ASCI 2010 appropriateness criteria for cardiac magnetic resonance imaging: a report of the Asian Society of Cardiovascular Imaging cardiac computed tomography and cardiac magnetic resonance imaging guideline working group



# Introduction
Due to differences in culture, healthcare systems, ethnicity [bib_ref] Racial and ethnic differences in cardiovascular disease risk factors: a systematic review, Kurian [/bib_ref] , socioeconomic status [bib_ref] How does socioeconomic development affect risk of mortality? An age-period-cohort analysis from..., Chung [/bib_ref] and disease prevalence [bib_ref] Prevalence and prognosis of patients with heart failure in Tokyo: a prospective..., Goda [/bib_ref] [bib_ref] Evolving cardiovascular disease prevalence, mortality, risk factors, and the metabolic syndrome in..., Zheng [/bib_ref] , existing guidelines for cardiac computed tomography (CT) and cardiac magnetic resonance (MR) developed by western professional societies are often not applicable in Asian countries. In March 2009, the Asian Society of Cardiovascular Imaging (ASCI), as the only society in Asia dedicated solely to cardiovascular imaging, nominated 7 representatives from different Asian countries to form a working group to provide recommendations on cardiac CT and cardiac MR. Detailed background of this project has previously been described in the ASCI cardiac CT criteria report, the first publication from the working group, which summarized the opinions of leading cardiac CT practitioners in Asia on 51 indications [bib_ref] ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the..., Asci Cct &amp; Cmr Guideline Working [/bib_ref]. As the second step, we present here the ASCI cardiac MR appropriateness criteria. The purpose of this report is to serve as a reference for Asian practitioners to promote and improve their use of cardiac MR by providing appropriateness ratings for common clinical indications.

# Methods
ASCI cardiac MR appropriateness criteria were developed through the same process as used for ASCI CT appropriateness criteria published earlier this year [bib_ref] ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the..., Asci Cct &amp; Cmr Guideline Working [/bib_ref]. Briefly, we employed the modified Delphi method with one-round data collection to evaluate the cardiac MR appropriateness [bib_ref] International, multidisciplinary update of the 2006 Appropriateness Criteria for cardiac computed tomography, Carbonaro [/bib_ref] [bib_ref] ACCF proposed method for evaluating the appropriateness of cardiovascular imaging, Patel [/bib_ref]. A total of 25 panelists were nominated [Japan 6, Korea 5, Taiwan 4, China 3, Hong Kong (China) 3, Singapore 2, Thailand 2] by Working Group members, and approved by the Working Group with consensus.
In the development of the cardiac MR indications, the Working Group members agreed to use the 33 cardiac MR indications provided by the ACCF 2006 appropriateness criteria as the framework [bib_ref] appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a..., Hendel [/bib_ref]. Indications considered for the ASCI 2010 cardiac CT appropriateness criteria were added and integrated to derive 50 indications which were approved by the Working Group. Among the 50 indications, 28 were in common with ACCF 2006 appropriateness criteria and 39 were in common with ASCI 2010 CT appropriateness criteria. Three indications [risk assessment in general populations with low, moderate and high coronary heart disease risk using coronary magnetic resonance angiography (MRA)] were original indications of ASCI cardiac MR appropriateness criteria.
A questionnaire was emailed to the 25 Technical Panel members. After completion, the questionnaires were collected by the ASCI office. The questionnaires were collected during a period between October 13 and November [bib_ref] Late gadolinium-enhanced magnetic resonance imaging in acute and chronic myocardial infarction. Improved..., Ichikawa [/bib_ref]. Please refer to the online supplement for the complete questionnaire (Online Supplement 1).

## Definition of cardiac mr
There are a variety of techniques used for cardiac MR [bib_ref] Cardiac MRI in ischemic heart disease, Ishida [/bib_ref]. Basic protocols might include cine magnetic resonance imaging (MRI) for wall motion and delayed gadolinium enhancement MRI for the assessment of scar [bib_ref] Annular geometry in patients with chronic ischemic mitral regurgitation: three-dimensional magnetic resonance..., Kaji [/bib_ref] [bib_ref] Late gadolinium-enhanced magnetic resonance imaging in acute and chronic myocardial infarction. Improved..., Ichikawa [/bib_ref] [bib_ref] Late gadolinium enhancement by cardiovascular magnetic resonance heralds an adverse prognosis in..., Wu [/bib_ref] [bib_ref] Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on..., Kwong [/bib_ref] [bib_ref] Left ventricular systolic dyssynchrony is a predictor of cardiac remodeling after myocardial..., Zhang [/bib_ref] [bib_ref] Comparison of cardiovascular magnetic resonance of late gadolinium enhancement and diastolic wall..., Krittayaphong [/bib_ref] [bib_ref] Myocardial viability in chronic ischemic heart disease: comparison of delayedenhancement magnetic resonance..., Liu [/bib_ref] [bib_ref] Myocardial imaging with 18F-fluoro-2-deoxyglucose positron emission tomography and magnetic resonance imaging in..., Ohira [/bib_ref] [bib_ref] Frequency and distribution of late gadolinium enhancement in magnetic resonance imaging of..., Yamada [/bib_ref] [bib_ref] Effects of balloon-based distal protection during primary percutaneous coronary intervention on early..., Hahn [/bib_ref]. However, some may perform stress tests routinely using either perfusion MRI with adenosine [bib_ref] Diagnostic accuracy of stress myocardial perfusion MRI and late gadolinium-enhanced MRI for..., Kitagawa [/bib_ref] [bib_ref] Cardiac magnetic resonance imaging with pharmacological stress perfusion and delayed enhancement in..., Kobayashi [/bib_ref] or cine MRI with dobutamine [bib_ref] Dobutamine stress magnetic resonance imaging for the detection of coronary artery disease..., Gebker [/bib_ref] , while others may consider coronary and non-coronary MRA [bib_ref] Detection of coronary artery stenosis with whole-heart coronary magnetic resonance angiography, Sakuma [/bib_ref] [bib_ref] Clinical feasibility of free-breathing, gadolinium-enhanced magnetic resonance angiography for assessing extracardiac thoracic..., Ko [/bib_ref] as important parts of cardiac MR examinations. Moreover, different techniques can be utilized to assess certain aspects of cardiac morphology and function [bib_ref] Additional value of myocardial perfusion imaging during dobutamine stress magnetic resonance for..., Gebker [/bib_ref] [bib_ref] Imaging the physiology of the ischemic cascade: are 2 tools better than..., Kwong [/bib_ref] [bib_ref] Diffusion tensor magnetic resonance imaging mapping the fiber architecture remodeling in human..., Wu [/bib_ref] [bib_ref] New twodimensional global longitudinal strain and strain rate imaging for assessment of..., Chow [/bib_ref]. Since cardiac MR is still an intense field of research and development, it is also possible for appropriateness to be influenced by the availability of newer scanners and more sophisticated imaging techniques [bib_ref] Contrast-enhanced whole-heart coronary magnetic resonance angiography at 3.0-T: a comparative study with..., Yang [/bib_ref]. Thus, the Working Group decided to leave the definition of cardiac MR to the judgment of the Technical Panel members. Resulting variations in definitions might be an important reflection of the current perspectives of the leading Asian cardiac MR practitioners. In the questionnaire, the term ''cardiac MR'' was defined as including motion, stress and rest perfusion, delayed gadolinium enhancement, flow measurement, black blood T2-weighted imaging, and coronary MRA.

## Rating system
The rating system used in this Asian survey is the same as previously used in other appropriateness criteria reports and ASCI CT appropriateness criteria. The panelists were asked to assess whether the use of cardiac MR for various indications was appropriate, uncertain or inappropriate. The Technical Panel scored each indication as follows: Score 7-9: Appropriate test for the specific indication. Test is generally acceptable and a reasonable approach for the listed indication. Score 4-6: Uncertain for specific indication. Test may be generally acceptable and may be a reasonable approach for the indication. Uncertainty also implies that more research or patient information or both are needed to classify the indication definitively. Score 1-3: Inappropriate test for specific indication. Test is not generally acceptable and is not a reasonable approach for the indication.
In a panel with 23-25 members, 'highly agreed' was defined as 7 or fewer panelists rating outside the threepoint region containing the median. 'Disagreement' was defined as at least 8 panelists rating in either extreme . Median values for each indication served as the final scoring if there was no disagreement among Technical Panelists [bib_ref] ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the..., Asci Cct &amp; Cmr Guideline Working [/bib_ref] [bib_ref] ACCF proposed method for evaluating the appropriateness of cardiovascular imaging, Patel [/bib_ref] [bib_ref] appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a..., Hendel [/bib_ref]. If there was disagreement, the final appropriateness score was set as uncertain regardless of the median.

# Results
The questionnaires were emailed to the Technical Panel members on . Completed questionnaires were returned from 23 members [Japan 6, Korea 5, Taiwan 4, China 2, Hong Kong (China) 2, Singapore 2, Thailand 2] by November 11. Their specialties were radiology in 17 and cardiology in 6. The years of experience in the cardiovascular field ranged from 4 to 26 years while the experience of cardiac MR interpretation ranged from 300 to 3,000 examinations. For the cardiologists, the number of percutaneous coronary interventions performed range from 0 to 700 cases. The hospitals they were working in included city hospitals, medical centers, and university hospitals, with in-patient bed numbers ranging from 440 to 5,600. The complete list of Technical Panel members is provided at the beginning of this report.
Among the indications rated by Technical Panel, none showed disagreement. There were 24 appropriate, 18 uncertain and 8 inappropriate indications. Technical Panel members highly agreed in 22 indications, including 19 appropriate and 3 inappropriate indications. The 'highly agreed' inappropriate indications were: use of cardiac MR for evaluation of chest pain syndrome in patients with low pre-test probabilities of CAD, interpretable ECGs and ability to exercise; use of cardiac MR for detection of CAD in asymptomatic patients with low coronary heart disease risk; and use of coronary MRA for risk assessment in patients with low coronary heart disease risk. A detail appropriateness rating result is provided as an online supplement (Online Supplement 2).
Compared with the ACCF 2006 report [bib_ref] appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a..., Hendel [/bib_ref] , only 4/ 28 (14%) indications changed their category. Indication no. 38 (''evaluation of LV function following myocardial infarction or in heart failure patients'') and no. 49 (''to detect post PCI myocardial necrosis'') were shifted from uncertain to appropriate. Indication no. 30 (''evaluation of bypass grafts and coronary anatomy'') and no. 31 (''history of percutaneous revascularization with stents'') were shifted from inappropriate to uncertain.
Compared with the ASCI cardiac CT appropriateness criteria report [bib_ref] ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the..., Asci Cct &amp; Cmr Guideline Working [/bib_ref] , 29/39 (74%) were in the same appropriateness category. In 7 indications, cardiac CT received a more favorable category than cardiac MR: indication no. 2 (''detection of CAD: symptomatic, intermediate pre-test probability of CAD. ECG interpretable and able to exercise''), no. 27 (''use of MRI for CAD evaluation before valve surgery''), no. 29 (''evaluation of complex lesions before PCI''), no. 30 (''evaluation of bypass grafts and coronary anatomy''), no. 31 (''history of percutaneous revascularization with stents''), no. 33 (''evaluation of bypass grafts and coronary anatomy greater than or equal to 5 years after CABG''), and no. 34 (''evaluation for in-stent restenosis and coronary anatomy after PCI''). On the other hand, cardiac MR received a more favorable category than cardiac CT in 3 indications; indication no. 38 (''evaluation of LV function following myocardial infarction or in heart failure patients''), no. 48 (''to determine the location and extent of myocardial infarction including 'noreflow' regions, post-acute myocardial infarction''), and no. 50 (''to determine viability prior to revascularization'').
The final ratings for cardiac MR are listed by indication sequentially and by appropriateness category.

# Discussion
This ASCI cardiac MR appropriateness criteria report was developed in order to reflect the current status of cardiac MR in Asia and the opinions of Asian cardiac MR leaders about appropriate indications for cardiac MR. This report should prove useful in clinical Among the 50 indications evaluated in this report, 28 were in common with the ACCF 2006 appropriateness criteria report [bib_ref] appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a..., Hendel [/bib_ref] , 39 were also included in the ASCI 2010 cardiac CT appropriateness criteria report [bib_ref] ASCI 2010 appropriateness criteria for cardiac computed tomography: a report of the..., Asci Cct &amp; Cmr Guideline Working [/bib_ref] and 3 indications were unique to this report. In contrast to the ASCI cardiac CT appropriateness criteria report in which an upward shift of appropriateness category was demonstrated in 51.3% (20/39) of the indications as compared with ACCF 2006 appropriateness criteria report, such a shift was seen in only 14.3% (4/28) of the indications in this cardiac MR appropriateness criteria report. The rapid advancement of CT technology [bib_ref] CT coronary angiography: the continuing challenges of validating and optimizing a new..., Nicol [/bib_ref] and associated accumulation of evidence of its clinical usefulness [bib_ref] Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and..., Dewey [/bib_ref] [bib_ref] Incremental value of adenosine-induced stress myocardial perfusion imaging with dual-source CT at..., Rocha-Filho [/bib_ref] [bib_ref] Diagnostic performance of coronary angiography by 64-row CT, Miller [/bib_ref] as well as reduction of its radiation levels [bib_ref] Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and..., Dewey [/bib_ref] may explain the faster expansion of appropriate indications for cardiac CT compared to the expansion seen for cardiac MR, which has seen comparatively few technical advances over the past 5 years.
One of the most significant features of the ASCI cardiac CT and cardiac MR appropriateness criteria reports is the high number of indications evaluated for both CT and MR. Although cardiac CT was originally developed for visualization of coronary anatomy, recent studies have demonstrated the potential usefulness of one-stop shop cardiac examination in assessment of function, myocardial ischemia and myocardial viability [bib_ref] Adenosine-induced stress myocardial perfusion imaging using dual-source cardiac computed tomography, Blankstein [/bib_ref] [bib_ref] Comprehensive assessment of myocardial perfusion defects, regional wall motion, and left ventricular..., Cury [/bib_ref]. Meanwhile, the introduction of whole heart coronary MRA has enabled routine imaging of coronary anatomy which is completely noninvasive and without the need for radiation exposure and contrast medium [bib_ref] Detection of coronary artery stenosis with whole-heart coronary magnetic resonance angiography, Sakuma [/bib_ref] [bib_ref] Assessment of coronary arteries with total study time of less than 30..., Sakuma [/bib_ref] [bib_ref] Comparison of 3D free-breathing coronary MR angiography and 64-MDCT angiography for detection..., Liu [/bib_ref]. Given the similarities in information obtainable, it is inevitable that CT and MR share many indications. In our questionnaire surveys, different panelists were selected for CT and MR. The panelists were not aware that similar surveys were being performed for the other modality, thus minimizing the extent to which their ratings were based on comparison to the other modality. Our survey demonstrated that CT received higher ratings than MR in the morphological assessment of native coronary arteries and bypass grafts before and after revascularization therapy. On the other hand, assessment of myocardial viability and fibrosis can be performed better with MR. However, most appropriateness ratings were similar for CT and MR, indicating that modality choice should be based on the technology and expertise available at each individual medical center.
''Use of coronary MRA in the risk assessment of general population'' was evaluated in this survey. This indication was evaluated because coronary MRA has been gaining popularity as a screening tool in recent years, since the introduction of wholeheart coronary MRA [bib_ref] Assessment of coronary arteries with total study time of less than 30..., Sakuma [/bib_ref] [bib_ref] Detection of coronary artery disease by free-breathing, whole heart coronary magnetic resonance..., Kunimasa [/bib_ref]. We found that experts in Asia consider this indication inappropriate in populations with low to intermediate coronary heart disease risk. Future research is needed to determine whether risk assessment of population with high coronary heart disease risk is appropriate or not.
This survey had several limitations. As was the case with the ASCI cardiac CT appropriateness criteria report, the Technical Panel in this study was dominated by experts from Eastern and Southeastern Asia reflecting the current academic contribution and participation in ASCI. We hope to see active participation in ASCI from Asian countries outside the Asia-Pacific region in the future. Secondly, many Technical Panelists proposed further clarification of the scan protocol. Although the importance of correct choice of MR scan protocol cannot be underestimated, this aspect is considered too complicated to be included in this questionnaire survey because of the diversity and rapid innovation of MR scan techniques We expect that this ASCI 2010 cardiac MR appropriateness criteria report will serve as a timely and useful guide for the establishment of clinical cardiac MR services in Asian countries. ASCI will continue to pay close attention to this field and keep Asian practitioners updated about developments in cardiac MR and new indications as they arise.
Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. Left atrial and pulmonary venous anatomy including dimensions of veins for mapping purposes [bib_ref] New twodimensional global longitudinal strain and strain rate imaging for assessment of..., Chow [/bib_ref] Evaluation of complex lesions before PCI (i.e., chronic total occlusions, bifurcation lesions) U (5)

# Appendix
Detection of CAD: post-revascularization (PCI or CABG)-evaluation of chest pain syndrome 30 Evaluation of bypass grafts and coronary anatomy U (5)

## 31
History of percutaneous revascularization with stents U (4)
Detection of CAD: post-revascularization (PCI or CABG)-asymptomatic 32 Evaluation of bypass grafts and coronary anatomy U (4)
Less than 5 years after CABG 33 Evaluation of bypass grafts and coronary anatomy U (4)
Greater than or equal to 5 years after CABG
[fig] Ping: Chai, MRCP (Cardiac Department, National University Heart Centre, Singapore), Anna K Chan, MB ChB (Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China), Liuquan Cheng, MD, PhD (Department of Radiology, Chinese PLA General Hospital, Beijing, China), Yeon Hyeon Choe, MD, PhD (Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea), Sang Il Choi, MD, PhD (Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea), Yuen Chi Ho, MBBS, FRCR, FHKCR (Department of Radiology, Queen Mary Hospital, Hong Kong, China), John Huang, MB ChB, MRCP, FRCR (Department of Diagnostic Radiology, Singapore General Hospital, Singapore), Gham Hur, MD, PhD (Departments of Diagnostic Radiology, Inje University Ilsanpaik Hospital, Korea), Yasutaka Ichikawa, MD (Department of Radiology, Matsusaka Central Hospital, Matsusaka, Japan), Misako Iino, MD, PhD (Department of Radiology, Tokai University Hospital, Isehara, Japan), Shuichiro Kaji, MD, PhD (Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan), Tae Hoon Kim, MD (Department of Radiology, Gangnam Severance Hospital, Yonsei University, Seoul, Korea), Sheung-Fat Ko, MD (Department of Radiology, Chang Gung university, College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan), Yasuyuki Kobayashi, MD (Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan), Rungroj Krittayaphong, MD, FACC, FESC (Division of Cardiology, Department of Medicine, Siriraj Hospital, Bangkok, Thailand), Jongmin Lee, MD, PhD (Department of Radiology, Kyungpook National University Hospital, Daegu, Korea), Whal Lee, MD (Department of Radiology, Seoul National University Hospital, Seoul, Korea), Noiko Oyama, MD, PhD (Department of Radiology, Hokkaido University Hospital, Sapporo, Japan), Pairoj Rerkpattanapipat, [/fig]
[table] Table 10: Structure and function [/table]
[table] Table 12: Positive cardiac enzymes without obstructive atherosclerosis on angiographyStructure and function-evaluation of intra-and extra-cardiac structuresPatients with technically limited images from echocardiogram or TEE [/table]
[table] Table 13: Uncertain indications (median score 4-6) Detection of CAD: symptomatic-evaluation of chest pain syndrome No ECG changes and serial enzymes negative Detection of CAD with prior test results-evaluation of chest pain syndrome 17Evidence of moderate to severe ischemia on stress test (exercise, perfusion, or stress echo) U (5)Risk assessment: preoperative evaluation for cardiac surgery or endovascular intervention-preoperative evaluation 27 Use of MRI for CAD evaluation before valve surgery U(6) [/table]
[table] Table 14: Detection of CAD: symptomatic-evaluation of chest pain syndrome 1Low pre-test probability of CAD I (2) ECG interpretable AND able to exercise [/table]