Appropriate Use Criteria for PET Myocardial Perfusion Imaging, David E. Winchester, MD


In the last decade, myocardial perfusion imaging (MPI) with PET has emerged to play a pivotal role in the clinical routine process for the detection of hemodynamically significant obstructive coronary artery disease (CAD) and cardiovascular risk stratification (1–5).

The high spatial and contrast resolution in concert with photon attenuation-free images of PET have led to high image quality

associated with the highest sensitivity and specificity of PET/CT perfusion imaging in the detection and characterization of CAD (1,2,6,7). In addition, the noninvasive evaluation and quantification of global and regional myocardial blood flow (MBF) in milliliters per gram per minute during hyperemic stress and at rest, as well as the calculation of the resulting myocardial flow reserve (MFR), extends the scope of standard MPI from the detection of advanced and flow-limiting epicardial CAD to a comprehensive assessment of ischemic burden. This improved scope results not only from the traditionally sought significant left main or multivessel disease, but also from the more recently appreciated cardiac effects of nonobstructive CAD and coronary microvascular disease (CMD), which conveys important diagnostic and incremental prognostic information (1,2,4–11).

The increased availability and high sensitivity of PET MPI in concert with concerns about missed diagnoses, however, may at

times lead to an inappropriate application of this technology. Thus, to avoid unnecessary financial burden on the health-care system and, in some cases, unnecessary exposure of patients to ionizing radiation, we have established a consensus document that outlines the most appropriate and cost-effective use of PET MPI. It is hoped that this expert guidance will help to render the use of PET MPI more consistent and will improve health-care outcomes for the targeted patient population while minimizing unnecessary imaging costs. The goal of this document is to describe the appropriate use of

PET MPI in patients with suspected or known CAD and in patients with suspected microvascular angina. Through these recommendations, it is expected that PET MPI will be applied to benefit these patients in the most cost-effective manner.

Representatives from the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the American College of Cardiology

(ACC), the American Society of Nuclear Cardiology (ASNC), the Canadian Cardiovascular Society (CCS), the Canadian Society of

Cardiovascular Nuclear and CT Imaging (CSCNCTI), the Society of Cardiovascular CT (SCCT), the American Heart Association

(AHA), the American College of Physicians (ACP), and the European Association of Nuclear Medicine (EANM) assembled as

an autonomous workgroup to develop the following appropriate use criteria (AUC). This process was performed in accordance with the Protecting Access to Medicare Act of 2014. This legislation requires that all referring physicians consult AUC by using a clinical decision support mechanism before ordering any advanced diagnostic imaging services. Such services are defined as diagnostic MRI, CT, nuclear medicine procedures (including PET), and others as specified by the Secretary of Health and Human Services in consultation with physician specialty organizations and other stakeholders (12). The AUC in this paper are intended to aid referring medical practitioners in the appropriate use of PET MPI for the most common scenarios encountered in patients with suspected or known CAD as well as in patients with suspected microvascular angina.

Thomas H. Schindler1, Timothy M. Bateman1, Daniel S. Berman1, Panithaya Chareonthaitawee1,2, Lorraine E. De
Blanche3, Vasken Dilsizian1,2, Sharmila Dorbala1, Robert J. Gropler1, Leslee Shaw4,5, PremSoman1,4, David E.Winchester6,
Hein Verberne7, Sukhjeet Ahuja1, Rob S. Beanlands1,2,4,8,9, Marcelo F. Di Carli1,10, Venkatesh L. Murthy1,
Terrence D. Ruddy1,8,9, and Ronald G. Schwartz1
1Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia; 2American Society of Nuclear Cardiology, Fairfax, Virginia;
3American College of Nuclear Medicine, Reston, Virginia; 4American College of Cardiology, Washington, D.C.; 5Society of
Cardiovascular Computed Tomography, Arlington, Virginia; 6American College of Physicians, Philadelphia, Pennsylvania;
7European Association of Nuclear Medicine, Vienna, Austria; 8Canadian Society of Cardiovascular Nuclear and CT Imaging, Ottawa,
Ontario, Canada; 9Canadian Cardiovascular Society, Ottawa, Ontario, Canada; and 10American Heart Association, Dallas, Texas