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AAC's criteria for appropriate vascular testing

When caring for patients with known or suspected disorders of the venous system, identifying the best methods for detecting clots early on can not only be cost-effective, but lifesaving, as many of these disorders can be fatal or result in long-term complications and hospitalization.

With this in mind, the American College of Cardiology (ACC), in collaboration with 10 other leading professional societies, issued a report that details criteria physicians can use to determine the best tests to employ when caring for these patients.1 The report also offers comprehensive guidance on when ­– or when not -- to transfer these patients for vascular testing to help detect problems such as venous insufficiency, blot clots in the leg, arm, or abdomen, or pulmonary embolism.

To develop the criteria for this report, a diverse group was assembled that included representatives from vascular medicine, cardiology, interventional radiology, orthopedic, and vascular surgery. They identified 116 clinical scenarios in which the use of vascular testing might be considered.

“Vascular lab testing is central to the care of patients with most peripheral vascular disorders, but appropriate use criteria for these [technologies] have lagged behind those for cardiac testing,” said Heather Gornik, MD, FACC, cardiologist and vascular medicine specialist at the Cleveland Clinic and chair of the writing committee. “With this report, we now have multidisciplinary criteria upon which we can start maximizing the quality and appropriateness of what we do in the vascular lab every day.”

Overall, the team found that vascular testing was deemed appropriate when clinical signs and symptoms are the main reason for the test. On the other hand, they found it is rarely appropriate to use these tests to screen patients without symptoms, even in those individuals who are more prone to clotting or who have had an extended intensive care unit or hospital stay, recent (major) orthopedic surgery, or a positive D-dimer blood test.

“Vascular ultrasound is now the best, most accurate test we have for diagnosing DVT, and it has clear advantages, including its low risk to the patient with no exposure to radiation or contrast dye and the fact that it is less expensive relative to other tests,” Dr. Gornik said. “But a lot of screening ultrasounds are done indiscriminately for asymptomatic patients, and we found there is little evidence to support that practice.”

“There is also growing need for comparative and cost-effectiveness research of vascular laboratory testing in the care and diagnosis of patients with deep vein thrombosis and pulmonary embolism,” Dr. Gornik said. “There are also a number of controversial areas that have not yet been fully explored, which we have outlined.”

The authors of this study stress that these criteria should not supersede sound clinical judgment for individual patients.

Reference 1. 2013 Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part II: Testing for Venous Disease and Evaluation of Hemodialysis Access. Journal of the American College of Cardiology