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Appropriateness criteria for stress echocardiography in patients with acute chest pain: Are we choosing wisely?
Letters to the Editor
to be regularly seen for follow-up for early detection of structural heart disease. ICDs play a role in the management of this disease, in particular conditions.
[5]
[6]
References [7] [1] Lemery R, Brugada P, Bella PD, Dugernier T, van den Dool A, Wellens HJ. Nonischemic ventricular tachycardia. Clinical course and long-term follow-up in patients without clinically overt heart disease. Circulation 1989;79:990–9. [2] Viskin S, Rosso R, Rogowski O, Belhassen B. The “short-coupled” variant of right ventricular outflow ventricular tachycardia: a not-so-benign form of benign ventricular tachycardia? J Cardiovasc Electrophysiol 2005;16:912–6. [3] Ventura R, Steven D, Klemm HU, et al. Decennial follow-up in patients with recurrent tachycardia originating from the right ventricular outflow tract: electrophysiologic characteristics and response to treatment. Eur Heart J 2007;28:2338–45. [4] Daniels DV, Lu YY, Morton JB, et al. Idiopathic epicardial left ventricular tachycardia originating remote from the sinus of Valsalva: electrophysiological characteristics,
[8]
[9]
[10]
387
catheter ablation, and identification from the 12-lead electrocardiogram. Circulation 2006;113:1659–66. Leenhardt A, Glaser E, Burguera M, Nürnberg M, Maison-Blanche P, Coumel P. Shortcoupled variant of torsade de pointes: a new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994;89:206–15. Postema PG, Christiaans I, Hofman N, et al. Founder mutations in the Netherlands: familial idiopathic ventricular fibrillation and DPP6. Neth Heart J 2011;19:290–6. Boukens BJ, Christoffels VM, Coronel R, Moorman AF. Developmental basis for electrophysiological heterogeneity in the ventricular and outflow tract myocardium as a substrate for life-threatening ventricular arrhythmias. Circ Res 2009;2(104):19–31. Sacher F, Victor J, Hocini M, et al. Caractéristiques morphologiques des extrasystoles ventriculaires initiatrices des fibrilations ventriculaires. Arch Mal Coeur Vaiss 2005;98:867–73. Kazmierczak J, de Sutter J, Tavernier R, Cuvelier C, Dimmer C, Jordaens L. Electrocardiographic and morphometric features in patients with ventricular tachycardia from right ventricular origin. Heart 1998;79:388–93. Wolf DA, Burke AP, Patterson KV, Virmani R. Sudden death following rupture of a right ventricular aneurysm 9 months after ablation therapy of the right ventricular outflow tract. Pacing Clin Electrophysiol 2002;25:1135–7.
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.08.021
Appropriateness criteria for stress echocardiography in patients with acute chest pain: Are we choosing wisely?☆,☆☆ Lisa Schmitz a, Naoyo Mori b, Bijoy K. Khandheria a, Anjan Gupta a,⁎ a b
Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI, USA Center for Urban Population Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
a r t i c l e
i n f o
Article history: Received 16 July 2012 Accepted 31 August 2012 Available online 27 September 2012 Keywords: Stress echocardiography Appropriateness criteria Chest pain
More than 5 million patients present with chest pain to emergency departments in the U.S. each year, and inappropriate discharge can pose potential patient consequences and physician liability [1]. Ordering a stress test during the emergency department visit rather than for outpatient follow-up is becoming more common as patient compliance can be suboptimal [2]. Stress echocardiography (echo) is frequently employed due to its efficiency and rapid results. In 2008, with updates in 2011, the American College of Cardiology and the American Society of Echocardiography (along with six other specialty societies) conducted a review of stress echo and published Appropriate Use Criteria (AUC) to aid in physician decision-making and performance [3,4]. By the 2008 AUC, a stress echo was deemed inappropriate if used for a patient who had ST-segment elevation on electrocardiography (ECG) or a high pretest probability of coronary artery disease (CAD). The only variable that classifies a stress echo as inappropriate per the 2011 AUC is a diagnosis of definite acute coronary syndrome (Table 1). ☆ Authorship statement: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ☆☆ Grant support: This work was not supported by any grants. ⁎ Corresponding author at: Aurora Cardiovascular Services, 2801 W. Kinnickinnic River Parkway, #845, Milwaukee, WI 53215, USA. Tel.: +1 414 649 3909; fax: + 1 414 649 3278.
To determine how this change in criteria could impact clinical practice, we performed a retrospective analysis of all patients presenting with acute chest pain to our hospital from June 2009 through March 2010. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by our institution's human research committee. Age, gender and chest pain descriptions were used to calculate pretest probabilities of CAD [5,6]. Low risk was defined as b10% pretest probability of CAD and high risk defined as N90% [3]. Stress echoes were characterized as appropriate or inappropriate using the 2008 and 2011 AUC category “Stress echocardiography for detection of CAD/risk assessment: Acute chest pain” [3,4]. The authors of this letter have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Over a 10-month period, 459 patients with chest pain were admitted. Of these patients, 300 (65%) underwent stress echo and 67 (15%) underwent myocardial perfusion imaging. The remainder of the study patients (n = 92) were deemed to be very low risk and did not have stress imaging nor were diagnosed with acute coronary syndrome. Of the 300 stress echoes, 194 (64.7%) were appropriate and 32 (10.7%) were inappropriate per the 2008 AUC. Another 74 (24.7%) stress echoes ordered in patients with low probability of CAD were unclassifiable per the 2008 AUC. Thrombolysis in Myocardial Infarction (TIMI) scores were significantly lower in the appropriate echo group, with 83.5% of patients having scores of zero or one (p b 0.001). Stress echo was more likely to be used inappropriately in younger patients (median age 48 vs. 63 years, pb 0.001) and in patients with a history of CAD (68.8% vs. 0.0%, pb 0.001). In stark contrast, no inappropriate imaging studies were identified per the 2011 AUC. The overall increase of diagnostic imaging in the last decade, as assessed by Medicare, has sparked an examination of appropriate use of cardiac imaging. AUC are being looked at by many reimbursement agencies as a potential means to assess payments; considering increasing health care costs, hospital systems should be strongly motivated to review
388
Letters to the Editor
Table 1 Appropriate Use Criteria for stress echocardiography: detection of CAD/risk assessment in symptomatic patients with acute chest pain.⁎ 2008 Criteria Appropriate Intermediate pretest probability of CAD No dynamic ST-segment changes on ECG and negative serial cardiac enzymes Inappropriate High pretest probability of CAD ST-segment elevation on ECG 2011 Criteria Appropriate Possible acute coronary syndrome No ischemic ECG changes or LBBB or paced rhythm Low-risk or high-risk TIMI score Negative or borderline, equivocal, minimally elevated troponin levels Inappropriate Definite acute coronary syndrome CAD = coronary artery disease; ECG = electrocardiogram; LBBB = left bundle branch block; TIMI = Thrombolysis in Myocardial Infarction. ⁎ Data taken from Douglas et al. [3] and American College of Cardiology Foundation Appropriate Use Criteria Task Force et al. [4].
the way testing is ordered. The high specificity of stress echo renders it a cost-effective diagnostic tool [7]. Its sensitivity is comparable to myocardial perfusion imaging but with less patient time commitment [8]. Stress echo offers immediate results, which enables clinicians to either treat or discharge patients quickly. Our findings arise in the midst of the Choosing Wisely™ Campaign, a promotion led by the ABIM Foundation with support and input from nine medical societies (including the American College of Cardiology and American Society of Nuclear Cardiology) [9]. This campaign arrives at a time when health care costs are competing against the quality and safety of health care. In hopes of encouraging physicians and patients to discuss treatment plans in these terms, it lists “Five Things” from each specialty noted to be duplicative or unnecessary and which may not improve overall health. Interestingly, it states not to perform cardiac imaging in chest pain patients at low risk of cardiac death or myocardial infarction. This statement is more in sync with the 2008 AUC. However, it contradicts the 2011 appropriateness criteria, which no longer risk stratifies these patients and therefore deems them appropriately indicated for a stress echo. Of the stress echoes ordered in this study, 10.7% were considered inappropriate based on the 2008 criteria; however, none were considered inappropriate based on the 2011 criteria. The 2011 criteria consider all stress echoes to be appropriate if a patient presents with acute chest pain and is not diagnosed with definite acute coronary syndrome, irrespective of patient pretest probability for CAD or TIMI risk score. In our patient population, 25% had low pretest probabilities of CAD. This low-risk group of patients was previously unclassified by the 2008 criteria. We call into question the true appropriateness of these stress echoes. Is it necessary to order a stress echo for a 30-year-old woman with atypical chest pain and no CAD risk factors, even if she is presenting to the emergency department with “acute chest pain?” The 2011 AUC would say ordering
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.08.060
such a test is acceptable; however, it is discouraged according to the Choosing Wisely™ Campaign. Acute chest pain versus nonacute ischemic equivalent is not defined by either the 2008 or 2011 criteria. This is a potential gray area for determining whether a study is inappropriate or not, regardless of which appropriateness criteria category you decide to choose. Approximately 15% of our stress echoes would be classified as inappropriate by both the new and old criteria under the category of “Evaluation of Chest Pain Syndrome/Ischemic Equivalent” (as opposed to “Detection of CAD: Acute Chest Pain”). This other category does take into account pretest probability and specifically classifies low-risk patients with an interpretable ECG who can exercise as inappropriate candidates for stress echo, a striking difference in the classification from the “Acute Chest Pain” category in the 2011 AUC. Our study suggests that further evaluation of the 2011 AUC is recommended, as stress echo for all patients presenting with acute chest pain but without definite acute coronary syndrome is now considered to be appropriate regardless of cardiovascular risk or pretest probability of CAD. Additionally, we show conflicting opinions regarding the appropriateness of cardiac imaging in comparison with the Choosing Wisely™ Campaign for low-risk patients presenting acutely with chest pain. We gratefully acknowledge the assistance of Barbara Danek, Joe Grundle and Katie Klein in the editorial preparation of this essay. References [1] Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010;26:1–31. [2] Richards D, Meshkat N, Chu J, et al. Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial. CJEM 2007;9:435–40. [3] Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/ SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. J Am Coll Cardiol 2008;51:1127–47. [4] American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et al. ACCF/ASE/ AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society ofCardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011;57:1126–66. [5] Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–8. [6] Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981;64:360–7. [7] Pellikka PA, Nagueh SF, Elhendy AA, et al. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 2007;20:1021–41. [8] Quiñones MA, Verani MS, Haichin RM, et al. Exercise echocardiography versus 201TI single-photon emission computed tomography in evaluation of coronary artery disease. Analysis of 292 patients. Circulation 1992;85:1026–31. [9] Choosing Wisely®. An initiative of the ABIM Foundation. Available at http:// www.ChoosingWisely.org Accessed May 13, 2012.
to be regularly seen for follow-up for early detection of structural heart disease. ICDs play a role in the management of this disease, in particular conditions.
[5]
[6]
References [7] [1] Lemery R, Brugada P, Bella PD, Dugernier T, van den Dool A, Wellens HJ. Nonischemic ventricular tachycardia. Clinical course and long-term follow-up in patients without clinically overt heart disease. Circulation 1989;79:990–9. [2] Viskin S, Rosso R, Rogowski O, Belhassen B. The “short-coupled” variant of right ventricular outflow ventricular tachycardia: a not-so-benign form of benign ventricular tachycardia? J Cardiovasc Electrophysiol 2005;16:912–6. [3] Ventura R, Steven D, Klemm HU, et al. Decennial follow-up in patients with recurrent tachycardia originating from the right ventricular outflow tract: electrophysiologic characteristics and response to treatment. Eur Heart J 2007;28:2338–45. [4] Daniels DV, Lu YY, Morton JB, et al. Idiopathic epicardial left ventricular tachycardia originating remote from the sinus of Valsalva: electrophysiological characteristics,
[8]
[9]
[10]
387
catheter ablation, and identification from the 12-lead electrocardiogram. Circulation 2006;113:1659–66. Leenhardt A, Glaser E, Burguera M, Nürnberg M, Maison-Blanche P, Coumel P. Shortcoupled variant of torsade de pointes: a new electrocardiographic entity in the spectrum of idiopathic ventricular tachyarrhythmias. Circulation 1994;89:206–15. Postema PG, Christiaans I, Hofman N, et al. Founder mutations in the Netherlands: familial idiopathic ventricular fibrillation and DPP6. Neth Heart J 2011;19:290–6. Boukens BJ, Christoffels VM, Coronel R, Moorman AF. Developmental basis for electrophysiological heterogeneity in the ventricular and outflow tract myocardium as a substrate for life-threatening ventricular arrhythmias. Circ Res 2009;2(104):19–31. Sacher F, Victor J, Hocini M, et al. Caractéristiques morphologiques des extrasystoles ventriculaires initiatrices des fibrilations ventriculaires. Arch Mal Coeur Vaiss 2005;98:867–73. Kazmierczak J, de Sutter J, Tavernier R, Cuvelier C, Dimmer C, Jordaens L. Electrocardiographic and morphometric features in patients with ventricular tachycardia from right ventricular origin. Heart 1998;79:388–93. Wolf DA, Burke AP, Patterson KV, Virmani R. Sudden death following rupture of a right ventricular aneurysm 9 months after ablation therapy of the right ventricular outflow tract. Pacing Clin Electrophysiol 2002;25:1135–7.
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.08.021
Appropriateness criteria for stress echocardiography in patients with acute chest pain: Are we choosing wisely?☆,☆☆ Lisa Schmitz a, Naoyo Mori b, Bijoy K. Khandheria a, Anjan Gupta a,⁎ a b
Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI, USA Center for Urban Population Health, University of Wisconsin-Milwaukee, Milwaukee, WI, USA
a r t i c l e
i n f o
Article history: Received 16 July 2012 Accepted 31 August 2012 Available online 27 September 2012 Keywords: Stress echocardiography Appropriateness criteria Chest pain
More than 5 million patients present with chest pain to emergency departments in the U.S. each year, and inappropriate discharge can pose potential patient consequences and physician liability [1]. Ordering a stress test during the emergency department visit rather than for outpatient follow-up is becoming more common as patient compliance can be suboptimal [2]. Stress echocardiography (echo) is frequently employed due to its efficiency and rapid results. In 2008, with updates in 2011, the American College of Cardiology and the American Society of Echocardiography (along with six other specialty societies) conducted a review of stress echo and published Appropriate Use Criteria (AUC) to aid in physician decision-making and performance [3,4]. By the 2008 AUC, a stress echo was deemed inappropriate if used for a patient who had ST-segment elevation on electrocardiography (ECG) or a high pretest probability of coronary artery disease (CAD). The only variable that classifies a stress echo as inappropriate per the 2011 AUC is a diagnosis of definite acute coronary syndrome (Table 1). ☆ Authorship statement: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. ☆☆ Grant support: This work was not supported by any grants. ⁎ Corresponding author at: Aurora Cardiovascular Services, 2801 W. Kinnickinnic River Parkway, #845, Milwaukee, WI 53215, USA. Tel.: +1 414 649 3909; fax: + 1 414 649 3278.
To determine how this change in criteria could impact clinical practice, we performed a retrospective analysis of all patients presenting with acute chest pain to our hospital from June 2009 through March 2010. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by our institution's human research committee. Age, gender and chest pain descriptions were used to calculate pretest probabilities of CAD [5,6]. Low risk was defined as b10% pretest probability of CAD and high risk defined as N90% [3]. Stress echoes were characterized as appropriate or inappropriate using the 2008 and 2011 AUC category “Stress echocardiography for detection of CAD/risk assessment: Acute chest pain” [3,4]. The authors of this letter have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Over a 10-month period, 459 patients with chest pain were admitted. Of these patients, 300 (65%) underwent stress echo and 67 (15%) underwent myocardial perfusion imaging. The remainder of the study patients (n = 92) were deemed to be very low risk and did not have stress imaging nor were diagnosed with acute coronary syndrome. Of the 300 stress echoes, 194 (64.7%) were appropriate and 32 (10.7%) were inappropriate per the 2008 AUC. Another 74 (24.7%) stress echoes ordered in patients with low probability of CAD were unclassifiable per the 2008 AUC. Thrombolysis in Myocardial Infarction (TIMI) scores were significantly lower in the appropriate echo group, with 83.5% of patients having scores of zero or one (p b 0.001). Stress echo was more likely to be used inappropriately in younger patients (median age 48 vs. 63 years, pb 0.001) and in patients with a history of CAD (68.8% vs. 0.0%, pb 0.001). In stark contrast, no inappropriate imaging studies were identified per the 2011 AUC. The overall increase of diagnostic imaging in the last decade, as assessed by Medicare, has sparked an examination of appropriate use of cardiac imaging. AUC are being looked at by many reimbursement agencies as a potential means to assess payments; considering increasing health care costs, hospital systems should be strongly motivated to review
388
Letters to the Editor
Table 1 Appropriate Use Criteria for stress echocardiography: detection of CAD/risk assessment in symptomatic patients with acute chest pain.⁎ 2008 Criteria Appropriate Intermediate pretest probability of CAD No dynamic ST-segment changes on ECG and negative serial cardiac enzymes Inappropriate High pretest probability of CAD ST-segment elevation on ECG 2011 Criteria Appropriate Possible acute coronary syndrome No ischemic ECG changes or LBBB or paced rhythm Low-risk or high-risk TIMI score Negative or borderline, equivocal, minimally elevated troponin levels Inappropriate Definite acute coronary syndrome CAD = coronary artery disease; ECG = electrocardiogram; LBBB = left bundle branch block; TIMI = Thrombolysis in Myocardial Infarction. ⁎ Data taken from Douglas et al. [3] and American College of Cardiology Foundation Appropriate Use Criteria Task Force et al. [4].
the way testing is ordered. The high specificity of stress echo renders it a cost-effective diagnostic tool [7]. Its sensitivity is comparable to myocardial perfusion imaging but with less patient time commitment [8]. Stress echo offers immediate results, which enables clinicians to either treat or discharge patients quickly. Our findings arise in the midst of the Choosing Wisely™ Campaign, a promotion led by the ABIM Foundation with support and input from nine medical societies (including the American College of Cardiology and American Society of Nuclear Cardiology) [9]. This campaign arrives at a time when health care costs are competing against the quality and safety of health care. In hopes of encouraging physicians and patients to discuss treatment plans in these terms, it lists “Five Things” from each specialty noted to be duplicative or unnecessary and which may not improve overall health. Interestingly, it states not to perform cardiac imaging in chest pain patients at low risk of cardiac death or myocardial infarction. This statement is more in sync with the 2008 AUC. However, it contradicts the 2011 appropriateness criteria, which no longer risk stratifies these patients and therefore deems them appropriately indicated for a stress echo. Of the stress echoes ordered in this study, 10.7% were considered inappropriate based on the 2008 criteria; however, none were considered inappropriate based on the 2011 criteria. The 2011 criteria consider all stress echoes to be appropriate if a patient presents with acute chest pain and is not diagnosed with definite acute coronary syndrome, irrespective of patient pretest probability for CAD or TIMI risk score. In our patient population, 25% had low pretest probabilities of CAD. This low-risk group of patients was previously unclassified by the 2008 criteria. We call into question the true appropriateness of these stress echoes. Is it necessary to order a stress echo for a 30-year-old woman with atypical chest pain and no CAD risk factors, even if she is presenting to the emergency department with “acute chest pain?” The 2011 AUC would say ordering
0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.08.060
such a test is acceptable; however, it is discouraged according to the Choosing Wisely™ Campaign. Acute chest pain versus nonacute ischemic equivalent is not defined by either the 2008 or 2011 criteria. This is a potential gray area for determining whether a study is inappropriate or not, regardless of which appropriateness criteria category you decide to choose. Approximately 15% of our stress echoes would be classified as inappropriate by both the new and old criteria under the category of “Evaluation of Chest Pain Syndrome/Ischemic Equivalent” (as opposed to “Detection of CAD: Acute Chest Pain”). This other category does take into account pretest probability and specifically classifies low-risk patients with an interpretable ECG who can exercise as inappropriate candidates for stress echo, a striking difference in the classification from the “Acute Chest Pain” category in the 2011 AUC. Our study suggests that further evaluation of the 2011 AUC is recommended, as stress echo for all patients presenting with acute chest pain but without definite acute coronary syndrome is now considered to be appropriate regardless of cardiovascular risk or pretest probability of CAD. Additionally, we show conflicting opinions regarding the appropriateness of cardiac imaging in comparison with the Choosing Wisely™ Campaign for low-risk patients presenting acutely with chest pain. We gratefully acknowledge the assistance of Barbara Danek, Joe Grundle and Katie Klein in the editorial preparation of this essay. References [1] Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010;26:1–31. [2] Richards D, Meshkat N, Chu J, et al. Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial. CJEM 2007;9:435–40. [3] Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/ SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. J Am Coll Cardiol 2008;51:1127–47. [4] American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et al. ACCF/ASE/ AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society ofCardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance Endorsed by the American College of Chest Physicians. J Am Coll Cardiol 2011;57:1126–66. [5] Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–8. [6] Chaitman BR, Bourassa MG, Davis K, et al. Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation 1981;64:360–7. [7] Pellikka PA, Nagueh SF, Elhendy AA, et al. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 2007;20:1021–41. [8] Quiñones MA, Verani MS, Haichin RM, et al. Exercise echocardiography versus 201TI single-photon emission computed tomography in evaluation of coronary artery disease. Analysis of 292 patients. Circulation 1992;85:1026–31. [9] Choosing Wisely®. An initiative of the ABIM Foundation. Available at http:// www.ChoosingWisely.org Accessed May 13, 2012.