The following are key points to remember from a 2024 multisociety appropriate use criteria (AUC) document for multimodality imaging in cardiovascular evaluation of patients undergoing nonemergent, noncardiac surgery:

1. This is the first AUC document to address cardiac imaging prior to noncardiac, nonemergent surgery. As surgical volumes continue to rise across the United States, this document will provide a framework to help clinicians decide when preoperative testing is appropriate and what modalities are most applicable in various clinical scenarios.
2. The appropriateness tables divide surgical procedures into seven categories: nonvascular (low-, intermediate-, or high-risk), vascular (intermediate- or high-risk), and solid organ transplant. The document includes 11 imaging modalities and 182 clinical scenarios. Scenarios stratify patients based on presence or absence of known/suspected heart disease, prior testing, symptoms, and functional status (exercise capacity of <4 METs vs. ≥4 METs).
3. For each clinical scenario, the 15-member expert rating panel has placed each modality into one of the following categories: Appropriate (generally acceptable and reasonable), May Be Appropriate (may be generally acceptable and reasonable), or Rarely Appropriate (not generally acceptable and not a reasonable approach). AUC do not rank modalities against each other—in any given clinical scenario, multiple modalities may be considered appropriate. In many scenarios in the document, multiple stress test modalities and computed tomography (CT) coronary angiography receive similar appropriateness ratings, and clinicians should choose modalities based on factors such as local availability and expertise.
4. Preoperative imaging is less often considered appropriate for asymptomatic patients with good functional status, and for those undergoing low-risk surgeries, than for patients with symptoms or impaired functional status, and for those undergoing high-risk surgeries.
5. While the document focuses largely on noninvasive imaging techniques, it also addresses transesophageal echocardiography and invasive coronary angiography (ICA). In the evaluation of known or suspected ischemic heart disease, noninvasive modalities such as stress echocardiography, nuclear myocardial perfusion imaging, and CT coronary angiography are more often considered appropriate than ICA. However, ICA receives some appropriate and may be appropriate ratings in scenarios involving abnormal prior findings, such as significant ventricular dysfunction and moderate- or high-risk stress test results.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Acute Heart Failure, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Coronary Angiography, Diagnostic Imaging, Heart Failure, Ischemia, Multimodal Imaging

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