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2019 ACC AUC for Multimodality Imaging in Nonvalvular Heart Disease

Clinical Quick Reference — Appropriate Use Criteria for Cardiac Imaging Modalities

Published: Journal of the American College of Cardiology (2019)
Societies: ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS
DOI: 10.1016/j.jacc.2018.10.038
View Full Guideline PDF

Overview and Scope

This 2019 Appropriate Use Criteria (AUC) document provides evidence-based guidance on the selection and interpretation of multimodality cardiac imaging in patients with nonvalvular structural heart disease. The document assesses 102 distinct clinical indications across 9 imaging modalities, spanning initial evaluation, serial assessment, and pre-procedural planning.

Key Principle: The goal is not to identify a single "best test" but to define the range of modalities that may be appropriate or rarely appropriate for specific clinical scenarios. Physician judgment, patient preference, and local expertise guide final selection.

Imaging Modalities Covered

This quick reference focuses on the highest-yield clinical scenarios and modality pairings. For complete coverage of all 102 indications, consult the full guideline PDF.

Appropriateness Use Criteria Rating Scale

Each indication-modality pairing is scored on a scale of 1 to 9, with scores aggregated into three categories that guide clinical decision-making:

Appropriate (7–9)
Procedure is acceptable and reasonable. Expected benefit significantly exceeds expected negative consequences.
May Be Appropriate (4–6)
Uncertain appropriateness. Additional evidence or patient-specific factors needed. Risks and benefits more balanced.
Rarely Appropriate (1–3)
Procedure generally not acceptable. Expected negative consequences outweigh expected benefits.
General Assumptions Underlying All Ratings:
  • Patient is suitable for the procedure with consideration of procedural risk
  • Qualified clinician obtains complete clinical history and physical examination
  • All patients receive optimal standard care (pharmacotherapy, lifestyle modification)
  • Radiation safety principles (ALARA) are applied for tests involving ionizing radiation
  • Cost is balanced against clinical benefit
Clinical Insight: When multiple modalities are rated in the same AUC category, selection depends on local expertise, modality availability, patient factors (renal function, body habitus, ability to cooperate), and cost. Multimodality imaging is often superior to single-test strategies for diagnostic and prognostic accuracy.

Initial Evaluation of Asymptomatic Patients

This section addresses imaging in asymptomatic or low-risk patients, including family history screening, pre-operative evaluation, and risk stratification in genetic/hereditary conditions.

Indication TTE CMR CT Echo 3D Stress Strain
Genetic disease (HCM, Marfan, ARVC, etc.) 9 8 2 5 1 5
Family hx of inherited cardiomyopathy 9 7 1 4 1 4
Pre-cardiotoxic therapy baseline (chemotherapy/radiation) 9 2 1 7 1 7
Aortic evaluation (Marfan, connective tissue disease) 8 7 8 5 1 1
Pre-participation athlete screening (asymptomatic, normal ECG) 3 1 1 1 1 1
Athlete with abnormal ECG, fhx, or HCM suspicion 9 1 2 4 4 5
Pulmonary arterial hypertension evaluation 9 4 4 2 1 2

Initial Evaluation of Symptomatic Patients

Imaging evaluation when patients present with clinical signs and/or symptoms of heart disease. This section covers the most common and high-yield clinical scenarios from the full 42-indication set in the guideline.

Heart Failure and Cardiomyopathy

Indication TTE Stress CMR CT PET
Initial eval: HF symptoms/signs 9 5 1 2 1
Suspected cardiomyopathy (ejection fraction unknown) 9 3 6 1 1
Evaluation for specific cardiomyopathy: HCM, restrictive, amyloid 9 2 7 2 6
Myocarditis or acute heart disease 9 2 8 1 4

Arrhythmias and Conduction Disorders

Indication TTE CMR CT Stress
Sustained VT or VF 9 3 2 6
Newly diagnosed RBBB 5 2 1 3
Atrial fibrillation (initial) 8 3 1 6
Syncope without other findings 8 2 2 4

Pericardial and Aortic Disease

Indication TTE TEE CMR CT
Suspected pericardial disease 9 4 5 1
Suspected acute aortic pathology (dissection) 7 8 1 9
Cardiac mass, tumor, or thrombus 9 7 8 1

Sequential and Follow-Up Testing

Re-evaluation strategies when prior imaging has been performed and clinical status changes, symptoms worsen, or therapy requires optimization.

Guidance for Serial Imaging

When to Perform Follow-Up Imaging

  • New or worsening symptoms despite therapy
  • Change in clinical examination or functional status
  • Before major surgical procedure
  • Periodic assessment in cardiomyopathy with potentially progressive disease
  • Device therapy optimization or potential complication
  • Response assessment after treatment initiation

When NOT to Perform Routine Follow-Up Imaging

  • Asymptomatic stable HF without clinical change: avoid <1 year
  • Known HTN without structural change: avoid <3 years
  • Chronic stable pericardial effusion without hemodynamic concern: only if clinical change
  • Post-myocarditis without ongoing symptoms: rarely appropriate <6 months

Common Re-Evaluation Scenarios

Indication TTE CMR TEE Stress
Known cardiomyopathy with new/worsening symptoms 8 5 3 5
Known HF with change in status 8 5 3 5
Periodic re-evaluation during cardiotoxic therapy 8 4 3 2
Equivocal initial imaging (clarify diagnosis) 3 6 2 4

Imaging for Transcatheter Interventions

Pre-, intra-, and post-procedural imaging for structural interventions including PFO/ASD closure and LAA occlusion.

PFO/Atrial Septal Defect (ASD) Closure

Scenario TTE (Bubble) TEE 3D-TEE ICE
Pre-Procedure: Anatomy and suitability assessment 7 8 5 —
Intra-Procedure: Real-time device guidance 1 7 7 8
Post-Procedure: Device closure adequacy at 6 months 7 — — —

Left Atrial Appendage (LAA) Occlusion

Scenario TTE TEE 3D-TEE ICE
Pre-Procedure: LAA morphology, sizing 6 9 7 —
Intra-Procedure: Device delivery and deployment — 9 6 6
Post-Procedure: Device closure, leak assessment (45 days) 4 8 — —

Stroke/TIA Evaluation

Indication TTE (Contrast) TEE MRA/CTA
Evaluate for cardiac source of emboli in stroke/TIA patient 8 7 6
Assess intracranial arteries (carotid, vertebral) — — 8
Right-to-left shunt assessment with maneuvers 8 7 —

Key Definitions and Methodology

Patient Classifications

Stages of Valvular Heart Disease

Stages of Heart Failure

AUC Methodology Overview

A 9-point scale was used, with scores aggregated into three categories (Appropriate 7–9, May Be Appropriate 4–6, Rarely Appropriate 1–3). An expert rating panel independently scored each indication based on available evidence, consensus guidelines, and clinical experience. Panelists considered diagnostic accuracy, therapeutic impact, prognostic significance, procedural safety, radiation exposure, cost, and patient burden. The final score for each indication represents the median panel assessment.

Important Note: These AUC ratings reflect 2019 evidence and expert opinion. Future research and emerging technologies may warrant revision of specific indications. The ratings are intended to inform, not replace, individualized clinical judgment.

Related Calculators for Cardiac Assessment

Complement guideline-recommended imaging with these calculators to quantify risk, assess prognosis, and monitor therapy response in heart failure and cardiomyopathy.

HCM SCD Risk

5-year sudden cardiac death risk prediction in hypertrophic cardiomyopathy.

MAGGIC Heart Failure

1- and 3-year mortality risk in HF patients across EF ranges.

H₂FPEF Score

Diagnostic score for HFpEF vs. other causes of dyspnea.

HFpEF Diagnostic Score

Clinical and echographic likelihood of HFpEF diagnosis.

LV Mass Index

Left ventricular mass normalized to body surface area.

E/e' Ratio Calculator

Estimate LV filling pressures and diastolic function.

Left Atrial Volume Index

LA volume normalized to BSA; marker of AF risk and prognosis.
Integration Strategy: Use imaging modalities rated Appropriate in this guideline to obtain accurate measurements (chamber size, function, strain, volumes), then input those values into these calculators for risk quantification and prognostic estimation.