Q&A: New ER Cardiac Imaging Guidelines

In January, the American College of Radiology and the American College of Cardiology jointly issued imaging guidelines for patients presenting to the ER with complaints of chest pain. The document, which was published in the Journal of the American College of Radiology and the Journal of the American College of Cardiology, reviews and rates 20 clinical scenarios related to chest pain that could require emergency imaging.

Patients with complaints of chest pain are the second largest group of ER patients, representing 5.4% of the nearly 130 million ER visits in 2010, according to authors of the guidelines. While diagnosis is often based on the patient’s clinical presentation and history, if the cause is not obvious, imaging may help identify or exclude potentially life-threatening conditions.

Diagnostic Imaging interviewed co-author Frank Rybicki, MD, PhD, professor and chair of radiology at the University of Ottawa, chief of medical imaging at the Ottawa Hospital in Canada, and chairperson for the ACR Metrics Committee, as well as vascular imaging specialty chair for the ACR Appropriateness Criteria, about the new guidelines.

Why did you undertake this project?

Before this guideline document, there were some recommendations for the different clinical scenarios, but they were not comprehensive and they were not put together in one place. Imaging is very important in the emergency room and it’s costly. There was a large unmet need to gather guidelines for this purpose and then to put them into a simple format so that they could be used by emergency room physicians.

How are the guidelines broken down?

There are four entry points into the clinical scenarios, and from those four entry points, there are 20 clinical scenarios that cover a large number of patients who present to the emergency room with chest pain and require imaging. This document provides guidelines for appropriate imaging for these patients. All major imaging modalities that are applicable for emergency room patients were included.

These 20 clinical scenarios are easy to interpret. They cover a large fraction of the patients who will come to the emergency room with chest pain, and the document should help guide the clinician’s clinical judgment on the initial appropriate imaging study to order for these patients.

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The writing panel included stakeholders from cardiology, emergency medicine, and radiology. There was a separate group of reviewers who critically reviewed the document, and then there was a third independent group of raters. That rating panel also included the key stakeholders, and readers of the document can identify the individual raters who represented each society.

There are campaigns, such as the Choosing Wisely Campaign, which are designed to educate people-including the general public-about the appropriateness of certain tests and treatments. Would patients benefit from knowing these types of guidelines as well?

The guidelines are developed for emergency room physicians and the tables are designed to be readily accessible and easily read from the palm of the physician’s hand. The authors recognize that patients have increasing, and important, awareness of their medical conditions. We also recognize that patients may be able to ascertain which of the four entry points that they fall in. It may be harder for a patient to correctly place themselves into one of the20 clinical scenarios or indications. However, it is important for patients to understand that there are specific indications and that guidelines for each indication now exist to help guide appropriate imaging.

What has the response to the guidelines been?

Overall, a large majority of the readership of these guidelines have strongly welcomed them. The process for developing the document has been extensively used and validated, and the separation of the writing, review, and rating panels ensured that the rating was as impartial as possible. Because the members of the rating panel covered so many sub-specialties, there were several scenarios for which some modalities received a rating of M*. This refers to “May be appropriate,” with the caveat that this was reached because mathematical consensus among the rating panel was not reached.

This is not a surprising result – different specialists have different views, and it is sometimes the case that the peer-reviewed literature offers support, but not definitive support, for a specific imaging modality for a specific clinical scenario. What this does, in fact, is identify areas where the stakeholders should focus on either more data, or further analyses and reflection on the data that do exist. It is also important to emphasize that these guidelines drew from all available peer-review literature, and both the writing panel and the independent review panel brought these data to the raters, who had a face-to-face meeting to clarify and vet any discrepancies. However, definitive peer-review data for each clinical scenario is often lacking. In this situation, the rating panel used their expert opinion to guide the document. These individuals were chosen by the societies represented in the rating panel because they are experts in the field. This is not a weakness – in fact it is a strength. Just as patients want their doctor to use expert opinion based on the best data to make clinical decisions, the rating panel used their expertise applied to the clinical data to determine the recommendations as they appear in the document.

What is next for you?

I’ve dedicated a large portion of my professional career to working on appropriateness criteria because I recognize that it is of critical importance, and that medicine needs to integrate these guidelines into clinical decision support. I will continue to do appropriateness criteria because it’s a key part of the Imaging 3.0 initiative at the ACR, and it’s a critical aspect of doing the best imaging possible for our patients.

In terms of this particular topic, I’ve expressed to our colleagues in all areas of medicine that I am happy to work with all groups to generate updates, perhaps develop more granular clinical scenarios, and to work on additional “living” documents as more information becomes available.