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## Complete Summary

#### GUIDELINE TITLE

Acute chest pain - no ECG or enzyme evidence of myocardial
ischemia/infarction.

#### BIBLIOGRAPHIC SOURCE(S)

Stanford W, Yucel EK, Bettmann MA, Casciani T, Gomes AS, Grollman JH,
Holtzman SR, Polak JF, Sacks D, Schoepf J, Jaff M, Moneta GL, Expert
Panel on Cardiovascular Imaging. Acute chest pain: no ECG or enzyme
evidence of myocardial ischemia/infarction. \[online publication\].
Reston (VA): American College of Radiology (ACR); 2005. 5 p. \[39
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Cardiovascular Imaging. Acute chest pain - no ECG
evidence of myocardial ischemia/infarction. Reston (VA): American
College of Radiology (ACR); 2001. 5 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s)/intervention(s) for which important revised
regulatory and/or warning information has been released.

-   [June 8, 2007, Troponin-I
    Immunoassay](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Architect):
    Class I Recall of all lots of the Architect Stat Troponin-I
    Immunoassay. The assay may report falsely elevated or falsely
    decreased results at and near a low level, which may impact patient
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute chest pain with no electrocardiogram (ECG) or enzyme evidence of
myocardial ischemia/infarction

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Cardiology\
Emergency Medicine\
Family Practice\
Internal Medicine\
Nuclear Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with acute chest pain without electrocardiogram (ECG) or enzyme
evidence of myocardial ischemia/infarction

#### TARGET POPULATION

Patients with acute chest pain with no electrocardiogram (ECG) or enzyme
evidence of myocardial ischemia/infarction

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

    -   Chest

    -   Barium swallow and upper gastrointestinal (GI) series

    -   Rib

    -   Cervical spine

    -   Thoracic spine

2.  Computed tomography (CT)

    -   Chest, multidetector (MDCT)

    -   Chest, single detector

3.  Magnetic resonance imaging (MRI), aortic

4.  Magnetic resonance angiography (MRA)

    -   Aortic

    -   Pulmonary artery

5.  Ultrasound (US)

    -   Transthoracic echocardiography (TTE)

    -   Transesophageal echocardiography (TEE)

    -   Stress echocardiography

    -   Gall bladder

    -   Peripheral venous

6.  Nuclear medicine (NUC)

    -   Myocardial perfusion scan

    -   Ventilation/perfusion (V/Q) scan

    -   Bone scan

7.  Positron emission tomography (PET), cardiac

8.  Invasive (INV)

    -   Catheter pulmonary angiography

    -   Coronary angiography with left ventricular (LV) gram

9.  Aortogram, thoracic

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed to reach agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by the participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Acute Chest Pain: No ECG or Enzyme Evidence of
Myocardial Ischemia/Infarction**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                    

  NUC, myocardial      8                   If myocardial etiology is
  perfusion scan                           suspected.

  CT, chest, multi     8                   Useful to rule out other sources
  detector (MDCT)                          for chest pain such as aortic
                                           dissection, pulmonary embolism,
                                           etc.

  US, transthoracic    6                   If CT is non-diagnostic.
  echocardiography                         
  (TTE)                                    

  US, transesophageal  6                   To exclude aortic dissection.
  echocardiography                         Especially if MDCT or MRI are not
  (TEE)                                    diagnostic and/or not available.

  CT, chest, single    6                    
  detector                                 

  MRI/MRA, aortic      6                    

  INV, catheter        6                   If MDCT is non-diagnostic and
  pulmonary                                pulmonary embolism is suspected.
  angiography                              

  NUC, V/Q scan        5                   May be appropriate if contrast
                                           administration is contraindicated.

  X-ray, barium        4                    
  swallow and upper GI                     
  series                                   

  X-ray, rib           4                    

  X-ray, cervical      4                    
  spine                                    

  X-ray, thoracic      4                    
  spine                                    

  US, stress           4                   May be indicated if cardiac
  echocardiography                         etiology is still suspected after
                                           negative CXR and MDCT.

  US, gall bladder     4                    

  US, peripheral       4                    
  venous                                   

  MRA, pulmonary       4                    
  artery                                   

  PET, cardiac         4                    

  Aortogram, thoracic  4                   Unless results of less invasive
                                           tests are equivocal.

  INV, coronary        4                   Last choice for evaluation. Only
  angiography with LV                      if other tests are equivocal.
  gram                                     Depends on noninvasive test.

  NUC, bone scan       2                    

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the table are listed at the end of the
\"Major Recommendations\" field.

**Introduction**

Patients frequently present to emergency departments with the classical
anginal symptoms of chest tightness and left arm pain. If these symptoms
are present and if an ECG shows evidence of ischemia, a cardiac etiology
for the chest pain is favored. Ischemic pain can also masquerade as
indigestion, muscle spasm, or myriad other complaints. Many patients,
however, present with chest pain without strong evidence of a cardiac
etiology, that is, with a normal or nondiagnostic ECG and serum markers
(i.e., troponins). In such patients, other diagnoses need to be
considered, and other imaging modalities need to be utilized.

Imaging modalities useful in evaluating patients presenting to the
emergency department without ECG or troponin evidence of myocardial
infarction/angina, but with suspected cardiac origin for the chest pain
are chest film, TEE and TTE, thallium 201 and technetium 99m perfusion
studies, positron emission tomography, technetium 99m pyrophosphate
infarct avid imaging, radionuclide ventriculography, cardiac
catheterization, and the CT determination of coronary calcium. Imaging
modalities to evaluate what are thought to be noncardiac causes of chest
pain include cervical and thoracic spine films, barium upper GI studies,
radionuclide esophageal transit time studies, pulmonary angiography, V/Q
scans, CT spine, aortic, and pulmonary artery studies, MRI spine and
aortic studies, abdominal ultrasound, and possibly mammography.

**Chest Film**

The chest film is extremely important in evaluating patients presenting
to the emergency room with chest pain, and it is usually the initial
imaging study obtained. Plain chest films can be diagnostic in
pneumothorax, pneumomediastinum, fractured ribs, acute or chronic
infections, and malignancies. Other conditions producing chest pain,
such as aortic aneurysms or dissections and pulmonary emboli, may be
suspected from the chest film, but the overall sensitivity is very low.

Calcifications may indicate pericardial disease, ventricular aneurysms,
intracardiac thrombi, or aortic disease. The presence of a Hampton hump,
Westermark sign, or pulmonary artery enlargement may indicate pulmonary
embolism. Mediastinal air may indicate a ruptured viscus or rupture of a
subpleural bleb.

**Transthoracic and Transesophageal Echocardiography**

TTE and TEE with or without pharmacologic stress can help define a
cardiac origin for chest pain when abnormalities of ventricular wall
motion are present. TTE may additionally be helpful in diagnosing
pericarditis, pericardial effusion, valvular dysfunction, and/or
intracardiac thrombus. TTE is helpful in diagnosing aortic dissection,
intracardiac thrombus, and valvular dysfunction. With TEE, the arch of
the aorta and the upper abdominal aorta are less well visualized;
however, the ascending and descending aorta are usually well seen. In a
small number of patients, mitral valve prolapse may be the cause for the
chest pain, and this condition could be recognized using transesophageal
echocardiography. Pharmacologic stress can add an additional element of
risk stratification to the echocardiographic examination, particularly
if coronary artery occlusive disease remains a concern.

**Conventional, Helical, and Electron Beam Computed Tomography**

Conventional CT can be diagnostic in pneumothorax, pneumonia,
malignancies, and chronic pulmonary disorders such as fibrosis and
granulomatous disease. It can also help to confirm central pulmonary
emboli, pulmonary infarcts, and aortic aneurysms and dissections.
Complications of aortic aneurysms such as leaks are also identifiable
with CT. Pericardial effusions, thickening, and calcifications are
readily seen. Electron beam CT and helical CT are additionally helpful
by diagnosing coronary artery calcification (atherosclerosis) as the
possible cause of the chest pain, although specificity is low.
Conversely, the absence of calcium is an excellent indicator of the
absence of significant coronary stenosis. Both types of CT have
additional utility in defining ventricular aneurysms, wall motion
abnormalities, and thrombus resulting from myocardial infarction. CT
angiography (CTA) is gaining utility in evaluating coronary stenosis and
detecting the presence of anomalous coronary arteries. MDCT is the
current standard rather than single-slice CT.

**Cervical and Thoracic Spine Films**

Films of the cervical and thoracic spine may be indicated to establish
vertebral abnormalities (e.g., vertebral body collapse or fracture) as a
cause of chest pain.

**Radionuclide Studies**

*Myocardial perfusion* studies using thallium 201, technetium 99m
sestamibi, or tetrofosmin scintigraphy can identify perfusion
abnormalities and help in establishing a cardiac cause for the chest
pain.

*Radionuclide ventriculography* can also help establish a cardiac
etiology for the chest pain by demonstrating abnormalities of
ventricular wall motion secondary to ischemia/infarction.

*Infarct avid imaging* with technetium 99m pyrophosphate can identify
acute myocardial infarction at 12-36 hours after infarct by showing
radioactive tracer uptake at the infarction site.

*Positron emission tomography* can reliably show myocardial perfusion
deficits using N13 ammonia agents and can document anaerobic myocardial
metabolism using F18 fluorodeoxyglucose. Again, these tests may be of
help in the patient suspected of having a cardiac etiology for the chest
pain and in whom the ECG and troponin are nondiagnostic.

**Magnetic Resonance**

MRI has utility in demonstrating spinal abnormalities and nerve root
compression as a cause of chest pain. It also has utility in
demonstrating myocardial wall motion abnormalities and/or pericardial
thickening and effusion. At times intracardiac thrombi can be seen;
however, other tests are usually better for establishing cardiac
etiologies as the source of the chest pain. Magnetic resonance perfusion
agents can show either a \"cold spot\" of myocardial infarction with the
use of T1 enhancing agents or a \"hot spot,\" using magnetic
susceptibility agents. These techniques may be helpful in establishing a
cardiac etiology for the chest pain where the ECG and troponin are
either negative or nondiagnostic. MR imaging incorporating dobutamine
and other pharmacologic stress agents increases sensitivity in
determining a cardiac etiology for chest pain.

**Cardiac Catheterization**

Cardiac catheterization with coronary angiography is the \"gold
standard\" for demonstrating coronary pathology. This is usually the
final diagnostic test in defining heart disease, although MDCT has
recently shown promise as an accurate noninvasive alternative,
particularly if the diagnosis is in question.

**Barium Swallow/Endoscopy**

Esophageal disorders may be the cause of chest pain in patients
presenting to the emergency department with symptoms typical of angina
but with negative ECG and troponins. A barium swallow or endoscopy and,
in some cases, radionuclide transit studies may be of help in diagnosing
esophageal spasm or reflux as an etiology of the chest pain.

**Abdominal Plain Films**

In limited instances, cholecystitis or cholangitis, renal disease,
perforated viscus, or diaphragmatic abnormalities may be an etiology for
chest pain. These disorders can often be suspected from an abdominal
plain film.

**Abdominal Ultrasonography**

Abdominal ultrasound may be indicated in establishing cholecystitis as a
cause for the chest pain. Ultrasound is also helpful in evaluating
pancreatitis and/or abscesses and other fluid collections.

**Pulmonary Angiography**

Pulmonary angiography had been considered to be the definitive test in
patients with suspected pulmonary embolism. Multidetector CT angiography
has largely replaced catheter pulmonary angiography. In addition to
being noninvasive and having the ability to demonstrate smaller emboli,
it has the added advantage of demonstrating other abnormalities that may
be the cause of the chest pain, such as neoplasm or pulmonary airspace
disease. The ventilation/perfusion scan is rapidly being replaced by
MDCT. At times it can be additionally helpful in establishing pulmonary
embolism as the etiology for the chest pain, although it is now
generally reserved for patients who cannot undergo CT pulmonary
angiography.

**Mammography**

On rare occasions fat necrosis or breast abscess can masquerade as
angina. If these conditions are suspected, a mammogram, breast
ultrasound, or MR studies may be indicated.

**Aortography**

As with pulmonary angiography, catheter-based aortography had been
considered the definitive imaging procedure in patients with aortic
dissection or aneurysmal disease. It has now been almost completely
replaced by CTA or MRA, as both are rapid, noninvasive, and able not
only to define the aortic lumen but also to characterize the aortic wall
and other pathology.

**Summary**

Although the patient\'s history is the most important factor in
establishing the etiology in patients presenting to the emergency
department with chest pain, other imaging modalities are frequently
used. The chest film is almost universally obtained; CT, MRI,
radionuclide studies, barium swallow, spine studies, plain films, and
angiography are useful when specific diagnoses are considered.

**Abbreviations**

-   CT, computed tomography

-   CXR, chest x-ray

-   ECG, electrocardiogram

-   GI, gastrointestinal

-   INV, invasive

-   LV, left ventricular

-   MDCT, multidetector computed tomography

-   MRA, magnetic resonance angiography

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   PET, positron emission tomography

-   TEE, transesophageal echocardiography

-   TTE, transthoracic echocardiography

-   US, ultrasound

-   V/Q, ventilation/perfusion scan

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with acute chest pain with no electrocardiogram (ECG) or enzyme
evidence of myocardial ischemia/infarction

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Stanford W, Yucel EK, Bettmann MA, Casciani T, Gomes AS, Grollman JH,
Holtzman SR, Polak JF, Sacks D, Schoepf J, Jaff M, Moneta GL, Expert
Panel on Cardiovascular Imaging. Acute chest pain: no ECG or enzyme
evidence of myocardial ischemia/infarction. \[online publication\].
Reston (VA): American College of Radiology (ACR); 2005. 5 p. \[39
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Cardiovascular
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: William Stanford, MD; E. Kent Yucel, MD (*Panel
Chair*); Michael A. Bettmann, MD; Thomas Casciani, MD; Antoinette S.
Gomes, MD; Julius H. Grollman, MD; Stephen R. Holtzman, MD; Joseph F.
Polak, MD, MPH; David Sacks, MD; Joseph Schoepf, MD; Michael Jaff, MD;
Gregory L. Moneta, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of Radiology
(ACR), Expert Panel on Cardiovascular Imaging. Acute chest pain - no ECG
evidence of myocardial ischemia/infarction. Reston (VA): American
College of Radiology (ACR); 2001. 5 p. (ACR appropriateness criteria).

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 20, 2001. The information
was verified by the guideline developer on March 14, 2001. This summary
was updated by ECRI on July 31, 2002. The updated information was
verified by the guideline developer on October 1, 2002. This summary was
updated by ECRI on March 17, 2006. This summary was updated by ECRI
Institute on July 12, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on Troponin-1 Immunoassay.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008