B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06

B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06

B. C. Kansupada, MD HeartCare Assoc ACC chapter talk 4/28/06

Nuclear Imaging 2006Nuclear Imaging 2006

Bindu Kansupada, MD, MBA, FACC

HeartCare Associates

Member Payors Committee PACC

DisclosureDisclosure

Consultant/speaker bureau for:

Medtronics Guident St. Judes Merck Bristol Myers Squib

Special Thanks:

Dr. PolkDr. Ronald SchwartzDr. Braunwald

Nuclear Cardiac Imaging Nuclear Cardiac Imaging (Myocardial Perfusion Imaging(Myocardial Perfusion Imaging))

Myocardial Perfusion Imaging – What is it?MPI Images – What does it look like?Clinical Value – What good is it?Comparison with other modalities

– Why MPI?

What is Myocardial Perfusion What is Myocardial Perfusion Imaging?Imaging?

In the U.S., nuclear cardiology (MPI) procedures have overtaken non-cardiology procedures in procedural volume.

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

1994 1995 1996 1997 1998 1999 2000 2001 2002

Pro

ced

ure

s (t

ho

usa

nd

s)

Non-cardiology Cardiology Total

MPI is a non-invasive nuclear imaging technique that uses radioactive imaging agents to image the heart.

Thallium - 201 Technetium-99 m Sestamibi Technetium-99 m Tetrofosmin

What is Myocardial Perfusion What is Myocardial Perfusion Imaging?Imaging?

What do MPI images look like?What do MPI images look like?

In a typical nuclear cardiac imaging exam, the physician reviews:– Static “Summed

Perfusion Images”– Dynamic “Gated

Images”

Perfusion Images are viewed in three orientations:SA – Short AxisVLA – Vertical Long AxisHLA - Horizontal Long Axis

What do MPI images look like? - What do MPI images look like? - Summed Perfusion ImagesSummed Perfusion Images

Stress

Rest

Stress

Rest

Stress

Rest

Stress

Rest

SA

SA

VLA

HLA

What do MPI images look like? - Summed Perfusion Images

• Summed images are used to assess cardiac perfusion. Rest and Stress images are compared to determine if a region of the heart is “ischemic” – starved of oxygen

• In the study below, the rest image indicates normal blood flow, but the stress image indicates abnormal blood flow in the Inferior-lateral region.

• This may indicate “ischemia” in this region of the heart – which is supplied by the LCX (left circumflex artery). There may be stenosis in that coronary artery.

Stress

Rest

What do MPI images look like? Gated Images

• Gated images are made possible by ECG-gated SPECT

• Physicians can now access cardiac function:

• Wall motion – does the LV contract uniformly?

• Ejection Fraction – does the LV pump out enough blood to the body?

SA

HLA

VLA

What Good is MPI? – Clinical Value• A nuclear stress test provides excellent negative predictive value

- Patients from the general population with normal MPI scans have <1% annual risk of cardiac events

What Good is MPI? – Clinical Value

• A gated nuclear stress test is a powerful tool to risk stratify patients for optimal management. • It is in effect a “gate-keeper” to the cardiac cath lab

Coronary Distribution (Left Ventricle)Coronary Distribution (Left Ventricle)

Remember ThisThe 3 coronary arteries are:LAD - left anterior descending arteryRCA - right coronary artery LCX - left circumflex coronary artery

Normal Myocardial Perfusion

Myocardial Ischemia

Myocardial Infarction

Type of Nuclear Type of Nuclear ImagingImaging

Gated Study

Gating process-Functional assessment

ventricular wall motion

ES and ED ventricular volumes

LV ejection fraction

normal = 64% +/- 12%

Gated Study

RadiopharmaceuticalTc-99m labeled red blood cellsin-vitro and in-vivo labeling

Imagesanteriorleft lateralleft anterior oblique (best LV separation)

Gated Study

Exercise assessmentstress done with bicyclerest EF to compare stress EF

Primary uses of testcongestive heart failurecardiomyopathychemo cardiotoxicity

First Pass Cardiac Study

What’s ‘first pass’?temporal separation of chambers

Functional assessmentventricular wall motionES and ED ventricular volumesLV and RV ejection fractionspulmonary transit time

First Pass Cardiac Study

Can be performed with exercise

stress done with bicyclerest EF to compare to stress EF

Primary uses of test

same as gated cardiac study better than gated at right ventricle assessment and cardiac shunts

Myocardial Perfusion Study

Assess coronary blood flow

Demonstrate blood perfusion of

the LV myocardium

Software allows gating for EF

3D reconstruction of heart

Myocardial Perfusion

RadiopharmaceuticalsThallium-201 chlorideTc-99m SestamibiTc-99m Tetrofosmin

SPECT acquisitionprovides cross-sectional images of the myocardium in the short axis, horizontal long axis and vertical long axis planes


Performed at rest & stress

Stress study optionstreadmill exercisepharmacologic stress agents

adenosinepersantine (dipyridamole)dobutamine


-Percentage of LV myocardium receiving decreased perfusion

-Differentiate ischemia from MI

-24 hour delayed images demonstrate myocardial viability (hibernating)

-Rest-only studies can provide information on acute MI’s

Exam Results

Myocardial Infarctionperfusion defect on rest & stress

Myocardial Ischemiaperfusion defect on stress only

Diagnostic Diagnostic ApproachApproach

Exercise ProtocolExercise Protocol

Exercise preferred modalityRadiopharmaceutical injected at peak and

continued exercise for another 1-2 minutes.If unable to exercise, unable to attain target

heart rate, or contraindications pharmacologic testing should be performed.

B-blockers should be held for 48 hoursNo caffeine for 24 hours.

Exercise TestingExercise Testing- - Contra Contra IndicationsIndications

Unstable AnginaDecompensated CHFUncontrolled hypertension (blood pressure

> 200/115 mm of Hg)Acute myocardial infarction within last 2 to

3 daysSevere pulmonary hypertensionRelative contraindication AS, HCM

Exercise TestingExercise Testing

Each of the protocols has advantages and disadvantages.

Quality control from preparation, acquisition to reading assure the best data.

Myocardial PerfusionScintigraphy: Myocardial PerfusionScintigraphy: Assessment of Diagnosis, Prognosis, and Assessment of Diagnosis, Prognosis, and Treatment Response of Cardiovascular Treatment Response of Cardiovascular

Risk.Risk.

Diagnosis, Prognosis, and Response to Therapy

Suspected Coronary artery diseaseKnown stable coronary artery diseasePrior to non-cardiac surgeryBefore and after cardiac revascularization

Myocardial PerfusionScintigraphy: Myocardial PerfusionScintigraphy: Assessment of Diagnosis, Prognosis, and Assessment of Diagnosis, Prognosis, and Treatment Response of Cardiovascular Treatment Response of Cardiovascular

RiskRisk

Diagnosis, Prognosis, and Response to Therapy Special populations (women, diabetics)

Evaluation of acute chest pain syndromesMyocardial infarctionScreening: Multiple risk factors, Family

historyResponse to medical therapy

Populations Who Benefit from Populations Who Benefit from SPECT MPISPECT MPI

Diagnostic and prognostic chest pain evaluationAnginaAtypical AnginaAtypical Chest PainNon-cardiac Chest PainPeri-operative risk of non-cardiac surgeryDiagnostic and prognostic evaluation of ACSEmergency DepartmentIn Hospital

Populations Who Benefit from Populations Who Benefit from SPECT MPI SPECT MPI

Hemodynamic/prognostic assessment of known CAD High risk asymptomatic populatios Diabetes, Metabolic syndrome, insulin resistance syndrome Family history of sibling with coronary event Mediastinal radiation Multiple coronary risk factor Monitoring effectiveness of surgical and percutaneous

revascularization Monitoring effectiveness of “ medical revascularization”

120

2742 Men1394 Women

+ MPI

+ EXERCISE

CLINICAL

Incremental Prognostic Value of MPI Testing: Men vs. Women

Specificity of MPI with SPECTProcedures in Women

P=.0004

Heart Disease in Women: Heart Disease in Women: Lessons From The Past DecadeLessons From The Past Decade

The importance of studying gender specific aspects of CAD have helped in the following clinical dilemmas:

Presentation of CAD: women are older than men Less Specific clinical manifestations of CAD in

women Greater Difficulty in Diagnosis: women>men More sever consequences of MI when it occurs in

women

Detecting CAD in WomenDetecting CAD in Women Evidence from numerous medical societies uniformly

supports association of exercise ECG has lower diagnostic accuracy in women (more false positive)

Critical Factors Affects Accuracy: Functional Capacity, Rest ST-T changes, Hormonal Factors

SPECT was better able to identify and satisfy women at high risk for future events.

Extent of total perfusion abnormality, extent of reversible perfusion abnormality, multivessel abnormality, & large perfusion abnormality are all strong predictors of future cardiac events.

Await RCT data from the WOMEN study to provide further detail as to the value of SPECt in accessing risk in women.

Long –Term outcome of Patients Long –Term outcome of Patients With Intermediate-Risk Exercise With Intermediate-Risk Exercise Electrocardiograms who Do Not Electrocardiograms who Do Not

Have Myocardial Perfision Defects Have Myocardial Perfision Defects on Radionuclide Imagingon Radionuclide Imaging

ResultsCardiovascular survival was 99.8% at 1 year,

99.0% at 5 years and 98.5% at 7 years.Near-normal scans and cardiac enlargement were

independent predictors of time to cardiac death.Cardiac survival time free of myocardial infarction

or revascularization was 87.1% at 7 years.

Summary: Summary: Acute Rest Imaging in 2005Acute Rest Imaging in 2005

Strong predictor of short-term cardiac events Very high negative predictive value for acute MI Interpretative differences between acute and stress

imaging requires experience. Use in clinical decision-making and other acute

situations Consider as a gateway of opportunity to assess

intermediate to long term risk of patient -> value of stress imaging following acute resting evauation.

DIAD: Detection of Ischemia is DIAD: Detection of Ischemia is Asymptomatic DiabetesAsymptomatic Diabetes

Abnormalities were observed in:- 22 % of patients with > 2 risk factors (66 of 306)- 22 % of patients with < 2 risk factors (45 of 204)

Greater than one in five diabetic patients without symptoms have an abnormal gated SPECT MPI

Selecting only patients who meet ADA guidelines would have failed to identify 41 % of patients with ischemia

Radionuclide MPS in Pre-Radionuclide MPS in Pre-operative Risk Assessmentoperative Risk Assessment

Perfusion imaging works so well in predicting outcome, we tend to overuse it

For patients with positive perfusion study, try to avoid revascularization unless the patient needs it regardless of upcoming surgery.

Recent study demonstrates no benefit compared to beta blockade peri-operatively.

High risk subsets will benefit long term. Treat patients with mild reversible defects medically Avoid noncardiac surgery within 6 weeks of bare metal stenting Among patients who have CAD, or who are at risk of CAD, consider

preoperative beta blockade and statins. Several studies in clinical settings in which the ACC/AHA guidelines

were followed have demonstarted their effectiveness.

Shortcut to indications for noninvasive testing-Shortcut to indications for noninvasive testing- Perform if any 2 of 3 factors are present.Perform if any 2 of 3 factors are present.

High surgical risk operations- AAA & PVD- Long procedures with lg fluid shifts or blood loss

2. Poor functional capacity ( < 4 METs)3. Intermediate clinical predictors presents

- CAD>> Angina ( CCS I & II)>> Prior MI- CHF- Diabetes or renal insufficiency.

Coronary Blood FlowCoronary Blood Flow

Myocardial blood flow reduction correlates with degree of stenosis

Flow reserve reduces with coronary stenoses of 45-50 %

Able to maintain resting flow untill stenosis is 80-90 %

Coronary Blood Flow RatesCoronary Blood Flow Rates

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

mg/miin/g

Baseline Adeno Dipy Dobuta Exercise

Blood Flow

Prognostic Prognostic Variables of Variables of

Gated SPECTGated SPECT

Value of Stress MPI in the Value of Stress MPI in the general population: Stress MPI: general population: Stress MPI:

Prognostic SignificancePrognostic Significance

0

1

2

3

4

5

6

7

8

Normal Abnormal

Nonfatal MI/Cardiac Death Rate Per Year ( Percent)

Nonfatal MI/CardiacDeath Rate Per Year (Percent)

Prognosis

•Prognostic data are incremental•Normal scans: <1% cardiac event rate per year•Mildly abnormal scans:–<1% cardiac death rate–MI rate not affected by revascularization–Treatment may be medical (catheterization reserved for refractory symptoms)

Risk Stratification: PrognosisRisk Stratification: Prognosis

Risk of cardiac Death:

* Low

< 1 % per year

* Intermediate

1 – 3 % per year

* High

> 3 % per year

Risk Stratification: Noninvasive Risk Stratification: Noninvasive Testing MarkersTesting Markers

Amount of infarcted myocardiumAmount of jeopardized myocardiumDegree of jeopardyLeft vanticular systolic function

All can be assessed by measurements of perfusion or function

TID: transit Ischemic Dilation TID: transit Ischemic Dilation (Stress induced LV Cavity (Stress induced LV Cavity

Dilation)Dilation) Severe, extensive CAD (usually with classic ischemic

defect)

Left Main

Prox LAD

MVD Microvascular disease (no stress defect; atypical defects)

HTN

LVH

DCM

Prognostic implications of Prognostic implications of myocardial perfusion imaging.myocardial perfusion imaging.

Single-photon emission computed tomography Single-photon emission computed tomography perfusion images in two patients with stable perfusion images in two patients with stable

anginal symptoms.anginal symptoms.

Incremental value Of SPECTIncremental value Of SPECT

Evaluation of CAD: A Prognostic Approach

Patients with suspected CAD referred to SPECT

Normal Study Mildly Abnormal Study Mod-Severely Abnormal Study

RISK OF ADVERSE EVENT

LOW INTERMEDIATE HIGH

Reassurance/Risk factor modification

Aggressive risk factor modification

Revascularization

Myocardial Perfusion Imaging with Gated SPECT

Evaluation of CAD:

A Diagnostic ApproachPatients withpossible CAD

Normal DIAGNOSTIC TES Abnormal

Low likelihood of CAD Intermediate to highlikelihood of CAD

Risk factormodification

Revascularization

Cost Effective Cost Effective ApproachApproach

Myocardial perfusion imaging

•Cost effectiveness•MPI as gatekeeper •Incremental information

•High sensitivity •Exclude disease•Fewer false negatives •Higher downstream costs in undiagnosed pts•No need for 2nd test vs. low sensitivity low cost•High specificity•Reduces number of false positive tests •Reduced downstream testing

Principles of Cost-Effective Diagnosis and Management of CAD using MPS

END Study: Financial Analysis of Treatment Strategies

•11,249 consecutive stable angina patients •Two treatment groups –Direct catheterization –Stress MPI followed by selective catheterization •Cohorts matched by pretest probability of CAD•Strategy: cost minimization at equal mortality risk•Cost evaluation –Diagnostic (early): SPECT, catheterization–Follow-up (late): includes costs of PTCA, CABG Adapted from Shaw LJ, et al.J Am CollCardiol. 1999;33:661-669. Cost-effectiveness: Assessing the Prognostic Approach

END: Angiographic findings

END Study: Outcome by Screening Strategy

Pretest Clinical Risk (n=5,423) Pretest Clinical Risk (n=5,826)* P <.01 vs catheterization.

Cost Effectivenessin

Clinical Practice

•Patient risk assessed?•Low risk, negative testing •Intermediate risk, further testing•If risk < 1% then no further testing needed

Why to Practice Why to Practice Appropriateness Appropriateness Criteria based Criteria based Practice?Practice?One may not get reimbursed.One may not get reimbursed.Inappropriate test could increase financial Inappropriate test could increase financial burden to society.burden to society.Possible increased radiationPossible increased radiation

Appropriateness Criteria: SPECT MPIAppropriateness Criteria: SPECT MPI

Tables 1 through 9 sequentially list the 52 indications by purpose, clinical scenario, and their ratings, as obtained from the second-round rating sheets. In addition, Tables 10 through 12 arrange the indications into three main scoring categories—those that were rated as inappropriate (I, me dian score of 1 to 3), uncertain or possibly appropriate (U, median score of 4 to 6), and appropriate (A, median score of 7 to 9), respectively.


Table 10 lists the 13 indications that were rated as inappropriate (i.e., the imaging test is not generally accept-able and is not a reasonable approach for the indication). This does not preclude, however, the performance of the test if justifiable because of special clinical and patient circumstances. It is likely that reimbursement for the test will require a documented exception from the physician.

Table 10. Inappropriate Indications (Median Rating of 1 to 3)

Indication

AppropriatenessCriteria

(Median Score)

Detection of CAD: Symptomatic—Evaluation of Chest Pain Syndrome

1. ~ Low pre-test probability of CAD~ ECG interpretable AND able to exercise

I (2.0)

Detection of CAD Symptomatic—Acute Chest Pain (in Reference to Rest Perfusion Imaging)

8.~ High pre-test probability of CAD

~ ECG: ST elevation

I (1.0)

Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)

10. ~ Low CHD risk (Framingham risk criteria) I (1.0)

Risk Assessment: General and Specific Patient Populations—Asymptomatic

17. ~ Low CHD risk (Framingham) I (1.0)


Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms—Normal Prior SPECT MPI Study

21. ~ Normal initial RNI study~ High CHD risk (Framingham)~ Annual SPECT MPI study

I (3.0)

Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms—Abnormal Catheterization OR Prior SPECT MPI Study

23.~ Known CAD on catheterization OR prior SPECT MPIstudy in patients who have not had revascularizationprocedure~ Asymptomatic OR stable symptoms~ Less than 1 year to evaluate worsening disease

I (2.5)

Risk Assessment With Prior Test Results: Asymptomatic—Prior Coronary Calcium Agatston Score

28. ~ Agatston score less than 100 I (1.5)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—Low-Risk Surgery

31. ~ Preoperative evaluation for non-cardiac surgery riskassessment

I (1.0)


Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—Intermediate-Risk Surgery

32. ~ Minor to intermediate perioperative risk predictor~ Normal exercise tolerance (greater than or equal to 4 METS)

I (3.0)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—High Risk Surgery

36. ~ Asymptomatic up to 1 year post normal catheterization,non-invasive test, or previous revascularization

I (3.0)

RiskAssessment: Following Acute Coronary Syndrome STEMI—Hemodynamically

Signs of Cardiogenic Shock, or Mechanical Complications

Unstable,

38. ~ Thrombolytic therapy administered I (1.0)

Risk Assessment: Following Acute Coronary Syndrome—Asymptomatic Post-Revascularization (PCI or CABG)

40. ~ Routine evaluation prior to hospital discharge I (1.0)

Risk Assessment: Post-Revascularization (PCI or CABG)—Asymptomatic

47. ~ Symptomatic prior to previous revascularization I (3.0)

~ Less than 1 year after PCI


Indication

Appropriateness

Criteria(Median Score)


3. ~ Intermediate pre-test probability of CAD A (7.0)

~ ECG interpretable AND able to exercise


~ ECG uninterpretable OR unable to exercise

5. ~ High pre-test probability of CAD A (8.0)

~ ECG interpretable AND able to exercise

6. ~ High pre-test probability of CAD A (9.0)

~ ECG uninterpretable OR unable to exercise

Detection of CAD: Symptomatic—Acute Chest Pain (in Reference to Rest Perfusion Imaging)

7. ~ Intermediate pre-test probability of CAD~ ECG: no ST elevation AND initial cardiac enzymes negative

A (9.0)

Table 11. Appropriate Indications (Median Rating of 7 to 9)

Detection of CAD: Symptomatic—New-Onset/Diagnosed Heart Failure With Chest Pain Syndrome


Detection of CAD: Asymptomatic—New-Onset or Diagnosed Heart Failure or LV Systolic Dysfunction

Without Chest Pain Syndrome

12. ~ Moderate CHD risk (Framingham) A (7.5)

~ No prior CAD evaluation AND no planned cardiaccatheterization

Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)—New-Onset Atrial Fibrillation

15. ~ High CHD Risk (Framingham) A (8.0)

~ Part of the evaluation

Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)—Ventricular Tachycardia

16. ~ Moderate to high CHD risk (Framingham) A (9.0)



19. ~ Moderate to high CHD risk (Framingham)A (8.0)

~ High-risk occupation (e.g., airline pilot)

20. ~ High CHD risk (Framingham) A (7.5)

Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms—Normal Prior SPECT MPI Study

22. ~ Normal initial RNI studyA (7.0)

~ High CHD risk (Framingham)~ Repeat SPECT MPI study after 2 years or greater


Risk Assessment With Prior Test Results: Asymptomatic OR Stable Symptoms—Abnormal Catheterization or Prior SPECT MPI Study

24.

~ Known CAD on catheterization OR prior SPECT MPI studyin patients who have not had revascularization procedure

A (7.5)

~ Greater than or equal to 2 years to evaluate worsening disease

Risk Assessment With Prior Test Results: Worsening Symptoms—Abnormal Catheterization OR Prior SPECT MPI Study

25. ~ Known CAD on catheterization OR prior SPECT MPI study A (9.0)


Indication

Appropriateness

Criteria(Median Score)

Risk Assessment With Prior Test Results: Asymptomatic—Prior Coronary Calcium Agatston Score

27. ~ Agatston score greater than or equal to 400 A (7.5)

Risk Assessment With Prior Test Results: UA/NSTEMI, STEMI, orChest Pain Syndrome—Coronary Angiogram

29. ~ Stenosis of unclear significance A (9.0)

Risk Assessment With Prior Test Results—Duke Treadmill Score

30. ~ Intermediate Duke treadmill score~ Intermediate CHD risk (Framingham)

A (9.0)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—Intermediate-Risk Surgery

33.~ Intermediate perioperative risk predictor ORPoor exercise tolerance (less than 4 METS)

A (8.0)


Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—High-Risk Surgery

35. ~ Minor perioperative risk predictor ANDA (8.0)

~ Poor exercise tolerance (less than 4 METS)

Risk Assessment: Following Acute Coronary Syndrome—STEMI-Hemodynamically Stable

37.~ Thrombolytic therapy administered~ Not planning to undergo catheterization

A (8.0)

Risk Assessment: Following Acute Coronary Syndrome—UA/NSTEMI—No Recurrent Ischemia OR No Signs of HF

39. ~ Not planning to undergo early catheterization A (8.5)

Risk Assessment: Post-Revascularization (PCI or CABG)—Symptomatic

41. ~ Evaluation of chest pain syndrome A (8.0)



44. ~ Asymptomatic prior to previous revascularization A (7.5)

~ Greater than or equal to 5 years after CABG

45. ~ Symptomatic prior to previous revascularization A (7.5)

~ Greater than or equal to 5 years after CABG

Assessment of Viability/Ischemia: Ischemic Cardiomyopathy(Includes SPECT Imaging for Wall Motion and Ventricular Function)

50.~ Known CAD on catheterization~ Patient eligible for revascularization

A (8.5)

Evaluation of Left Ventricular Function

51. ~ Non-diagnostic echocardiogram A (9.0)

Evaluation of Ventricular Function:Use of Potentially Cardiotoxic Therapy (e.g., Doxorubicin)

52. ~ Baseline and serial measurements A (9.0)


Indication

AppropriatenessCriteria

(Median Score)


2.~ Low pre-test probability of CAD~ ECG uninterpretable OR unable to exercise

U* (6.5)

Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)

11. ~ Moderate CHD risk (Framingham) U (5.5)

Detection of CAD: Asymptomatic—Valvular Heart Disease Without Chest Pain Syndrome

13.~ Moderate CHD risk (Framingham)~ To help guide decision for invasive studies

U (5.5)

Table 12. Uncertain Indications (Median Rating of 4 to 6)

Detection of CAD: Asymptomatic (Without Chest Pain Syndrome)—New-Onset Atrial Fibrillation

14. ~ Low CHD risk (Framingham)~ Part of the evaluation

U* (3.5)


18. ~ Moderate CHD risk (Framingham) U (4.0)

Risk Assessment With Prior Test Results: Asymptomatic—CT Coronary Angiography

26. ~ Stenosis of unclear significance U* (6.5)

Risk Assessment: Preoperative Evaluation for Non-Cardiac Surgery—High-Risk Surgery

34.~ Minor perioperative risk predictor~ Normal exercise tolerance (greater than orequal to 4 METS)

U (4.0)



42.~ Asymptomatic prior to previousrevascularization~ Less than 5 years after CABG

U (6.0)

43. ~ Symptomatic prior to previous revascularization~ Less than 5 years after CABG

U (4.5)


46.~ Asymptomatic prior to previousrevascularization~ Less than 1 year after PCI

U* (6.5)

48.~ Asymptomatic prior to previousrevascularization~ Greater than or equal to 2 years after PCI

U* (6.5)

49. ~ Symptomatic prior to previous revascularization~ Greater than or equal to 2 years after PCI

U (5.5)



Summary:Median Score 7 to 9 ---- AppropriateMedian Score 1 to 3 ---- InappropriateMedian Score 4 to 6 ---- Uncertain

Pre-Cert Requirements in SE-PAPre-Cert Requirements in SE-PA

IMPORTANT INFORMATION REGARDING DIAGNOSTIC IMAGING SERVICES—NUCLEAR CARDIOLOGY STUDIES

INDEPENDENT BLUE CROSS HAS CONTRACTED WITH AMERICAN IMAGING MANAGEMENT, INC (AIM) TO IMPLEMENT A NEW RADIOLOGY QUALITY INITIATIVE FOR OUTPATEINT NON-EMERGENT DIAGNOSTIC IMAGING SERVICES FOR NUCLEAR CARDIOLOGY.(KEYSTONE HPE, PERSONAL CHOICE, AMERIHEALTH NJ, PPO HMO)


THE ORDERING PHYSICIAN IS TO CONTACT AIM VIA NAVINET, PHONE OR FAX, WHETHER THE ORDERING PHYSICIAN IS A PCP OR A SPECIALIST.

CALL CENTER TEL NUMBER IS—800-227-3116

FAX NUMBER IS—800-610-0050 PROVIDERS MAY ACCESS AIM’S CLINICAL

GUIDELINES AND OTHER EDUCATIONAL RESOURCES BY SELECTING THE AIM LINK ON NAVINET OR BY ACCESSING AI’S WEBSITE AT WWW.AMERICANIMAGING.NET


FOR QUESTIONS REGARDING AIM PROGRAM CALL CUSTOMER SERVICE DEPARTMETN AT 800-252-2021(AIM).

FOR CLAIM RELATED QUESTIONS

PLEASE CONTACT IBC PROVIDER SERVICES DEPARTMENT –HMO CALL 215-567-3590 OR 800-227-3119/ FOR PPO CALL 800-332-2566 OR YOUR NETWORK COORDINATOR.


KEYSTONE MERCY—AETNATHE ABOVE PLANS HAVE ENTERED

INTO AN ARRANGEMENT WITH NATIONAL IMAGING ASSOCIATES

(NIA) FOR OUT PATEINT IMAGING MANAGEMENT SERVICES.

CALL 800-642-7597—FOR AETNA PRECERTIFICATON FOR NIA

CALL 866-642-9700—FOR MERCY PRECERTIFICATION FOR NIA


OXFORD HEALTH PLAN AND HEALTHNET HAVE AN AGREEMENT WITH CARECORE

NEW JERSY BLUES(ONLY IF DONE IN NJ) CALL (866) 496-6200-FOR

PRECERTIFICATION-REMEMBER YOU HAVE TO HAVE ANY OF THE FOLLOWING CERTIFICATES ON FILE WITH CARECORE Nuclear Certificates valid from ONE OF the following (any one):


CBNC---Certification Board of Nuclear Cardiology

CCNC---Certification Council of Nuclear Cardiology

ABNM-American Board of Nuclear Medicine ABR—American Board of Radiology ALSO THE NUCLEAR FACILITY HAS TO

BE CERTIFIED BY CARECORE GUIDELINES.

Thank YouThank You

Documents

B. C. Kansupada, MD, HeartCare Assoc. ACC chapter talk 4/28/06