Putting PatientFirst Imaging Into Practice

David Wolinsky, MD, MASNC, from Cleveland Clinic, was a co-creator of ASNC's PatientFirst Imaging initiative. We asked him about the program and how nuclear labs can incorporate PatientFirst Imaging into their own practices.

Q. What is PatientFirst Imaging, and why is it important today?

A. Cardiac imaging to detect coronary artery disease (CAD) has advanced significantly over the last decade. Now there are several imaging modalities available. Selecting the right imaging test is essential for making appropriate decisions about patient care.

ASNC’s PatientFirst Imaging initiative is based on the philosophy that no single imaging modality should be considered a first-line test. Instead, the diagnostic imaging test should be selected based on the patient’s unique characteristics and risk to obtain the best clinical information that will guide decision-making and answer the patient’s questions. PatientFirst Imaging is also about optimizing image acquisition, interpretation, and reporting.

Q. What are the most important considerations when selecting the right test?

A. First, consider the patient’s pretest probability of CAD to decide whether they need a test or not. The threshold of pretest probability has recently changed to more effectively predict disease. Refer to the 2021 AHA/ACC chest pain guidelines for updated pretest probability.

Because cardiac imaging modalities have unique limitations and contraindications, healthcare providers need to consider the patient’s comorbidities, age, and ability to exercise. Patient preference also should be factored into decisions.

Finally, when multiple modalities are considered appropriate, the choice should be based on local expertise and test availability.

To help select an appropriate imaging modality, the ACCF Multimodality Appropriate Use Criteria provide recommendations for 7 test modalities based on 80 patient scenarios.

Q. What can nuclear labs do to help ensure quality imaging?

A. Nuclear labs can follow optimal protocols and consider complementary tests, such as coronary calcium scoring, to increase the diagnostic and prognostic value of the test. Implementing a mechanism for attenuation correction and maximizing quantitative assessment are also ways to improve quality. In addition, having up-to-date imaging equipment and software is important for PatientFirst Imaging.

Q. How can labs optimize image interpretation and reporting?

A. ASNC recommends a systematic approach to interpretation. This includes evaluation of raw data (when available) and review of quantitative and qualitative perfusion data with ventricular function imaging and analysis of attenuation correction. Perfusion defects should be assessed based on size, severity, and location. Regional and global ventricular function data also should be assessed.

For an optimal final report, refer to ASNC guidelines on standardized reporting, which recommend including standardized data elements as well as a comparison to prior results and overall impressions. Nuclear labs should combine stress test results with imaging results into one report.

Q. How can labs implement a PatientFirst Imaging strategy?

A. Involve all stakeholders, including nuclear cardiologists, technologists, nuclear APPs, nurses, and administrators. Gain consensus on what equipment and software are needed and develop best practices for test selection, acquisition, interpretation, and reporting—all with the focus on patient satisfaction. By providing education about quality, PatientFirst Imaging helps referring providers and interventional cardiologistsmake the right clinical decisions for patient care.

ACC = American College of Cardiology; ACCF = American College of Cardiology Foundation;
AHA = American Heart Association; APP = advanced practice provider; ASNC = American Society of Nuclear Cardiology.

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