Background
Methods
Nr. | Title | Year | Role of CMR | I | IIa | IIb | III |
---|---|---|---|---|---|---|---|
1 | ▪ ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure [5] ▪ ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure [6] ▪ ACCF/AHA Guideline for the Management of Heart Failure [22] | 2017 2016 2013 | +++ | 0 | 2 | 2 | 0 |
2 | ▪ AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [7] ▪ AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [23] | 2017 2014 | +++ | 5 | 0 | 1 | 0 |
3 | ▪ ACC/AHA/HRS Guideline for Evaluation and Management of Patients With Syncope [24] | 2017 | +++ | 0 | 1 | 1 | 0 |
4 | ▪ AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease [4] | 2016 | +++ | 1 | 0 | 0 | 1 |
5 | ▪ ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia [25] | 2015 | + | ||||
6 | ▪ ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction [10] ▪ ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction [11] | 2015 2013 | + | ||||
7 | ▪ ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention [12] | 2011 | ++ | ||||
8 | ▪ ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery [15] ▪ ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery [16] | 2014 2007 | ++ | ||||
9 | ▪ ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease [8] ▪ ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease [17] | 2014 2012 | +++ | 1 | 4 | 0 | 3 |
10 | ▪ AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes [26] | 2014 | +++ | 1 | 0 | 0 | 0 |
11 | ▪ AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation [27] | 2014 | ++ | ||||
12 | ▪ AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults [28] | 2013 | + | ||||
13 | ▪ AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk [29] | 2013 | + | ||||
14 | ▪ ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults [30] | 2013 | + | ||||
15 | ▪ ACC/AHA Guideline on the Assessment of Cardiovascular Risk [31] | 2013 | + | ||||
16 | ▪ ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [9] ▪ ACC/AHA/HRS Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities [32] | 2012 2008 | ++ | ||||
17 | ▪ ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy [33] | 2011 | +++ | 2 | 1 | 3 | 0 |
18 | ▪ ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery [34] | 2011 | + | ||||
19 | ▪ AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 Update [13] ▪ AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update [14] | 2011 2006 | + | ||||
20 | ▪ ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery [20] | 2011 | +++ | 4 | 4 | 1 | 0 |
21 | ▪ ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease [21] | 2010 | +++ | 3 | 5 | 0 | 0 |
22 | ▪ ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults [18] | 2010 | +++ | 0 | 0 | 0 | 1 |
23 | ▪ ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease [19] | 2008 | +++ | 14 | 2 | 1 | 0 |
24 | ▪ ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death [35] | 2006 | +++ | 0 | 1 | 0 | 0 |
Class of recommendation | Definition | Suggested phrases for writing recommendations |
---|---|---|
Class I (strong) | Benefit >> > Risk | • is recommended • is indicated / useful / effective / beneficial • should be performed / administered / other • Comparative-Effectiveness phrases: − Treatment / strategy A is recommended / indicated in preference to treatment B − Treatment A should be chosen over treatment B |
Class IIa (Moderate) | Benefit > > Risk | • Is reasonable • Can be useful / effective / beneficial • Comparative-Effectiveness phrases − Treatment / strategy A is probably recommended / indicated in preference to treatment B − It is reasonable to choose treatment A over treatment B |
Class IIb (Weak) | Benefit ≥ Risk | • May / might be reasonable • May / might be considered • Usefulness / effectiveness is unknown / unclear / uncertain or not well established |
Class III: No benefit (Moderate) | Benefit = Risk | • Is not recommended • Is not indicated / useful / effective / beneficial • Should not be performed / administered / other |
Class III: Harm (Strong) | Risk > Benefit | • Potentially harmful • Causes harm • Associated with excess morbidity / mortality • Should not be performed / administered / other |
Level | Definition |
---|---|
Level A | • High quality evidence from more than 1 randomized controlled trial • Meta-analyses of high-quality randomized controlled trials • One or more randomized controlled trial corroborated by high-quality registry studies |
Level B-R (randomized) | • Moderate-quality evidence from 1 or more randomized controlled trial • Meta-analyses of moderate-quality randomized controlled trials |
Level B-NR (nonrandomized) | • Moderate-quality evidence from 1 or more well-designed well-executed nonrandomized studies, observational studies, or registry studies • Meta-analyses of such studies |
Level C-LD (limited data) | • Randomized or nonrandomized observational or registry studies with limitations of design or execution • Meta-analyses of such studies • Physiological or mechanistic studies in human subjects |
Level C-EO (expert opinion) | • Consensus of expert opinion based on clinical experience |
Results
-
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure [5]
-
2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure [6]
-
2013 ACCF/AHA Guideline for the Management of Heart Failure - A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [22]
Class | Level | Guideline | |
---|---|---|---|
Suspected / stable coronary artery disease | |||
Noninvasive imaging to detect myocardial ischemia and viability is reasonable in heart failure and coronary artery disease | IIa | C | |
Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR. | I | C | |
Pharmacological stress with CMR can be useful for patients with an intermediate to high pretest probability of obstructive ischemic heart disease, who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity. | IIa | B | Stable CAD [8] |
Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of ischemic heart disease, who are incapable of at least moderate physical functioning or have disabling comorbidity. | IIa | B | Stable CAD [8] |
Echocardiography, radionuclide imaging, CMR, and cardiac CT are not recommended for routine assessment of LV function in patients with a normal ECG, no history of myocardial infarction, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. | III | C | Stable CAD [8] |
Routine reassessment (<1 year) of LV function with technologies such as echocardiography, radionuclide imaging, CMR, or cardiac CT is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated. | III | C | Stable CAD [8] |
CMR with pharmacological stress is reasonable for risk assessment in patients with stable ischemic heart disease who are able to exercise to an adequate workload but have an uninterpretable ECG. | IIa | B | Stable CAD [8] |
Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with stable ischemic heart disease who are able to exercise to an adequate workload and have an interpretable ECG. | III | C | Stable CAD [8] |
Pharmacological stress CMR is reasonable for risk assessment in patients with stable ischemic heart disease who are unable to exercise to an adequate workload regardless of interpretability of ECG. | IIa | B | Stable CAD [8] |
Acute coronary syndrome | |||
Imaging with ventriculography, echocardiography, or magnetic resonance imaging should be performed to confirm or exclude the diagnosis of stress (Takotsubo) cardiomyopathy. | I | B | NSTEMI [26] |
Before coronary revascularization | |||
Viability assessment is reasonable before revascularization in heart failure patients with coronary artery disease | IIa | B | |
Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with stable ischemic heart disease, who are being considered for revascularization of known coronary stenosis of unclear physiological significance. | I | B | Stable CAD [8] |
Heart failure | |||
Radionuclide ventriculography or MRI can be useful to assess LVEF and volume | IIa | C | |
MRI is reasonable when assessing myocardial infiltration or scar | IIa | B | |
Ventricular arrhythmia | |||
MRI, cardiac computed tomography (CT), or radionuclide angiography can be useful in patients with ventricular arrhythmias when echocardiography does not provide accurate assessment of LV and RV function and/or evaluation of structural changes. | IIa | B | Ventricular arrhythmias [35] |
Hypertrophic cardiomyopathy | |||
CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis. | I | B | HCM [33] |
CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography. | I | B | HCM [33] |
CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive. | IIa | B | HCM [33] |
In selected patients with known HCM, when SCD risk stratification is inconclusive after documentation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement (LGE) may be considered in resolving clinical decision making. | IIb | C | HCM [33] |
The usefulness of the following potential SCD risk modifiers is unclear but might be considered in selected patients with HCM for whom risk remains borderline after documentation of conventional risk factors: CMR imaging with LGE. | IIb | C | HCM [33] |
Athlete’s heart | |||
Extended monitoring (including MRI) can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation. | IIa | C-LD | Syncope [24] |
Storage disease | |||
CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy. | IIb | C | HCM [33] |
Vascular disease | |||
Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography. (Level of Evidence: C) | I | C | |
Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter greater than 4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter greater than 4.5 cm, this evaluation should be performed annually. | I | C | |
Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic peripheral artery disease in whom revascularization is considered | I | B-NR | Peripheral Artery Disease [4] |
Invasive and noninvasive angiography (ie, CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic peripheral artery disease. | III | B-R | Peripheral Artery Disease [4] |
In patients with acute, focal ischemic neurological symptoms corresponding to the territory supplied by the left or right internal carotid artery, magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is indicated to detect carotid stenosis when sonography either cannot be obtained or yields equivocal or otherwise nondiagnostic results. | I | C | Carotid and vertebral artery [20] |
When an extracranial source of ischemia is not identified in patients with transient retinal or hemispheric neurological symptoms of suspected ischemic origin, CTA, MRA, or selective cerebral angiography can be useful to search for intracranial vascular disease. | IIa | C | Carotid and vertebral artery [20] |
When the results of initial noninvasive imaging are inconclusive, additional examination by use of another imaging method is reasonable. In candidates for revascularization, MRA or CTA can be useful when results of carotid duplex ultrasonography are equivocal or indeterminate. | IIa | C | Carotid and vertebral artery [20] |
When intervention for significant carotid stenosis detected by carotid duplex ultrasonography is planned, MRA, CTA, or catheter-based contrast angiography can be useful to evaluate the severity of stenosis and to identify intrathoracic or intracranial vascular lesions that are not adequately assessed by duplex ultrasonography. | IIa | C | Carotid and vertebral artery [20] |
MRA without contrast is reasonable to assess the extent of disease in patients with symptomatic carotid atherosclerosis and renal insufficiency or extensive vascular calcification. | IIa | C | Carotid and vertebral artery [20] |
When complete carotid arterial occlusion is suggested by duplex ultrasonography, MRA, or CTA in patients with retinal or hemispheric neurological symptoms of suspected ischemic origin, catheter-based contrast angiography may be considered to determine whether the arterial lumen is sufficiently patent to permit carotid revascularization. | IIb | C | Carotid and vertebral artery [20] |
Noninvasive imaging by CTA or MRA for detection of vertebral artery disease should be part of the initial evaluation of patients with neurological symptoms referable to the posterior circulation and those with subclavian steal syndrome. | I | C | Carotid and vertebral artery [20] |
In patients whose symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended rather than ultrasound imaging for evaluation of the vertebral arteries. | I | C | Carotid and vertebral artery [20] |
Contrast-enhanced CTA, MRA, and catheter-based contrast angiography are useful for diagnosis of cervical artery dissection. | I | C | Carotid and vertebral artery [20] |
Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening. | I | B | Thoracic aorta [21] |
The initial evaluation of Takayasu arteritis or giant cell arteritis should include thoracic aorta and branch vessel computed tomographic imaging or magnetic resonance imaging to inves- tigate the possibility of aneurysm or occlusive disease in these vessels. | I | C | Thoracic aorta [21] |
For patients with isolated aortic arch aneurysms less than 4.0 cm in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 12- month intervals, to detect enlargement of the aneurysm. | IIa | C | Thoracic aorta [21] |
For patients with isolated aortic arch aneurysms 4.0 cm or greater in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 6-month intervals, to detect enlargement of the aneurysm. | IIa | C | Thoracic aorta [21] |
For imaging of pregnant women with aortic arch, descending, or abdominal aortic dilatation, magnetic resonance imaging (without gadolinium) is recommended over computed tomographic imaging to avoid exposing both the mother and fetus to ionizing radiation. Transesophageal echocardiogram is an option for imaging of the thoracic aorta. | I | C | Thoracic aorta [21] |
Computed tomographic imaging or magnetic resonance imaging of the thoracic aorta is reasonable after a Type A or B aortic dissection or after prophylactic repair of the aortic root/ ascending aorta. | IIa | C | Thoracic aorta [21] |
Computed tomographic imaging or magnetic resonance imaging of the aorta is reasonable at 1, 3, 6, and 12 months postdissection and, if stable, annually thereafter so that any threatening enlargement can be detected in a timely fashion. | IIa | C | Thoracic aorta [21] |
If a thoracic aortic aneurysm is only moderate in size and remains relatively stable over time, magnetic resonance imaging instead of computed tomographic imaging is reasonable to minimize the patient’s radiation exposure. | IIa | C | Thoracic aorta [21] |
MRI for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. | III | C | Risk assessment [18] |
Valvular heart disease | |||
CMR is indicated in patients with moderate or severe AR (stages B, C, and D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity. | I | B | |
CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE. | I | B | |
CMR or real-time 3D echocardiography may be considered for assessment of right ventricular systolic function and systolic and diastolic volumes in patients with severe tricuspid regurgitation (stages C and D) and suboptimal 2D echocardiograms. | IIb | C | |
Congenital heart disease | |||
Diagnostic and interventional procedures, including imaging (ie, echocardiography, MRI, or CT, advanced cardiac catheterization, and electrophysiology procedures for adults with complex and moderate CHD should be performed in a regional ACHD center with appropriate experience in CHD and in a laboratory with appropriate personnel and equipment. Personnel performing such procedures should work as part of a team with expertise in the surgical and transcatheter management of patients with CHD. | I | C | Congenital heart disease [19] |
(In bicuspid aortic valve disease) MRI/CT can be beneficial to add important information about the anatomy of the thoracic aorta. | IIa | C | Congenital heart disease [19] |
(In bicuspid aortic valve disease) MRI may be beneficial in quantifying aortic regurgitation when other data are ambiguous or borderline. | IIb | C | Congenital heart disease [19] |
(In supravalvular aortic stenosis) TTE and/or TEE with Doppler and either MRI or CT should be performed to assess the anatomy of the LVOT, the ascending aorta, coronary artery anatomy and flow, and main and branch pulmonary artery anatomy and flow. | I | C | Congenital heart disease [19] |
Every patient with coarctation (repaired or not) should have at least 1 cardiovascular MRI or CT scan for complete evaluation of the thoracic aorta and intracranial vessels. | I | B | Congenital heart disease [19] |
Evaluation of the coarctation repair site by MRI/CT should be performed at intervals of 5 years or less, depending on the specific anatomic findings before and after repair. | I | C | Congenital heart disease [19] |
Patients with suspected supravalvular, branch, or peripheral pulmonary stenosis should have baseline imaging with echocardiography-Doppler plus 1 of the following: MRI angiography, CT angiography, or contrast angiography. | I | C | Congenital heart disease [19] |
(In congenital coronary anomalies of ectopic arterial origin) CT or MRA is useful as the initial screening method in centers with expertise in such imaging. | I | B | Congenital heart disease [19] |
(In suspicion of a coronary arteriovenous fistula), if a continuous murmur is present, its origin should be defined either by echocardiography, MRI, CT angiography, or cardiac catheterization. | I | C | Congenital heart disease [19] |
The evaluation of all ACHD patients with suspected pulmonary arterial hypertension should include noninvasive assessment of cardiovascular anatomy and potential shunting, as detailed below: Diagnostic cardiovascular imaging via TTE, TEE, MRI, or CT as appropriate. | I | C | Congenital heart disease [19] |
Patients with tetralogy of Fallot should have echocardiographic examinations and/or MRIs performed by staff with expertise in ACHD. | I | C | Congenital heart disease [19] |
Additional imaging with TEE, CT, or MRI, as appropriate, should be performed in a regional ACHD center to evaluate the great arteries and veins, as well as ventricular function, in patients with prior atrial baffle repair of d-TGA. | I | B | Congenital heart disease [19] |
Periodic MRI or CT can be considered appropriate to evaluate the anatomy and hemodynamics in more detail in patients with prior arterial switch operation. | IIa | C | Congenital heart disease [19] |
(In congenitally corrected transposition of the great arteries), echocardiography-Doppler study and/or MRI should be performed yearly or at least every other year by staff trained in imaging complex CHD. | I | C | Congenital heart disease [19] |
The following diagnostic evaluations are recommended for patients with congenitally corrected transposition of the great arteries: ECG, chest x-ray, echocardiography-Doppler study, MRI, exercise testing. | I | C | Congenital heart disease [19] |
(In patients with prior repair of congenitally corrected transposition of the great arteries), echocardiography-Doppler study and/or MRI should be performed yearly or at least every other year by staff trained in imaging complex CHD. | I | C | Congenital heart disease [19] |
All patients with prior Fontan type of repair should have periodic echocardiographic and/or magnetic resonance examinations performed by staff with expertise in ACHD. | I | C | Congenital heart disease [19] |
Syncope | |||
Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in selected patients presenting with syncope of suspected cardiac etiology. | IIb | B-NR | Syncope [24] |
Recommendations for non-invasive cardiac imaging in heart failure | Classa
| Levelb
| Page |
---|---|---|---|
Radionuclide ventriculography or MRI can be useful to assess LVEF and volume | IIa | C | 18 |
Noninvasive imaging to detect myocardial ischemia and viability is reasonable in heart failure and coronary artery disease | IIa | C | 18 |
Viability assessment is reasonable before revascularization in heart failure patients with coronary artery disease | IIa | B | 18 |
MRI is reasonable when assessing myocardial infiltration or scar | IIa | B | 18 |
Classa
| Levelb
| Page | |
---|---|---|---|
Aortic regurgitation | |||
CMR is indicated in patients with moderate or severe AR (stages B, C, and D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity. | I | B | 29 |
Bicuspid aortic valve disease | |||
Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography. | I | C | 32 |
Serial evaluation of the size and morphology of the aortic si- nuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter greater than 4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter greater than 4.5 cm, this evaluation should be performed annually. | I | C | 33 |
Mitral regurgitation | |||
CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE. | I | B | 43 |
Noninvasive imaging (stress nuclear/positron emission tomog- raphy, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR. | I | C | 50 |
Tricuspid regurgitation | |||
CMR or real-time 3D echocardiography may be considered for assessment of right ventricular systolic function and systolic and diastolic volumes in patients with severe tricuspid regurgitation (stages C and D) and suboptimal 2D echocardiograms. | IIb | C | 54 |
-
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope [24]
-
2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease [4]
Recommendations for cardiac imaging in syncope | Classa
| Levelb
| Page |
---|---|---|---|
Computed tomography (CT) or magnetic resonance imaging (MRI) may be useful in selected patients presenting with syncope of suspected cardiac etiology. | IIb | B-NR | 25 |
Extended monitoring (including MRI) can be beneficial for athletes with unexplained exertional syncope after an initial cardiovascular evaluation. | IIa | C-LD | 64 |
Recommendations for imaging for anatomic assessment | Classa
| Levelb
| Page |
---|---|---|---|
Duplex ultrasound, computed tomography angiography (CTA), or magnetic resonance angiography (MRA) of the lower extremities is useful to diagnose anatomic location and severity of stenosis for patients with symptomatic peripheral artery disease in whom revascularization is considered | I | B-NR | 24 |
Invasive and noninvasive angiography (ie, CTA, MRA) should not be performed for the anatomic assessment of patients with asymptomatic peripheral artery disease. | III | B-R | 25 |
-
2015 ACC/AHA/HRS Guideline for the management of adult patients with supraventricular tachycardia [25]
-
2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention and the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction [10]
-
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction [11]
-
2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention [12]
Diagnosis stable coronary artery disease | Classa
| Levelb
| Page |
---|---|---|---|
Pharmacological stress with CMR can be useful for patients with an intermediate to high pretest probability of obstructive ischemic heart disease, who have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity. | IIa | B | 22 |
Pharmacological stress CMR is reasonable for patients with an intermediate to high pretest probability of ischemic heart disease, who are incapable of at least moderate physical functioning or have disabling comorbidity. | IIa | B | 24 |
-
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes [26]
Classa
| Levelb
| Page | |
---|---|---|---|
Resting imaging to assess cardiac structure and function | |||
Echocardiography, radionuclide imaging, CMR, and cardiac CT are not recommended for routine assessment of LV function in patients with a normal ECG, no history of myocardial infarction, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. | III | C | 29 |
Routine reassessment (<1 year) of LV function with technologies such as echocardiography, radionuclide imaging, CMR, or cardiac CT is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated. | III | C | 31 |
Risk assessment in patients able to exercise | |||
CMR with pharmacological stress is reasonable for risk assessment in patients with stable ischemic heart disease who are able to exercise to an adequate workload but have an uninterpretable ECG. | IIa | B | 30 |
Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with stable ischemic heart disease who are able to exercise to an adequate workload and have an interpretable ECG. | III | C | 30 |
Risk assessment in patients unable to exercise | |||
Pharmacological stress CMR is reasonable for risk assessment in patients with stable ischemic heart disease who are unable to exercise to an adequate workload regardless of interpretability of ECG. | IIa | B | 30 |
Risk assessment regardless of patients’ ability to exercise | |||
Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with stable ischemic heart disease, who are being considered for revascularization of known coronary stenosis of unclear physiological significance. | I | B | 31 |
-
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation [27]
Stress (Takotsubo) cardiomyopathy
| Classa
| Levelb
| Page |
---|---|---|---|
Imaging with ventriculography, echocardiography, or magnetic resonance imaging should be performed to confirm or exclude the diagnosis of stress (Takotsubo) cardiomyopathy. | I | B | 49 |
-
2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults [28]
-
2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk [29]
-
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults [30]
-
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk [31]
-
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy [33]
Classa
| Levelb
| Page | |
---|---|---|---|
CMR for the diagnosis of HCM | |||
CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis. | I | B | 14 |
CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography. | I | B | 14 |
CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive. | IIa | B | 14 |
CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy. | IIb | C | 14 |
CMR for risk stratification in HCM | |||
In selected patients with known HCM, when SCD risk stratification is inconclusive after documentation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement (LGE) may be considered in resolving clinical decision making. | IIb | C | 14 |
The usefulness of the following potential SCD risk modifiers is unclear but might be considered in selected patients with HCM for whom risk remains borderline after documentation of conventional risk factors: CMR imaging with LGE. | IIb | C | 27 |
-
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery [34]
-
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery [20]
-
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease [21]
Classa
| Levelb
| Page | |
---|---|---|---|
Carotid artery | |||
In patients with acute, focal ischemic neurological symptoms corresponding to the territory supplied by the left or right internal carotid artery, magnetic resonance angiography (MRA) or computed tomography angiography (CTA) is indicated to detect carotid stenosis when sonography either cannot be obtained or yields equivocal or otherwise nondiagnostic results. | I | C | 15 |
When an extracranial source of ischemia is not identified in patients with transient retinal or hemispheric neurological symptoms of suspected ischemic origin, CTA, MRA, or selective cerebral angiography can be useful to search for intracranial vascular disease. | IIa | C | 15 |
When the results of initial noninvasive imaging are inconclusive, additional examination by use of another imaging method is reasonable. In candidates for revascularization, MRA or CTA can be useful when results of carotid duplex ultrasonography are equivocal or indeterminate. | IIa | C | 15 |
When intervention for significant carotid stenosis detected by carotid duplex ultrasonography is planned, MRA, CTA, or catheter-based contrast angiography can be useful to evaluate the severity of stenosis and to identify intrathoracic or intracranial vascular lesions that are not adequately assessed by duplex ultrasonography. | IIa | C | 15 |
MRA without contrast is reasonable to assess the extent of disease in patients with symptomatic carotid atherosclerosis and renal insufficiency or extensive vascular calcification. | IIa | C | 15 |
When complete carotid arterial occlusion is suggested by duplex ultrasonography, MRA, or CTA in patients with retinal or hemispheric neurological symptoms of suspected ischemic origin, catheter-based contrast angiography may be considered to determine whether the arterial lumen is sufficiently patent to permit carotid revascularization. | IIb | C | 15 |
Vertebral artery | |||
Noninvasive imaging by CTA or MRA for detection of vertebral artery disease should be part of the initial evaluation of patients with neurological symptoms referable to the posterior circulation and those with subclavian steal syndrome. | I | C | 47 |
In patients whose symptoms suggest posterior cerebral or cerebellar ischemia, MRA or CTA is recommended rather than ultrasound imaging for evaluation of the vertebral arteries. | I | C | 47 |
Contrast-enhanced CTA, MRA, and catheter-based contrast angiography are useful for diagnosis of cervical artery dissection. | I | C | 52 |
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2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults [18]
Classa
| Levelb
| Page | |
---|---|---|---|
Recommendations for acute thoracic aortic disease | |||
Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening. | I | B | 43 |
Recommendations for Takayasu arteritis and giant cell arteritis | |||
The initial evaluation of Takayasu arteritis or giant cell arteritis should include thoracic aorta and branch vessel computed tomographic imaging or magnetic resonance imaging to inves- tigate the possibility of aneurysm or occlusive disease in these vessels. | I | C | 28 |
Recommendations for aortic arch aneurysms | |||
For patients with isolated aortic arch aneurysms less than 4.0 cm in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 12- month intervals, to detect enlargement of the aneurysm. | IIa | C | 58 |
For patients with isolated aortic arch aneurysms 4.0 cm or greater in diameter, it is reasonable to reimage using computed tomographic imaging or magnetic resonance imaging, at 6-month intervals, to detect enlargement of the aneurysm. | IIa | C | 58 |
Recommendations for chronic aortic diseases in pregnancy | |||
For imaging of pregnant women with aortic arch, descending, or abdominal aortic dilatation, magnetic resonance imaging (without gadolinium) is recommended over computed tomographic imaging to avoid exposing both the mother and fetus to ionizing radiation. Transesophageal echocardiogram is an option for imaging of the thoracic aorta. | I | C | 64 |
Recommendations for surveillance of thoracic aortic disease or previously repaired patients | |||
Computed tomographic imaging or magnetic resonance imaging of the thoracic aorta is reasonable after a Type A or B aortic dissection or after prophylactic repair of the aortic root/ ascending aorta. | IIa | C | 76 |
Computed tomographic imaging or magnetic resonance imaging of the aorta is reasonable at 1, 3, 6, and 12 months postdissection and, if stable, annually thereafter so that any threatening enlargement can be detected in a timely fashion. | IIa | C | 76 |
If a thoracic aortic aneurysm is only moderate in size and remains relatively stable over time, magnetic resonance imaging instead of computed tomographic imaging is reasonable to minimize the patient’s radiation exposure. | IIa | C | 76 |
-
2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (ACHD) [19]
Recommendation for imaging of plaque | Classa
| Levelb
| Page |
---|---|---|---|
MRI for detection of vascular plaque is not recommended for cardiovascular risk assessment in asymptomatic adults. | III | C | 32 |
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2006 ACC/AHA/ESC Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death [35]
Classa
| Levelb
| Page | |
---|---|---|---|
Recommendations for adults with congenital heart disease (ACHD) | |||
Diagnostic and interventional procedures, including imaging (ie, echocardiography, MRI, or CT, advanced cardiac catheterization, and electrophysiology procedures for adults with complex and moderate CHD should be performed in a regional ACHD center with appropriate experience in CHD and in a laboratory with appropriate personnel and equipment. Personnel performing such procedures should work as part of a team with expertise in the surgical and transcatheter management of patients with CHD. | I | C | 12–13 |
Bicuspid aortic valve disease | |||
MRI/CT can be beneficial to add important information about the anatomy of the thoracic aorta. | IIa | C | 45 |
MRI may be beneficial in quantifying aortic regurgitation when other data are ambiguous or borderline. | IIb | C | 45 |
Supravalvular aortic stenosis | |||
TTE and/or TEE with Doppler and either MRI or CT should be performed to assess the anatomy of the LVOT, the ascending aorta, coronary artery anatomy and flow, and main and branch pulmonary artery anatomy and flow. | I | C | 50 |
Aortic coarctation | |||
Every patient with coarctation (repaired or not) should have at least 1 cardiovascular MRI or CT scan for complete evaluation of the thoracic aorta and intracranial vessels. | I | B | 52 |
Evaluation of the coarctation repair site by MRI/CT should be performed at intervals of 5 years or less, depending on the specific anatomic findings before and after repair. | I | C | 53 |
Supravalvular, branch, and peripheral pulmonary stenosis | |||
Patients with suspected supravalvular, branch, or peripheral pulmonary stenosis should have baseline imaging with echocardiography-Doppler plus 1 of the following: MRI angiography, CT angiography, or contrast angiography. | I | C | 61 |
Congenital coronary anomalies of ectopic arterial origin | |||
CT or MRA is useful as the initial screening method in centers with expertise in such imaging. | I | B | 65 |
Coronary arteriovenous fistula | |||
If a continuous murmur is present, its origin should be defined either by echocardiography, MRI, CT angiography, or cardiac catheterization. | I | C | 67 |
Congenital heart disease and pulmonary arterial hypertension | |||
The evaluation of all ACHD patients with suspected pulmonary arterial hypertension should include noninvasive assessment of cardiovascular anatomy and potential shunting, as detailed below: Diagnostic cardiovascular imaging via TTE, TEE, MRI, or CT as appropriate. | I | C | 70 |
After repaired of tetralogy of Fallot | |||
Patients with tetralogy of Fallot should have echocardiographic examinations and/or MRIs performed by staff with expertise in ACHD. | I | C | 73 |
Dextro-Transposition of the great arteries | |||
Additional imaging with TEE, CT, or MRI, as appropriate, should be performed in a regional ACHD center to evaluate the great arteries and veins, as well as ventricular function, in patients with prior atrial baffle repair of d-TGA. | I | B | 80 |
Periodic MRI or CT can be considered appropriate to evaluate the anatomy and hemodynamics in more detail in patients with prior arterial switch operation. | IIa | C | 80 |
Congenitally corrected transposition of the great arteries | |||
Echocardiography-Doppler study and/or MRI should be performed yearly or at least every other year by staff trained in imaging complex CHD. | I | C | 87 |
The following diagnostic evaluations are recommended for patients with congenitally corrected transposition of the great arteries: ECG, chest x-ray, echocardiography-Doppler study, MRI, exercise testing. | I | C | 87 |
In patients with prior repair of congenitally corrected transposition of the great arteries, echocardiography-Doppler study and/or MRI should be performed yearly or at least every other year by staff trained in imaging complex CHD. | I | C | 89 |
After Fontan Procedure | |||
All patients with prior Fontan type of repair should have periodic echocardiographic and/or magnetic resonance examinations performed by staff with expertise in ACHD. | I | C | 97 |
Recommendations for CMR for patients with ventricular arrhythmias and the prevention of sudden cardiac death | Classa
| Levelb
| Page |
---|---|---|---|
MRI, cardiac computed tomography (CT), or radionuclide angiography can be useful in patients with ventricular arrhythmias when echocardiography does not provide accurate assessment of LV and RV function and/or evaluation of structural changes. | IIa | B | 19 |