Cardiac Groups Outline Appropriate Imaging For Chest Pain in ER

Frank J. Rybicki, MD, PhD Professor, Chair and Chief, Department of Radiology The University of Ottawa, Faculty of Medicine and The Ottawa Hospital Editor-in-Chief, 3D Printing in Medicine

Dr. Frank Rybicki Interview with:
Frank J. Rybicki, MD, PhD
Professor, Chair and Chief, Department of Radiology
The University of Ottawa, Faculty of Medicine and
The Ottawa Hospital
Editor-in-Chief, 3D Printing in Medicine

Medical Research: What is the background for this document?

Dr. Rybicki: This document represents a conglomeration of the approach to appropriateness of three large medical professional groups. The American College of Radiology Appropriateness Criteria® are evidence based guidelines to assist referring physicians to order the most appropriate imaging test for a wide range of clinical scenarios. The Appropriateness Criteria are divided by organ section, and while they include emergent imaging studies, there is not a single publication to provide imaging guidance for patients who present to the emergency room with chest pain. The American College of Cardiology Appropriate Use Criteria provides evidence based data for a very large gamut of cardiovascular conditions. These guidelines include emergent cardiovascular imaging; however the Appropriate Use Criteria are divided by modality and like the ACR have not specially addressed this important, high risk patient population. The American College of Emergency Physicians, a key stakeholder group that represents referring physicians, has developed a large number of guidelines but also has not organized this group of imaging recommendations. Thus, the background of this document was a joint effort among all three societies to update, harmonize, and publish contemporary guidelines that can be readily incorporated into clinical practice but also provide standards for a large fraction of patients who come to the emergency room with chest pain who require imaging to evaluate for a life threatening diagnosis.

Medical Research: What types of chest pain conditions are covered by these guidelines?

Dr. Rybicki: Based on the background as noted above, the Writing Group for this important document included cardiologists, emergency physicians, and radiologists. Since the group was charged with describing common clinical scenarios seen in contemporary practice, there are four entry points for chest pain conditions. They are as follows:

  1. Suspected Non-ST Segment Elevation Acute Coronary Syndrome
  2. Suspected Pulmonary Embolism
  3. Suspected Acute Syndrome of the Aorta
  4. Patients for Whom a Leading Diagnosis is Problematic or not Possible 

Medical Research: How is Appropriateness for Chest Pain Imaging determined? What is the ranking scale?

Dr. Rybicki: The writing group adopted the AQA principles of Appropriateness. The document then followed the RAND UCLA Appropriateness Method. The writing panel reviewed and analyzed the evidence and summarized this analysis in a draft document. The document organized the evidence into clinical scenarios that are important to health care providers and may consider imaging procedures. The document was reviewed by experts from key medical specialty societies and revised by the writing panel. The rating panel rated the risks and benefits (appropriateness) of performing the imaging procedures for each clinical scenario. This group met to vet discrepancies and clarify the rating process.

The ranking scale includes Appropriate, May Be Appropriate, and Rarely Appropriate. Moreover, the assignment of one of these three categories is determined by the group median rating. When individual ratings vary too widely from the group median rating, the exam was assigned the category of May Be Appropriate*, with the asterisk to denote the variation.

Medical Research: What should clinicians and patients take away from your report?

Dr. Rybicki: Clinicians and patients should recognize that the publication represents the most comprehensive, rigorous, and objective approach to evaluate the appropriateness of imaging for patients who present to the emergency room with chest pain. All of the recommendations are evidence based and all peer-review evidence was used and most heavily weighted in the guideline development. The four entry points are divided into 20 clinical scenarios. There scenarios were identified for their high clinical relevance. However, rigorous data are lacking for some scenarios; this results in the integration of clinical expertise with peer-reviewed data. In areas where data are more scarce, ratings can be supplemented with expertise. Appropriate practice recommendations are often criticized because of the input of clinical expertise. My clinical practice included working as an emergency radiologist and then as a dedicated cardiothoracic imager. Based on interacting with patients with active chest pain and those who care for them for the last 13 years, I have observed that what is most highly desired is not only data from a peer-review publication if available, but also thoughtful input of the data currently available as evaluated by experts in the field. For this reason I find it hard to argue with the current guidelines, or other like them; they provide exactly this information for practicing experts to guide the best possible clinical decisions.

Medical Research: What recommendations do you have for future research as a result of this study? 

Dr. Rybicki: In a similar context to my statements above, it must be noted that there is a large, unmet need for more data to assess this important cohort of patients. For all clinical scenarios, better and more comprehensive data will provide better guidelines. For example, publications like the current document can lead research focused on areas where consensus was not reached. 

Medical Research: Is there anything else you would like to add?

Dr. Rybicki: Another important factor supporting the use of appropriate imaging is the integration of these guidelines into clinical decision support tools. These tools such as ACR Select TM and its European counterpart ESR iGuide can be incorporated into computerized ordering and EHR systems to guide providers when ordering medical imaging scans. The “Chest Pain in the ED” guidelines are developed and formatted properly for incorporation into these standard formats that can be easily consumed by emergency medicine physicians and used for international educational efforts.


ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain

Published online: January 22, 2016

Frank J. Rybicki, James E. Udelson, W. Frank Peacock, Samuel Z. Goldhaber, Eric M. Isselbacher, Ella Kazerooni, Michael C. Kontos, Harold Litt, Pamela K. Woodard, Joseph S. Alpert, George A. Andrews, Edward P. Chen, David T. Cooke, Ricardo C. Cury, Daniel Edmundowicz, Victor Ferrari, Louis G. Graff, Judd E. Hollander, Lloyd W. Klein, Jonathan Leipsic, Phillip D. Levy, John J. Mahmarian, Craig Rosenberg, Geoffrey Rubin, R. Parker Ward, Charles White, E. Kent Yucel, J. Jeffrey Carr, Frank J. Rybicki, Richard D. White, Pamela K. Woodard, Manesh Patel, Pamela Douglas, Robert C. Hendel, Christopher Kramer, John Doherty

Journal of the American College of Radiology

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Frank J. Rybicki, MD, PhD (2016). Cardiac Groups Outline Appropriate Imaging For Chest Pain in ER