients with suspected infective endocarditis. The primary role of CT chest is in evaluating pulmonary complications of infective endocarditis and can be particularly helpful in right-sided endocarditis for demonstrating septic pulmonary infarcts and abscesses [13,14].


Infective Endocarditis

Infective Endocarditis. CT Heart Function and Morphology CT is less accurate than TTE and transesophageal echocardiography (TEE) for identifying valvular vegetation. Consequently, the primary role of CT is in evaluating complications of infective endocarditis such as paravalvular and myocardial abscesses and pseudoaneurysms [15-20]. In depicting aortic valve pseudoaneurysms, one study showed a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%, 87.5%, 91.7%, and 100%, respectively [18]. The primary weakness of CT is in detecting native aortic valve vegetations <1 cm in size for which the NPV was 55.5%. However, the sensitivity, specificity, PPV, and NPV were all 100% for vegetations >1 cm in size [18]. One study also showed CT to lack sensitivity for detecting valve perforations when compared with TEE [17]. Compared with echocardiography, CT may be superior in both detecting and visualizing the full extent of a paravalvular abscess, pseudoaneurysm, or fistula, particularly in patients with prosthetic valves [7,10,20-23]. CT may be equivalent or superior to echocardiography in identifying vegetations and valve dehiscence in suspected prosthetic valve endocarditis [7,22,24]. CT may also be utilized to assess for abnormalities in the mobility of mechanical heart valves [24].


Infective Endocarditis

Infective Endocarditis. CTA Chest There is limited evidence in the literature for the use of CTA chest for assessing patients with suspected infective endocarditis. The primary role of CTA chest is in evaluating complications of infective endocarditis such as septic pulmonary infarcts and abscesses as well as paravalvular abscess, depending on CTA acquisition technique [13,14].


Infective Endocarditis

Infective Endocarditis. CTA Coronary Arteries There is limited evidence in the literature for the use of coronary CTA (CCTA) for assessing patients with suspected infective endocarditis. CCTA has a role in preoperative planning and assessment of coronary artery disease before surgery [15,17], wherein the risks of selective coronary angiography may be considerable. Given the well- established high NPV of CCTA, its use for the presurgical assessment of significant coronary artery disease allows for a noninvasive alternative to cardiac catheterization [15,25,26]. Although the use of CCTA and CT-derived fractional flow reserve has not been studied in a patient population with suspected infective endocarditis, extrapolating from the available literature suggests that selective CT-derived fractional flow reserve in patients found to have coronary artery disease on CCTA may play a role in guiding treatment decisions [27,28].


Infective Endocarditis

Infective Endocarditis

Infective Endocarditis. Infective Endocarditis


Infective Endocarditis

Infective Endocarditis. FDG-PET/CT Heart There is limited evidence in the literature for the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT in suspected infective endocarditis. One prospective study showed a low sensitivity of 39% for diagnosing infective endocarditis when compared with the modified Duke criteria [29]. Another retrospective study showed a sensitivity of 0% for diagnosing native valve endocarditis when compared with the modified Duke criteria [30].


Infective Endocarditis

Infective Endocarditis. Some recent studies have shown potential clinical value of FDG-PET/CT in infective endocarditis [31]. A prospective study with 72 patients showed that adding abnormal FDG uptake around a prosthetic valve to the modified Duke criteria at admission increased the sensitivity for the diagnosis of prosthetic valve endocarditis from 70% to 97% [32]. Another smaller prospective study showed that adding PET/CT to the modified Duke criteria in patients with an intermediate probability of infective endocarditis and an implantable cardiac device increased diagnostic accuracy [33]. However, when looking at a cohort of patients with native and prosthetic valves, one study showed a relatively low sensitivity of 39% for the diagnosis of infectious endocarditis [29]. Another retrospective study showed a sensitivity of 0% for diagnosing native valve endocarditis when compared with the modified Duke criteria [30].


Infective Endocarditis

Infective Endocarditis. In patients with congenital heart disease and intravascular or intracardiac prosthetic material, one prospective study showed that the use of PET/CT in addition to the modified Duke criteria, increased the diagnostic accuracy from 61.2% to 85.1% [34].


Infective Endocarditis

Infective Endocarditis. Fluoroscopy Heart There are no data to support the use of cardiac fluoroscopy in suspected infective endocarditis. On rare occasions, cardiac fluoroscopy may be indicated for evaluating mechanical prosthetic cardiac valves afflicted with endocarditis [35]. Valve fluoroscopy is used to detect excess mobility of the mechanical prosthetic valve during the cardiac cycle (a finding highly suggestive of valve dehiscence due to infective endocarditis) or to detect immobility of mechanical prosthetic valve leaflets secondary to infected pannus or thrombus.


Infective Endocarditis

Infective Endocarditis. WBC Scan Heart White blood cells (WBCs) may be labeled with either indium-111 (In-111), Tc-99m, or gallium-67 (Ga-67) [36]. There is limited evidence in the literature for the use of WBC scans in suspected infective endocarditis. One center reported a sensitivity of 0% for the detection of valvular vegetations by In-111 WBC in 7 patients with known vegetations seen by TEE [37].


Infective Endocarditis

Infective Endocarditis. Radiography Chest The chest radiograph is used to determine cardiac chamber size and the presence and severity of pulmonary venous hypertension and edema. It is also used to monitor the severity of the hemodynamic consequences of valvular regurgitation caused by infective endocarditis and to assess the response to treatment. In right-sided endocarditis, the chest radiograph may be effective in demonstrating pulmonary infarcts and abscesses as sequelae of septic emboli.


Infective Endocarditis

Infective Endocarditis. US Echocardiography Transthoracic Resting TTE resting plays an important role in the evaluation of infective endocarditis and is currently the only imaging criterion included in the modified Duke criterion used for a diagnosis of infective endocarditis [39]. It can demonstrate vegetations on cardiac valves, valvular regurgitation, and paravalvular abscess. It is the most frequently used imaging study for confirming the diagnosis of infective endocarditis. The demonstration of vegetations by echocardiography is 1 of the 2 major modified Duke criteria required for the diagnosis of a definite endocarditis [39,40].


Infective Endocarditis

Infective Endocarditis. Studies show that criteria for the diagnosis, which include the findings on TTE [40,41], were significantly better than traditional criteria based on clinical and bacteriologic criteria.


Infective Endocarditis

Infective Endocarditis. Several studies evaluated the diagnostic value of TTE and TEE in relation to the pretest probability of infective endocarditis based on clinical assessment in pediatric [42] and adult [43] patients. These studies concluded that


Infective Endocarditis

Infective Endocarditis


Infective Endocarditis

Infective Endocarditis. TTE has a lower yield in patients with low probability of endocarditis. TEE is the procedure of choice for patients with intermediate or high probability of endocarditis.


Infective Endocarditis

Infective Endocarditis. In right-sided endocarditis, TTE and TEE performed comparably, demonstrating similar numbers of vegetations and frequency of tricuspid regurgitation [1,44].


Infective Endocarditis

Infective Endocarditis. In left-sided native valve Staphylococcus aureus endocarditis, the presence of an intracardiac abscess and left ventricular ejection fraction <40% on echocardiography have been shown to be independent predictors of in- hospital mortality [45]. In this same group of patients, intracardiac abscess and valve perforation on echocardiography have been shown to be independent predictors of 1-year mortality [45].


Infective Endocarditis

Infective Endocarditis. One large retrospective study has shown that in low- to intermediate-risk patients using a strict negative criterion on TTE beyond the absence or presence of valvular vegetations increases the sensitivity and NPV of TTE (sensitivity: 98% versus 43%; NPV: 97% versus 87%) [46].


Infective Endocarditis

Infective Endocarditis. US Echocardiography Transesophageal TEE plays an important role in the evaluation of infective endocarditis [39]. It is used in suspected infective endocarditis to directly identify or exclude valvular vegetations, paravalvular abscess, and valvular regurgitation [47,48]. It is the most sensitive imaging technique for identifying vegetations, the presence of which is the hallmark for a definitive diagnosis of infective endocarditis [40]. Ultrasound (US) diagnosis of infective endocarditis provides better diagnostic accuracy than using clinical criteria alone [41]. TEE has been shown to have up to a 98.6% NPV in suspected infective endocarditis [49]. TEE has better sensitivity than TTE for detecting vegetations [40]. TEE has better sensitivity and accuracy than TTE for identifying paravalvular abscesses [40]. TEE is indicated for suspected infective endocarditis of prosthetic valves; it is significantly more accurate than TTE [40]. Authors of a review in 2010 noted that TEE has sensitivity and specificity of >90% for detecting intracardiac lesions associated with infective endocarditis [40].


Infective Endocarditis

Infective Endocarditis. Several studies evaluated the diagnostic value of TTE and TEE in relation to the pretest probability of infective endocarditis based on clinical assessment in pediatric [42] and adult [43] patients. These studies concluded that TTE has a lower yield in patients with low probability of endocarditis. TEE is the procedure of choice for patients with intermediate or high probability of endocarditis. Although TEE has been shown to have significantly higher sensitivity than TTE for identifying vegetations [40], specificities were similar at 91% to 100% for TEE and 91% to 98% for TTE.


Infective Endocarditis


Infective Endocarditis

Infective Endocarditis. The size and other characteristics of vegetations on echocardiography have been shown to be useful in predicting complications such as peripheral embolization [50]. In left-sided native valve S. aureus endocarditis, the presence of an intracardiac abscess and left ventricular ejection fraction <40% on echocardiography has been shown to be independent predictors of in-hospital mortality [45]. In this same group of patients, intracardiac abscess and valve perforation on echocardiography have been shown to be independent predictors of 1-year mortality [45].


Infective Endocarditis

Infective Endocarditis. Variant 2: Known or suspected infective endocarditis. Additional imaging to direct patient management or treatment. Arteriography Coronary The primary role of catheterization is for the presurgical evaluation of the coronary arteries [7,12]. It may be used to assess the severity of valvular dysfunction and ventricular function, but this use has largely been replaced by echocardiography [12].


Infective Endocarditis

Infective Endocarditis. CT Chest The primary role of CT chest is in evaluating complications of infective endocarditis after a diagnosis has been made. Routine CT chest can be helpful in right-sided endocarditis for demonstrating septic pulmonary infarcts and abscesses, osteomyelitis, and for preoperative assessment and surgical planning [25].


Infective Endocarditis

Infective Endocarditis. CT Heart Function and Morphology The primary role of CT heart is in evaluating complications of infective endocarditis such as paravalvular and myocardial abscesses and pseudoaneurysms [15-20,51]. In depicting aortic valve pseudoaneurysms, one study showed a sensitivity, specificity, PPV, and NPV of 100%, 87.5%, 91.7%, and 100%, respectively [18]. Compared with echocardiography, CT may be superior in both detecting and visualizing the full extent of a paravalvular


Infective Endocarditis

Infective Endocarditis

Infective Endocarditis. Infective Endocarditis


Infective Endocarditis

Infective Endocarditis. abscess, pseudoaneurysm, or fistula, particularly in patients with prosthetic valves [7,10,20-23]. CT may be equivalent or superior to echocardiography in identifying vegetations and valve dehiscence in suspected prosthetic valve endocarditis [7,22,24]. CT may also be utilized to assess for abnormalities in the mobility of mechanical heart valves and to identify causes of mechanical valve dysfunction that are missed on echocardiography and fluoroscopy [24].


Infective Endocarditis

Infective Endocarditis. CTA Chest The primary role of CTA chest is in evaluating complications of infective endocarditis such as septic pulmonary infarcts and abscesses, paravalvular abscess depending on CTA acquisition technique [13,14], and aortic pseudoaneurysms. CTA chest can also be helpful for preoperative assessment of vasculature and surgical planning [25].


Infective Endocarditis

Infective Endocarditis. CTA Coronary Arteries CCTA has a role in preoperative planning and assessment of coronary artery disease before surgery [15,17], where the risks of selective coronary angiography may be considerable. Given the well-established high NPV of CCTA, its use for the presurgical assessment of significant coronary artery disease allows for a noninvasive alternative to cardiac catheterization [15,25,26]. Although the use of CCTA and CT-derived fractional flow reserve has not been studied in a patient population with suspected infective endocarditis, extrapolating from the available literature suggests that selective CT-derived fractional flow reserve in patients found to have coronary artery disease on CCTA may play a role in guiding treatment decisions [27,28].


Infective Endocarditis

Infective Endocarditis. FDG-PET/CT Heart Some recent studies have shown potential clinical value of FDG-PET/CT in infective endocarditis [31]. One study showed that FDG-PET/CT detected clinically unsuspected sites of extracardiac infection in up to 24% of cases [52]. Several single-center studies have shown promise in identifying cardiovascular implantable electronic device infections using FDG-PET/CT with sensitivities ranging from 60% to 100% and specificities ranging from 86% to 100% [4,53-55]. In cases in which TTE and TEE were normal or equivocal, 2 studies showed that FDG-PET/CT was able to detect periprosthetic abscesses [56,57], which has been shown to occur in nearly 30% of cases [47].


Infective Endocarditis

Infective Endocarditis. Fluoroscopy Heart Cardiac fluoroscopy may be indicated for evaluating mechanical prosthetic cardiac valves afflicted with endocarditis [35]. Valve fluoroscopy is used to detect excess mobility of the mechanical prosthetic valve during the cardiac cycle (a finding highly suggestive of valve dehiscence due to infective endocarditis) or to detect immobility of mechanical prosthetic valve leaflets secondary to infected pannus or thrombus.


Infective Endocarditis

Infective Endocarditis. WBC Scan Heart WBCs may be labeled with either In-111, Tc-99m, or Ga-67 [36]. This may be used for identifying and localizing infected vegetations and paravalvular abscesses [39,58]. When echocardiography is inconclusive in suspected prosthetic valve endocarditis, a WBC scan has been shown to have a lower sensitivity than FDG-PET/CT (64% versus 93%, respectively) but a higher specificity (100% versus 71%, respectively) for the diagnosis of endocarditis [39,59].


Infective Endocarditis

Infective Endocarditis. Radiography Chest The chest radiograph is used to determine cardiac chamber size and the presence and severity of pulmonary venous hypertension and edema. It is also used to monitor the severity of the hemodynamic consequences of valvular regurgitation caused by infective endocarditis and to assess the response to treatment. In right-sided endocarditis, the chest radiograph may be effective in demonstrating pulmonary infarcts and abscesses as sequelae of septic emboli.


Infective Endocarditis

Infective Endocarditis


Infective Endocarditis

Infective Endocarditis. US Echocardiography Transthoracic Resting After the diagnosis of infective endocarditis is made, echocardiography can be used to make an informed decision for surgical treatment and play an important role in prognostication. Echocardiography is an excellent tool to evaluate for heart failure, which is a strong indication for valve surgery in several clinical scenarios [39].


Infective Endocarditis

Infective Endocarditis. In left-sided native valve S. aureus endocarditis, the presence of an intracardiac abscess and left ventricular ejection fraction <40% on echocardiography have been shown to be independent predictors of in-hospital mortality [45]. In this same group of patients, intracardiac abscess and valve perforation on echocardiography have been shown to be independent predictors of 1-year mortality [45].


Infective Endocarditis

Infective Endocarditis. US Echocardiography Transesophageal After the diagnosis of infective endocarditis is made, echocardiography can be used to make an informed decision for surgical treatment and play an important role in prognostication. Echocardiography is an excellent tool to evaluate for heart failure, which is a strong indication for valve surgery in several clinical scenarios [39].


Infective Endocarditis

Infective Endocarditis. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and rating round tabulations for each recommendation.


Infective Endocarditis

Infective Endocarditis. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Introduction/Background In the United States, atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death for both men and women [1]. Although improvements in awareness, knowledge, and medications have led to a decrease in death rates, the burden of disease remains very high [1,2]. Identification of patients who may benefit from early intervention prior to development of symptoms has been shown to reduce mortality and morbidity [3].


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. There is a well-established discordance between the prognostic accuracy of current risk estimation scores versus imaging when directly measuring the burden of atherosclerosis for the assessment of individual ASCVD risk as a guide to optimally manage preventive therapies [6]. Imaging allows for the detection of subclinical coronary atherosclerosis. Patients with familial hyperlipidemia in particular have a high prevalence of subclinical coronary atherosclerosis that is independently associated with cardiovascular risk [7]. The coronary artery calcium (CAC) score is a validated measure of overall coronary atherosclerotic burden, the strongest known imaging measure of risk in asymptomatic individuals. Individual data derived from this and other imaging tests provide useful prognostic information for patient management and can complement current risk prediction models [8].


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. The purpose of this document is to discuss the use of diagnostic imaging tests in asymptomatic patients who are at elevated risk of future cardiovascular events related to atherosclerosis. The tests are to improve targeted preventive efforts based on patient risk and are aimed at identification of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. aPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. bResearch Author, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. cPanel Chair, Duke University Medical Center, Durham, North Carolina. dUniversity of Louisville School of Medicine, Louisville, Kentucky. eUniversity of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah. fThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. gKaiser Permanente, Los Angeles, California. hSanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology Expert. iUniversity of Washington, Seattle, Washington. jUniversity of California San Diego, San Diego, California. kHarvard Medical School, Boston, Massachusetts. lNaval Medical Center Portsmouth, Portsmouth, Virginia. mMassachusetts General Hospital, Boston, Massachusetts. nLoyola University Medical Center, Maywood, Illinois; Society for Cardiovascular Magnetic Resonance. oUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. pAscension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear Cardiology Expert. qSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Reprint requests to: publications@acr.org


Asymptomatic Patient at Risk for CAD

Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Asymptomatic Patient at Risk for CAD


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Resting image modalities (ultrasound [US], scintigraphy, CT, and MRI) depict late findings of CAD, such as ventricular dilatation and wall-motion abnormalities, and can directly visualize the morphology of infarcted myocardial segments. Intravascular US, an invasive technique, can detect both calcified and noncalcified plaque. Myocardial perfusion can be assessed by stress, rest, and/or delayed imaging, which can be accomplished by US (via assessment of wall-motion changes at stress versus rest, or with contrast echocardiography); cardiac perfusion scintigraphy (via comparison of first-pass radiotracer perfusion to the ventricle at stress versus rest, or measurement of coronary blood flow); and MRI (via comparison of wall-motion or first-pass gadolinium enhancement of the ventricle during stress versus rest). Cardiac MRI is performed with ECG synchronization and may be performed without and with IV contrast and before and after vasodilators or inotropes if stress myocardial perfusion assessment is desired. MR angiography (MRA) of the coronary arteries is possible without or with IV contrast, but it only depicts luminal blood and cannot depict calcified plaque. Myocardial scarring, infarction, and viability can be assessed by cardiac MRI or cardiac PET.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. OR Discussion of Procedures by Variant Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging. CT Coronary Calcium The CAC score first became available and validated with electron beam CT, and in the modern era, MDCT is used to acquire this data. Several multicenter trials have assessed the use of CAC in asymptomatic patients at intermediate risk for CAD. In the Multi-Ethnic Study of Atherosclerosis (MESA), Joshi et al [14] followed 6,814 participants


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. CTA Coronary Arteries There is no relevant literature supporting the use of coronary CTA (CCTA) in asymptomatic patients at low risk of CAD. Choi et al [19] identified atherosclerotic plaques in 215 of 1,000 middle-aged asymptomatic patients with 2% prevalence of plaque in the low-risk group.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. US Echocardiography Transthoracic Resting There is no relevant literature supporting the use of transthoracic echocardiography (TTE) resting in asymptomatic patients at low risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. US Echocardiography Transthoracic Stress There is no relevant literature supporting the use of TTE stress in asymptomatic patients at low risk of CAD. The sensitivity and specificity of the test is 72% to 83% and 84% to 95%, respectively, for identification of ischemic myocardium and has been validated only in elevated risk populations [20].


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRI Heart Function with Stress There is no relevant literature supporting the use of MRI heart function with stress in asymptomatic patients at low risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRI Heart Function and Morphology Weir-McCall et al [22] demonstrated an overall low utility of resting MRI via abnormal late gadolinium enhancement in asymptomatic low-risk volunteers (0.67% of whom were found to have abnormalities, including myocardial infarction), with only 0.2% of volunteers having a previously unrecognized myocardial infarction.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Radiography Chest There is no relevant literature to support the use of chest radiographs to evaluate asymptomatic patients at low risk of CAD.


Asymptomatic Patient at Risk for CAD


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging. CT Coronary Calcium Kondos et al [24] found that any measurable coronary calcium was independently related to hard (death and myocardial infarction) and soft (revascularization procedure) events in men and women at low to intermediate pretest risk; this finding provided incremental prognostic information over conventional risk factors.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. CTA Coronary Arteries In a recent study, Di Cesare et al [33] showed utility of CCTA in asymptomatic patients at intermediate risk of stenosis detection in 112 out of 185 (60.5%) patients: 56 patients (30.2%) had mild stenosis, 49 patients (26.5%) had moderate stenosis, only 3 patients (1.6%) had severe stenosis, and in 4 patients (2.2%) evaluation could not be determined.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. US Echocardiography Transthoracic Resting There is no relevant literature supporting the use of TTE resting in asymptomatic patients at intermediate risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Asymptomatic Patient at Risk for CAD US Echocardiography Transthoracic Stress The sensitivity and specificity of stress TTE is 85% and 89%, respectively, has been validated only in populations at elevated risk, and is best utilized to search for obstructive major epicardial coronary stenosis [34]. There is no relevant literature to support the use of stress TTE in asymptomatic patients at intermediate risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRA Coronary Arteries MRA of the coronary arteries can assess for arterial patency and pathologic wall thickening but not calcific burden, and it cannot reliably assess small distal vessels [35,36]. There is no relevant literature to support the use of MRA of the coronary arteries in asymptomatic patients at intermediate risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRI Heart Function and Morphology There is no relevant literature to support the use of MRI heart function and morphology to evaluate asymptomatic patients at intermediate risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRI Heart Function with Stress The IMPACT II study demonstrated a sensitivity of 67% and specificity of 61% for detection of ischemic heart disease, including 533 patients in the intermediate-risk population [37]. The vast majority of the patients in this study were symptomatic, with angina pectoris. The sensitivity and specificity of the test in the asymptomatic intermediate-risk population has not been validated.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Radiography Chest There is no relevant literature to support the use of chest radiographs alone as a test to evaluate asymptomatic patients at intermediate risk of CAD.


Asymptomatic Patient at Risk for CAD

Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Asymptomatic Patient at Risk for CAD


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. plaque only seen on CTA. With a mean follow-up period of 2.65 years, MACE rate was 0% in CAD negative and higher (1.2%) in CAD positive by CTA.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. In a large multicenter registry of 27,125 patients (which included both symptomatic and asymptomatic patients), Min et al [45] found that CCTA improved discrimination by maximal stenosis, number of obstructive vessels, and segment stenosis score (C-index 0.77, 0.77, and 0.78, respectively) beyond age, gender, and CAC score (C-index 0.64) in a small subset of 400 asymptomatic patients. Similarly, CCTA findings improved risk reclassification by per patient maximal stenosis (integrated discrimination improvement [IDI] index, 0.03; P = .03) and number of obstructive vessels (IDI index, 0.06; P = .002), and by trend for segment stenosis score (IDI, 0.03; P = .06).


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. US Echocardiography Transthoracic Resting There is no relevant literature supporting the use of resting TTE in asymptomatic patients at high risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. US Echocardiography Transthoracic Stress TTE performed at rest and stress can assess for inducible wall-motion abnormalities, thus revealing ischemic heart disease. The sensitivity and specificity of the test is 72% to 83% and 84% to 95%, respectively, and has been validated only in symptomatic elevated risk populations and is best utilized to identify obstructive major epicardial coronary stenosis [20]. There is no relevant literature to support the use of stress TTE in asymptomatic patients at high risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRA Coronary Arteries MRA of the coronary arteries can assess for arterial patency and pathologic wall thickening but not calcific burden, and it cannot reliably assess small, distal vessels [35,36]. There is no relevant literature to support the use of MRA of the coronary arteries in asymptomatic patients at high risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRI Heart Function with Stress There is no relevant literature supporting the use of MRI heart function with stress in asymptomatic patients at high risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. MRI Heart Function and Morphology Cardiac MRI can assess resting left ventricular function and potential ischemic scar burden. There is no relevant literature supporting the use of cardiac MRI as a screening test in asymptomatic patients at high risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Radiography Chest There is no relevant literature supporting the use of chest radiographs over other modalities as a screening test in asymptomatic patients at high risk of CAD.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Asymptomatic Patient at Risk for Coronary Artery Disease PCAs. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Asymptomatic Patient at Risk for CAD


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. In general, the diagnostic evaluation of children with traumatic spine injury is determined by clinical findings, such as pain, limitation of movements, and neurological deficits, as well as injury mechanisms (eg, high- versus low-energy trauma mechanisms) [6]. However, the clinical assessment of spine injuries in children may be limited in unconscious or intubated patients, in children with intellectual disabilities, and in children who lack the ability to communicate because of their developmental stage (typically <2 years of age) [7,8].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Two major clinical decision rules, the National Emergency X-Radiography Utilization Study (NEXUS) criteria [13] and the Canadian C-Spine Rule [14], were demonstrated to have high negative predictive values (97% and 100%, respectively) to rule out cervical spine injury in adults without the need for imaging. The first NEXUS validation study [15] included children, but the sample size was small and there were few young children with cervical spine injury and none <2 years of age. A later pediatric validation study showed that no clinically important injuries were missed when the NEXUS clinical decision rule was used [16]; however, this validation study was also limited by a low incidence of cervical spine injury and small numbers of very young children [17].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Reprint requests to: publications@acr.org


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. The Pediatric Emergency Care Applied Research Network (PECARN) study identified risk factors associated with cervical spine injury in children in a large case control study [18]. The advantage of these risk factors is that they were based on a pediatric population and demonstrated 98% sensitivity. However, these risk factors have not yet been prospectively validated in a pediatric population. We decided to use the PECARN age <16 years to frame the variants in this document. There has only been one study evaluating predictors of cervical spine injury in blunt trauma in patients <3 years of age [19]. The study used a large cohort and a retrospective study design and there were no subsequent validation studies [19] (see Appendix 1).


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Several congenital disorders have been associated with a higher risk for cervical injury in athletes. For example, increased ligamentous laxity in patients with Down syndrome is associated with higher rates of spinal cord injury; patients with achondroplasia and spinal stenosis are at risk for significant spinal cord injury at the cervicomedullary junction with hyperflexion and hyperextension; similar injury risks related to atlantoaxial instability probably apply in patients with mucopolysaccharidosis type VI and Marfan syndrome [20]. In addition, children receiving systemic glucosteroid therapy for inflammatory diseases, such as juvenile dermatomyositis, juvenile idiopathic arthritis, systemic lupus erythematosus, systemic arthritis, and systemic vasculitis, are at higher risk for vertebral body fractures [21,22].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Children may have cartilaginous injuries that are not visualized on radiographs but are better detected with MRI [24]. In adults, MRI is the modality of choice to evaluate thoracolumbar trauma patients with neurologic deficits, abnormal CT scans, and high clinical suspicion despite negative radiographic evaluation [25]. Recently, a scoring system based on injury morphology, neurological status, and integrity of the thoracolumbar posterior ligament complex has been introduced to guide treatment decisions in adults >17 years of age [26]. It was shown that MRI facilitates the ability to classify thoracolumbar fractures in adults and children [27,28].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Sacral fractures account for only 0.16% of all pediatric trauma patients [3]. In a retrospective study of 89 patients, only 5% sacral fractures were found, all of which were Denis zone 1 fractures [3], which are located lateral to the neural elements and commonly involve the sacral alae [29]. Adequate radiographs still miss 35% of sacral fractures; therefore, CT and MRI are superior to radiographs in the diagnosis of sacral fractures [29].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Imaging plays a crucial role in the detection and classification of traumatic spinal injuries in children. Failure to identify patients with an unstable spine injury and potential spinal cord compromise can lead to increased patient morbidity [7]. Conversely, the ability to identify patients without spinal injury can avoid unnecessary imaging and aids in the decision to discontinue spinal precaution protocols, which can result in skin breakdown and ulceration when used over prolonged periods of time [7].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Discussion of Procedures by Variant Variant 1: Child, 3 to 16 years of age, acute cervical spine trauma, meets low risk criteria (based on PECARN or NEXUS). Initial imaging. Radiography Cervical Spine The routine radiograph of the cervical spine in children with head trauma has a very low yield; in fact, the two cases of cervical injury in a cohort of 905 infants (0.02%) were due to an abusive trauma mechanism [4] (based on PECARN or NEXUS in Appendix 1).


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Cervical Spine In adult populations, CT is the superior screening modality for patients who are at very high risk for cervical spine injury. In children, there is no evidence in favor of replacing screening radiographs with CT in children at low risk for cervical spine injury [30].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Normal variants in young children <8 years of age, such as pseudosubluxation of C2-C3, absence of lordosis, C3 vertebral wedged appearance, widening of the atlantodental interval, prevertebral soft-tissue thickening,


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Young children and those with developmental delays may require sedation in order to obtain adequate CT and MR images. The risks of sedation should be balanced against the benefit of a CT, particularly when radiographs are normal [19].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI Cervical Spine MRI is not routinely used in the evaluation of suspected pediatric spine trauma in the absence of risk factors (based on PECARN or NEXUS in Appendix 1).


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Arteriography Cervicocerebral Cervicocerebral arteriography is not routinely used in the evaluation of suspected pediatric spine trauma in the absence of risk factors (based on PECARN or NEXUS in Appendix 1).


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. US Cervical Spine Ultrasound (US) is not routinely used in the evaluation of suspected pediatric spine trauma in the absence of risk factors (based on PECARN or NEXUS in Appendix 1).


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Myelography Cervical Spine Myelography is not routinely used in the evaluation of suspected pediatric spine trauma in the absence of risk factors (based on PECARN or NEXUS in Appendix 1).


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. For suspected ligamentous injury in conscious children, it was shown that cervical flexion and extension views in children and adults with acute blunt cervical trauma are unlikely to yield additional results [36,38-41] and are rarely needed in children [42]. Neck pain and muscle spasm may limit spinal motion of flexion and extension views in the acute setting and prevent the diagnosis of ligamentous injury from being made [34].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Cervical Spine CT cervical spine may be of value as a follow-up examination in patients who had radiographs with abnormal or ambiguous findings.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. The strengths of CT without intravenous (IV) contrast include its superior visualization of bony detail and ability to differentiate congenital variants from traumatic injuries. Dealing with an uncooperative child may lengthen the


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Normal variants in children <8 years of age, such as pseudosubluxation of C2-C3, absence of lordosis, C3 vertebral wedged appearance, widening of the atlantodental interval, prevertebral soft-tissue thickening, intervertebral widening, and pseudo-Jefferson fracture, can adversely affect the accuracy of CT imaging interpretations [19]. In addition, children <8 years of age may need to be sedated to obtain adequate cross- sectional imaging studies, which carries a low complication risk [19].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Cervical ligamentous injury may remain undetected on CT imaging [19], and CT is not considered an effective modality for evaluation of this type of injury [49]. CT alone performs similarly in the classification of subaxial cervical spine injury as CT and MRI combined [50]. Fat-saturated T2-weighted MRI has been shown to be superior to CT and radiographs in children with craniocervical junction and soft-tissue injury [51]. In cases where MRI is not available or the patient cannot safely undergo MRI, CT performs similarly to MRI in the evaluation of unstable cervical trauma [52].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. The spine in children >8 years of age is considered to be similar to the adult spine in that the cervical spine fulcrum is located at the C3-C4 level [12]. In this age group, the lower cervical spine is more commonly injured with trauma and may be difficult to confidently evaluate on radiographs [17].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. In a study of unconscious intubated adult patients, lateral radiographs were shown to have a sensitivity of only 51.7% for unstable injuries, while CT showed sensitivity of 98.1%, specificity of 98.8%, and a negative predictive value of 99.7% [30,43].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. There is no pediatric scientific literature to support the use of contrast-enhanced CT in the setting of spinal trauma, although IV contrast may be given when whole-body CT is performed to evaluate for other traumatic injuries [53-55].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI Cervical Spine MRI of cervical spine may be of value as a follow-up examination in patients who have an abnormal neurological examination.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI without IV contrast is considered the reference standard for evaluation of soft tissues [48,56], although one study showed that MRI detected osseous injury in children with a sensitivity of 100% and a specificity of 97% [48]. MRI was shown to be superior to CT and radiographs in children with craniocervical junction injuries to ligaments and the spinal cord, including soft-tissue injuries that are best seen on fat-saturated T2 sequences [51]. It was shown in adults that while MRI has high sensitivity for soft-tissue injury, its lack of specificity makes it less suitable for operative decision making [45].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI is the modality of choice in children who fulfill criteria for myelopathy or SCIWORA [51,57-59]. It has been shown in children and adults that MRI following a completed cervical CT did not add any clinically significant information [7,60-64]. Some reports stated that adult cervical injuries were detected with MRI and not with CT and that these changed management [65,66]. A study of 45 patients showed that children with normal radiography and CT may have signs of traumatic cervical injury on MRI [51]. However, a recent meta-analysis showed that the pooled incidence of unstable injuries detected by MRI but missed on CT was 0.0029% [67].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI can identify vascular intramural hematomas and early ischemic spinal cord injuries and thus identify patients who may benefit from additional vascular imaging and management of ischemic complications [68]. Disadvantages include lengthy examination times in an environment where patient monitoring can be difficult. The requirement for a motion-free examination and the need for optimal positioning in children may lengthen examination times or require sedation.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. There are no pediatric studies comparing IV contrast versus noncontrast MRI for the detection of spinal cord injury, but adult studies have shown that contrast-enhanced MRI may be more effective in the evaluation of severe soft-tissue injury but is not more effective for the detection of spinal cord injury [77].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CTA Neck There are currently no sufficient reports regarding outcomes of vascular imaging in children with spinal trauma. Cervical vascular injury in pediatric blunt trauma can be seen in 11.5% of pediatric patients [68]. CT angiography (CTA) has been validated against digital subtraction angiography (DSA) for imaging of cerebrovascular injury in adults, but DSA remains the reference standard [68]. When compared to DSA, CTA has the benefit of being less time intensive, having a lower risk of iatrogenic injury, and having fewer complications than those associated with DSA (such as stroke or death, arterial dissection, and vasospasm) [68,78]. CTA can also be easily performed in conjunction with other CT examinations, and the noninvasive nature of CTA makes it better suited as a screening tool in cervical trauma patients [68,78-80]. Both CTA and MR angiography (MRA) may be considered in children with cervical trauma [68]. Certain risk factors can indicate the need for vascular screening, such as fractures involving the transverse foramen, traumatic facet dislocations (with or without fracture), ligamentous injury, neurological deficits, and fractures of C1-C3 [68,80-82]. Injury patterns at C2 that are specifically associated with vertebral artery injury in adults are dens fractures and traumatic spondylolisthesis [83]. Cerebrovascular injury after blunt trauma was diagnosed with CTA in 5.8% of 137 children with blunt trauma [84]. Scoring systems to identify adult patients that should undergo vascular imaging exist, but they have not been validated in children [85].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRA Neck In adults, the role of MRA relative to DSA is less well established [68]. Studies comparing CTA, MRA, and DSA have found that CTA has comparable accuracy compared to DSA, while MRA tended to overestimate stenosis and occlusion [68]. Lower-grade vascular injuries may be missed with CTA but not with DSA, even though they are usually asymptomatic [80]. A benefit of MRA over CTA and DSA is its ability to identify intramural hematomas and early ischemic injuries [68]. To date, despite the benefits of MRI as a noninvasive examination, the Eastern Association for the Surgery of Trauma states that MRA should not be considered as the sole imaging modality for blunt cerebrovascular injury based on lower sensitivity of MRA relative to DSA in detecting traumatic vascular injuries in adults [86].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Arteriography Cervicocerebral DSA remains the reference standard for cerebrovascular injury in adults [68]. There is no recent scientific literature evaluating the use of DSA in children with spinal trauma. DSA is more time consuming and associated with severe risks, including thrombosis, that could lead to stroke or death, arterial dissection, and vasospasm [68,78].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. US Cervical Spine The value of US has only recently been explored in pediatric cervical spine trauma and is not yet established [87]. Integrity of the posterior ligamentous complex plays an integral role for stability of the spine, and presence of posterior ligamentous complex injury may indicate more severe damage and change treatment interventions [88]. MRI is the modality of choice for evaluation of the posterior ligamentous complex, but it was shown that its sensitivity and specificity are lower than previously thought [89].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Myelography Cervical Spine CT myelography is rarely performed and has been largely replaced with MRI. Exceptional indications may exist for patients with contraindications to MRI and in whom impending cord compression is suspected [90].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Variant 3: Child, younger than 3 years of age, acute cervical spine trauma, Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. Initial imaging. Radiography Cervical Spine In children <3 years of age and in children with delays or other deficits, lack of verbal and cognitive skills represents the main limiting factor for establishing appropriate imaging indications based on the clinical examination. Anatomically, in children <3 years of age the dentocentral synchondrosis is still open and the C3-C7 neural arches have not yet fused [91]. A review of the National Trauma Data Bank showed that 48% of cervical


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. spine injuries in children <3 years of age occurred in the lower cervical spine [54]. Nonetheless, children <3 years of age on average and children in forward-facing car seats can experience odontoid fractures, particularly with rapid deceleration with flexion [91]. Radiographs in conjunction with NEXUS criteria were used to clear 80% of cervical spine injuries in a cohort of 575 patients <3 years of age [42]. Certain clinical criteria have been proposed specifically in children <3 years of age to determine the necessity of imaging [19].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. A study comparing cervical spine clearance in unconscious pediatric patients using plain cervical radiographs, flexion-extension under fluoroscopy, CT, and MRI imaging found that flexion-extension fluoroscopy in children with negative cervical radiographs and/or CT imaging is superior to MRI because MRI lacks specificity with regards to differentiating ligamentous edema from rupture [44,45].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Cervical Spine CT cervical spine may be of value as a follow-up examination in patients who had radiographs with abnormal or ambiguous findings.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Normal variants in children <3 years of age, such as pseudosubluxation of C2-C3, absence of lordosis, C3 vertebral wedged appearance, widening of the atlantodental interval, prevertebral soft-tissue thickening, intervertebral widening, and pseudo-Jefferson fracture, can adversely affect the accuracy of CT imaging interpretations [19]. In addition, children <3 years of age may need to be sedated to obtain adequate cross- sectional imaging studies, which carries a low complication risk [19].


Suspected Spine Trauma Child PCAs


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. The best imaging modality for evaluation of newborn spinal cord injury secondary to cervical spine trauma is MRI [92]. Neonatal spinal cord injury is a rare condition with an estimated incidence of 1 in 80,000 live births.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI was shown to be superior to CT and radiographs in children with craniocervical junction injuries, including soft-tissue injuries that are best seen on fat-saturated T2 sequences [51].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CTA Neck There are currently no sufficient reports regarding outcomes of vascular imaging in children with spinal trauma. Cervical vascular injury in pediatric blunt trauma can be seen in 11.5% of pediatric patients [68]. CTA has been validated against DSA for imaging of cerebrovascular injury in adults, but DSA remains the reference standard [68]. When compared to DSA, CTA has the benefit of being less time intensive, having a lower risk of iatrogenic injury, and having fewer complications than those associated with DSA (such as stroke or death, arterial dissection, and vasospasm) [68,78]. CTA can also be easily performed in conjunction with other CT examinations, and the noninvasive nature of CTA makes it better suited as a screening tool in cervical trauma patients [68,78-80]. Both CTA and MRA may be considered in children with cervical trauma [68]. Certain risk factors can indicate the need for vascular screening, such as fractures involving the transverse foramen, traumatic facet dislocations (with or without fracture), ligamentous injury, neurological deficits, and fractures of C1-C3 [68,80-82]. Injury patterns at C2 that are specifically associated with vertebral artery injury in adults are dens fractures and traumatic spondylolisthesis [83]. Cerebrovascular injury after blunt trauma was diagnosed with CTA in 5.8% of 137 children with blunt trauma [84]. Scoring systems to identify adult patients that should undergo vascular imaging exist, but they have not been validated in children [85].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRA Neck In adults, the role of MRA relative to DSA is less well established [68]. Studies comparing CTA, MRA, and DSA have found that CTA has comparable accuracy compared to DSA, while MRA tended to overestimate stenosis and occlusion [68]. Lower-grade vascular injuries may be missed with CTA but not with DSA, even though they are usually asymptomatic [80]. A benefit of MRA over CTA and DSA is its ability to identify intramural hematomas and early ischemic injuries [68]. To date, despite the benefits of MRI as a noninvasive examination, the Eastern Association for the Surgery of Trauma states that MRA should not be considered as the sole imaging


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Arteriography Cervicocerebral DSA remains the reference standard for cerebrovascular injury in adults [68]. There is no recent scientific literature evaluating the use of DSA in children with spinal trauma. DSA is more time consuming and associated with severe risks that include thrombosis that could lead to stroke or death, arterial dissection, and vasospasm [68,78].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Variant 4: Child, younger than 16 years of age, acute thoracolumbar spine trauma. Initial imaging. Radiography Thoracic and Lumbar Spine It was estimated that only 0.6% to 0.9% of all pediatric spinal injuries affect the thoracolumbar supine [93]. There are currently no national guidelines to inform clinicians whether an imaging examination would be beneficial for an individual patient or not [93]. Thoracic and lumbar spine injuries are most commonly seen in children >9 years of age [3].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. The clinical diagnosis of thoracolumbar spine fractures in children is frequently difficult because the clinical assessment has only 81% sensitivity and 68% specificity [24]. This argues in favor of screening children with thoracolumbar trauma with radiographs, regardless of clinical symptoms. However, a prospective study in 50 children with thoracolumbar trauma showed that AP and lateral radiographs missed 22% of fractures when compared to MRI [24]. As shown in adults, it may be useful to screen for thoracolumbar fractures by using reconstructed spine images from chest, abdomen, and pelvis MDCT when available [94-96].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Sacral fractures account for only 0.16% of all pediatric trauma patients [3]. In a retrospective study of 89 patients, only 5% sacral fractures were found, all of which were Denis zone 1 fractures [3], which are located lateral to the neural elements and commonly involve the sacral alae [29]. Another study reported that adequate radiographs miss 35% of sacral fractures and, therefore, CT and MRI are superior to radiography in the diagnosis of sacral fractures [29].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Thoracic and Lumbar Spine CT spine may be of value as a follow-up examination in patients who had radiographs with abnormal or ambiguous findings.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. There are not sufficient data to support the routine use of MDCT without IV contrast in the clearance of pediatric blunt spinal trauma. As shown in adults, it may be useful to screen for thoracolumbar fractures by using reconstructed spine images from chest, abdomen, and pelvis MDCT, when available [94-96]. Adequate radiographs miss 35% of sacral fractures; therefore, CT and MRI are superior to radiography in the diagnosis of sacral fractures [29]. A recent study in adults showed that CT can identify posterior ligament complex injuries with satisfactory reliability, which can be useful for the classification of thoracolumbar fractures [97].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI Thoracic and Lumbar Spine MRI of the spine may be of value as a follow-up examination in patients who have an abnormal neurological examination.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRI without IV contrast has become the modality of choice for imaging of children with thoracolumbar trauma and is especially useful in detecting injuries that require surgical intervention and that may be missed on CT, such as epidural hematoma or traumatic disk herniation [93]. SCIWORA is more common in children <8 years of age and mostly affects the cervical spine, but thoracic spine involvement is seen in 13% of cases [93]. It has been reported that SCIWORA was found in up to 38% of pediatric patients with myelopathy and no fracture or


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. ligamentous injury on radiographs or CT [91]. In adults with SCIWORA, MRI screening did not yield positive findings in a substantial number of patients [98], but examinations in children were able to diagnose cord transection, contusion, and concussion in children <8 years of age with significant prognostic correlations [59]. In addition, children may have cartilaginous injuries that are not visualized on radiographs but are better detected with MRI [24]. It was shown that MRI facilitates the ability to classify thoracolumbar fractures in adults and children to aid in clinical decision making [27,28]. Adequate radiographs miss 35% of sacral fractures; therefore, CT and MRI are superior to radiography in the diagnosis of sacral fractures [29].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CTA Thoracic and Lumbar Spine CTA is not routinely used in the evaluation of children with thoracolumbar trauma.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. MRA Thoracic and Lumbar Spine MRA is not routinely used in the evaluation of children with thoracolumbar trauma.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Arteriography Thoracic and Lumbar Spine Arteriography is not routinely used in the evaluation of children with thoracolumbar trauma.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. US Thoracic and Lumbar Spine Integrity of the posterior ligamentous complex plays an integral role for stability of the spine, and presence of posterior ligamentous complex injury may indicate more severe damage and change treatment interventions [88]. MRI is the modality of choice for evaluation of the posterior ligamentous complex, but it was shown that its sensitivity and specificity are lower than previously thought [89]. In a prospective study of 18 adult patients with acute thoracolumbar burst fractures, US was used to assess the posterior ligament complex and achieved a sensitivity of 99% and a specificity of 75% (P < .05) when compared to operative results and preoperative radiographs, CT, and MRI [99].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. CT Myelography Thoracic and Lumbar Spine CT myelography is rarely performed and has been largely replaced with MRI. Exceptional indications may exist for patients with contraindications to MRI and in whom impending cord compression is suspected [90].


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. Summary of Recommendations Variant 1: Imaging is not recommended for the initial imaging of children 3 to 16 years of age with acute cervical spine trauma that meets low risk criteria (based on PECARN or NEXUS). Variant 2: Radiographs of the cervical spine are usually appropriate for the initial imaging of children 3 to 16 years of age with acute cervical spine trauma with at least one risk factor with reliable clinical examination (based on PECARN or NEXUS). The panel did not agree on recommending CT cervical spine without IV contrast or MRI cervical spine without IV contrast in children 3 to 16 years of age with this clinical condition. There is insufficient medical literature to conclude whether or not these patients would benefit from these procedures. CT cervical spine without IV contrast or MRI cervical spine without IV contrast as the initial imaging of children 3 to 16 years of age with acute cervical spine trauma and at least one risk factor with reliable clinical examination (based on PECARN or NEXUS) is controversial but may be appropriate. Variant 3: Radiographs of the cervical spine are usually appropriate for the initial imaging of children younger than 3 years of age with acute cervical spine trauma with a Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points. The panel did not agree on recommending MRI cervical spine without IV contrast in children younger than 3 years of age with this clinical condition. There is insufficient medical literature to conclude whether or not these patients would benefit from these procedures. MRI cervical spine without IV contrast as the initial imaging of children younger than 3 years of age with acute cervical spine trauma with a Pieretti-Vanmarcke weighted score greater than or equal to 2 to 8 points is controversial but may be appropriate. Variant 4: Radiographs of the thoracic and lumbar spine are usually appropriate for the initial imaging of children younger than 16 years of age with suspected thoracolumbar spine trauma. The panel did not agree on recommending CT thoracic and lumbar spine without IV contrast or MRI thoracic and lumbar spine without IV contrast in children younger than 16 years of age with this clinical condition. There is insufficient medical literature to conclude whether or not these patients would benefit from these procedures. CT thoracic and lumbar spine without IV contrast or MRI thoracic and lumbar spine without IV contrast as the initial imaging of children younger than 16 years of age with suspected thoracolumbar spine trauma is controversial but may be appropriate.


Suspected Spine Trauma Child PCAs

Suspected Spine Trauma Child PCAs. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Suspected New Onset and Known Nonacute Heart Failure. Introduction/Background Heart failure (HF) is a highly prevalent and complex clinical syndrome resulting from any structural or functional impairment of ventricular filling or ejection of blood [1]. HF may result from disorders of the pericardium, myocardium, valves, or great vessels as well as from certain systemic metabolic abnormalities [1].


Suspected New Onset and Known Nonacute Heart Failure. While survival after the initial manifestation of HF has improved because of greater evidence-based treatment of risk factors and complications [6,7], the death rate remains high, with approximately 50% of HF cases dying within 5 years of initial diagnosis [7,8]. One in 9 deaths had HF mentioned on the death certificate, and HF was the underlying cause in over 60,000 deaths in 2013 [9].


Suspected New Onset and Known Nonacute Heart Failure. There is significant financial impact associated with HF, which is likely to increase in coming decades. In 2012, the total expense related to HF nationally was estimated to be $30.7 billion, with 68% attributable to direct medical costs [4]. By 2030, the total annual expense of HF is projected to increase by almost 127% to $69.7 billion [4].


Suspected New Onset and Known Nonacute Heart Failure. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Suspected New Onset and Known Nonacute Heart Failure. Reprint requests to: publications@acr.org


Suspected New Onset and Known Nonacute Heart Failure. Suspected New-Onset and Known Nonacute Heart Failure HFrEF is typically found in the setting of a form of dilated cardiomyopathy, representing a large group of heterogeneous myocardial disorders characterized by ventricular dilation and depressed myocardial contractility in the absence of abnormal loading conditions (eg, hypertension or valvular disease) [1]. In clinical practice and multicenter HF trials, the etiology of HF has often been categorized into either ischemic cardiomyopathy or nonischemic cardiomyopathy [1,14]. Thus, once a case of HFrEF has been identified, the basic distinction between an ischemic etiology and a nonischemic etiology with the support from imaging (see Variant 3) facilitates further diagnostic assessment and therapeutic planning, with guidance in further imaging provided by other reports on appropriate use of imaging [15].


Suspected New Onset and Known Nonacute Heart Failure. Overview of Imaging Modalities Radiography Chest Information provided by chest radiography about: (1) noncardiovascular (eg, lung parenchymal disease) and cardiovascular (eg, cardiomegaly) anatomy of the chest [16]; (2) pulmonary vascular and edema patterns (eg, stages of pulmonary venous hypertension) [17]; and (3) vascular (eg, chronic coronary atherosclerosis) [18] and nonvascular (eg, calcified pericardial thickening) [19] calcification has potential applications to evaluation of the aforementioned HF variants. The appropriateness of the chest radiograph in the setting of suspicion of acute or potentially unstable chronic cardiopulmonary disease by history or physical examination has been previously established [20].


Suspected New Onset and Known Nonacute Heart Failure. US Echocardiography Transthoracic Stress or Resting Echocardiography relies on ultrasonic waves to produce dynamic, usually tomographic versus volumetric images emphasizing a wide range of functional measures of cardiac chamber function and intravascular and intracavity flow in normal and various disease states, including HF, from which important hemodynamic measurements can be made in most patients noninvasively by transthoracic echocardiography (TTE) [21,22]. Despite its relatively weaker anatomic and histologic evaluation capabilities compared to some other cardiac imaging modalities, its risk-free nature, unless performed more invasively as transesophageal echocardiography (TEE), facilitates its use in the assessment of HF.


Suspected New Onset and Known Nonacute Heart Failure. SPECT or SPECT/CT MPI Rest and Stress Utilizing intravenously administered tracers, Single-photon emission computed tomography (SPECT) or SPECT/CT (ie, SPECT with CT attenuation correction) can provide insights into cardiac pathophysiology, including abnormalities of ventricular function (global and regional) and myocardial perfusion imaging (MPI) [23-25].


Suspected New Onset and Known Nonacute Heart Failure. FDG-PET/CT Heart and Rb-82 PET/CT Heart Utilizing rubidium-82 (Rb-82), PET/CT is capable of reflecting myocardial physiology, including perfusion, wall motion, and cardiac flow reserve; this can be valuable in assessing HF [23-25]. Evaluation of myocardial viability can be performed utilizing fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG) as the PET agent [23-25].


Suspected New Onset and Known Nonacute Heart Failure. MRI Heart Cardiac MRI remains heavily reliant on electrocardiographic referencing of imaging data acquisition to the cardiac cycle and uses a magnetic field and radio waves to create detailed tomographic or volumetric images of high contrast. Depending upon the imaging acquisition employed and whether or not a gadolinium-based contrast agent was used and how and when administered relative to data acquisition, images demonstrating a range of abnormalities of (1) anatomy (eg, reduced thickness of ventricular wall, enlargement of atrial cavity, or increased thickness of pericardial sac); (2) histology (eg, myocardial edema, infiltration, deposition, or fibrosis); or (3) physiology (eg, depressed LVEF, restrictive transatrioventricular diastolic inflow, or reduced resting versus stress-induced myocardial strain or first-pass perfusion) [26-28]. These capabilities are potentially beneficial in assessing HF. Potential complications must be considered on a patient-by-patient basis before its use.


Suspected New Onset and Known Nonacute Heart Failure. CTA Coronary Arteries Referencing of image acquisition to the electrocardiographic recording facilitates high temporal and spatial resolution images of cardiovascular tissues that, when combined with intravenously administered iodinated contrast agents, permits primarily for the evaluation of coronary artery disease (CAD) as an etiology for newly diagnosed HF (coronary CT angiography [CTA]). Additionally, these advances can also be used for imaging during dynamic bolus contrast enhancement for the assessment of first-pass tissue perfusion (eg, myocardium) at rest or during pharmacologically induced stress, or the volumetric visualization of intraluminal/intracavity anatomy (eg, coronary artery, LV chamber) or arterial wall changes in static images (ie, CTA; or, without the use


Suspected New Onset and Known Nonacute Heart Failure. Suspected New-Onset and Known Nonacute Heart Failure


Suspected New Onset and Known Nonacute Heart Failure. of intravenous contrast for coronary calcification, calcium scoring for risk stratification). Delayed imaging helps further the detection of fibrous or fatty tissue replacement in cardiac structures (eg, LV wall) [26,29,30]. Despite marked improvements, prevailing concerns about potential complications are still limitations to the use of this modality.


Suspected New Onset and Known Nonacute Heart Failure. Arteriography Coronary Although a traditional gold standard for diagnosing disease of the coronary arteries or ventricles, conventional catheter-based selective coronary angiography is increasingly focused (eg, 38%) on patient-centric atherosclerotic CAD treatment planning or postrevascularization assessment [31]. It is supported by several complementary technologies allowing further characterization of plaque significance (eg, intravascular ultrasonography [US], fractional flow reserve) [32,33]. While concurrent LV ventriculography is dissuaded for LVEF determinations [34], direct hemodynamic measurements reflecting cardiac function maintain a distinct role in assessing a range of cardiovascular conditions in complicated clinical cases.


Suspected New Onset and Known Nonacute Heart Failure. Stress Examinations The objective of stress testing is typically to evaluate the extent and adequacy of the hyperemic response, thereby assessing the ability of the coronary circulation to augment flow to meet increasing work demand (ie, coronary flow reserve) [35]. When used in combination with imaging, depending on the degree and duration of induced ischemia, stress testing elicits and evaluates the ischemic endpoints that relate to coronary supply or demand imbalance characteristic of CAD. This ischemic cascade includes sequential abnormalities in the following order: perfusion, myocardial stiffening, wall motion abnormalities, electrocardiographic stress test segment changes, and chest pain.


Suspected New Onset and Known Nonacute Heart Failure. When appropriate, exercise-based stress testing is preferred to pharmacologically induced stress testing; unfortunately, it is impractical in many imaging environments, moreover for patients unable to adequately exercise [35]. Thus, the pharmacologic stress perfusion endpoint (achieved with a coronary artery dilating agent, such as adenosine or regadenoson) of induced coronary flow heterogeneity is used with the various forms of MPI; the functional ischemic endpoint (achieved with a myocardial inotropic agent, such as dobutamine) of induced wall motion abnormalities is detected and monitored during dynamic myocardial contraction imaging.


Suspected New Onset and Known Nonacute Heart Failure. Discussion of Procedures by Variant Prompt evidence-based diagnosis and treatment of new-onset nonacute HF may help decrease hospital stay, costs related to treatment, and mortality. Unfortunately, the accurate diagnosis of HF in the primary care setting is difficult and partly related to frequent suboptimal access to, and use of, cardiac imaging [36].


Suspected New Onset and Known Nonacute Heart Failure. Variant 1: Suspected new-onset nonacute heart failure, not previously diagnosed. Initial imaging. Radiography Chest Historically, chest radiograph has been commonly used in the assessment of patients with suspected new-onset HF in the outpatient setting. Regardless of the acuity of new-onset HF, it is prudent to consider the impact of the training, experience, and focus of the chest radiography interpreter. For patients presenting to the emergency department (ED) with supportive clinical and laboratory evidence of HF, the accuracy in identifying HF on chest radiograph can vary from 78% for first-year emergency medicine residents, 85% for emergency medicine attendees, and 95% for radiologists [37].


Suspected New Onset and Known Nonacute Heart Failure. A radiological score based on the sum of selected signs of congestion on chest radiograph correlates well with both findings on physical examination and lung impedance measurements during periods of sudden onset of HF [38]. Accordingly, in patients presenting to an ED with signs and symptoms of HF, those with sudden onset more likely demonstrate evidence of congestion on chest radiograph than those without sudden onset [39].


Suspected New Onset and Known Nonacute Heart Failure. However, in ambulatory patients being evaluated in the community for suspected new-onset HF with standardized diagnostic evaluation, including chest radiography and TTE, a combination of 3 items from history plus 6 from physical examination have independent diagnostic value (c-statistic 0.83), increasing when supplemented by N- terminal pro-B-type natriuretic peptide (NT-proBNP) (c-statistic 0.86); chest radiography does not make a significant diagnostic contribution [40].


Suspected New Onset and Known Nonacute Heart Failure. US Echocardiography Transthoracic Resting and Stress Evaluation of cardiac structure and function for newly suspected or potential HF, with rest-only echocardiography for the assessment of cardiac structure and function can be made accurately to guide therapy. Multicenter studies Suspected New-Onset and Known Nonacute Heart Failure


Suspected New Onset and Known Nonacute Heart Failure. Independent of and incremental to basic parameters (eg, LV mass, left atrial [LA] size, and mitral regurgitation) provided by TTE, the following insights can be gained from more advanced echocardiographic techniques in the setting of suddenly decompensated ventricular function: (1) need for HF hospitalization based on LV global longitudinal strain derived using speckle-tracking technology [51]; (2) risk of all-cause 1-year mortality based on Doppler-determined transmitral to mitral annular early diastolic velocity ratio reflecting LV filling pressure [52]; and (3) risk for in-hospital mortality, rehospitalization, and cardiovascular mortality by early mitral inflow velocity to early diastolic mitral annular velocity reflecting LV filling pressure estimated with Doppler [53]. Cardiac filling pressures can be estimated from physical examination with modest accuracy, and exposure to echocardiographic data may not significantly enhance accuracy beyond bedside examination alone, both for left- heart and right-heart pressures [54].


Suspected New Onset and Known Nonacute Heart Failure. However, in ambulatory patients being evaluated in the community for suspected of nonacute new-onset HF using standardized diagnostic evaluation, TTE was shown to not make a significant diagnostic contribution [40].


Suspected New Onset and Known Nonacute Heart Failure. Nuclear Medicine Ventriculography Radionuclide ventriculography (RNV) is an additional alternative that may be applied to the evaluation of cardiac function [41]. One of its benefits is its significant reproducibility, which has been used to track the efficacy of a variety of therapeutic interventions for patients with HF [41,55-57].


Suspected New Onset and Known Nonacute Heart Failure. SPECT or SPECT/CT MPI Rest and Stress There is no evidence to support the use of rest and stress SPECT/CT MPI as an initial imaging modality for suspected new-onset nonacute HF.


Suspected New Onset and Known Nonacute Heart Failure. FDG-PET/CT Heart and Rb-82 PET/CT Heart There are only minimal data on the use of PET/CT for evaluation of newly suspected or potential HF [23-25].