TABLE 5-2.

American College of Radiology Appropriateness Criteria for Chest X-ray or Computed Tomography in Common Clinical Scenarios

Clinical Scenario	ACR Rating for X-ray Chest	ACR Rating for CT Chest
Acute chest pain
•Low probability of coronary artery disease	9	CTA chest (noncoronary): 6—Useful in ruling out other causes of chest pain such as aortic dissection, pulmonary embolism, pneumothorax, pneumonia.
•Suspected aortic dissection	9—Should be performed if readily available at the bedside and does not cause delay in obtaining a CT or MRI. Alternative causes of chest pain may be discovered. Not the definitive test for aortic dissection.	CTA chest and abdomen: 9—Recommended as the definitive test in most patients with suspicion of aortic dissection.
•Suspected pulmonary embolism	9—to exclude other causes of chest pain	CTA chest (noncoronary): 9—Current standard of care for detection of PE.
Chronic chest pain
•High probability of coronary artery disease	3—Usual initial imaging study in cardiac patients. Although used frequently, chest radiographs can neither establish nor exclude chronic ischemic heart disease. Insensitive for detecting coronary arterial calcification. Limited value in patients with high risk of CAD.	CTA coronary arteries: 7—Very good accuracy and negative predictive value in low to intermediate risk groups. However, may have false negatives in high-risk group, and negative studies may still require further diagnostic testing. Coronary calcification often found in older high-risk patients (especially males) can limit coronary luminal assessment.
•Low to intermediate probability of coronary artery disease	9	CTA chest (noncoronary) with contrast: 8— Important examination for pulmonary embolism and thoracic aortic aneurysm/dissection. To rule out PE and evaluate lung pathology. Appropriate for chronic anginal chest pain.CTA coronary arteries with contrast: 8—Can be used to assess for coronary atherosclerosis,anomalous coronary artery, and pericardial disease. High negative predictive value will exclude coronary artery disease and allow triage management to focus on more likely diagnoses. To eliminate unnecessary catheterizations.
CHF
•Symptomatic, new onset or recurrent	9	2—readily diagnosed on CT obtained for other indications
•Known CHF, stable or asymptomatic	4
Dyspnea—suspected cardiac origin	8	CTA coronary arteries: 6CTA coronary arteries with advanced low dose techniques: 6CTA chest (noncoronary): 6
Suspected bacterial endocarditis	9	CT heart function and morphology with contrast: 6—Multidetector with maximal temporal and spatial resolution. Probably indicated to rule out paravalvular abscess and/or psedoaneurysm. Emerging technology.
Known or Suspected congenital heart disease in the adult	7	CT heart function and morphology with contrast: 7. May be alternative to MRI and TTE/TEE. High spatial resolution to evaluate small and tortuous vessels. For evaluation of airway. CTA coronary arteries with contrast: 6. When there is a high index of suspicion for fistula or anomalous coronaries.CTA coronary arteries with contrast with advanced low dose techniques: 6. Important in young to middle-age adults because of reduced radiation dose.
Acute respiratory illness	Varies—see Table 5-3	Varies
Acute respiratory illness in HIV-positive patients	9	CT chest without contrast: 8—When negative, equivocal, or nonspecific chest radiograph.
Chronic dyspnea—suspected pulmonary origin	8-9—depends on age and examination	Any age, nonrevealing or nondiagnostic clinical, standard radiography, and laboratory studies. In the setting of chronic dyspnea, the most appropriate imaging study is a thin section high resolution chest CT: 9. If a patient has dyspnea not clearly of pulmonary origin, other entities such as chronic or acute pulmonary embolism may need to be excluded. In that setting, a thin section chest CT with intravenous contrast is appropriate. See the ACR Appropriateness Criteria® topic on “Acute Chest Pain–Suspected Pulmonary Embolism”.
Hemoptysis,Two risk factors (>40 years old and >40 pack-year history)	9	without contrast: 6 (useful for patients with renal failure or contrast allergy.); with contrast: 8 (optimal study shows enhancement of the systemic arteries.)
Rib fractures, adult < 65 years of age	8—PA view. Rib views are given a rating of 2.	2—with or without contrast
Routine admission and preoperative chest radiography		NA
•Asymptomatic, history and physical unremarkable	2 (preoperative or routine)
•Acute cardiopulmonary findings by history or physical	9 (preoperative or routine)
•Chronic cardiopulmonary disease in the elderly (>age 70), previous chest radiograph within 6 months available	6 (preoperative), 4 (routine admission)
•Chronic cardiopulmonary disease in the elderly (>age 70), previous chest radiograph within 6 months not available	8 (preoperative or routine)
Routine chest radiographs in uncomplicated hypertension (asymptomatic)		NA
•Mild hypertension—diastolic pressure 90-104 mm Hg	1	NA
•Moderate or severe hypertension—diastolic pressure 105-114 or ≥115 mm Hg	5	NA
Screening for pulmonary metastases	8-9—depends on malignancy type	7-9—depends on malignancy type; noncontrast CT
Solitary pulmonary nodule	NA—chest x-ray presumably already performed, demonstrating lesion	CT chest with contrast: 6CT chest without contrast: 8
Staging of bronchogenic carcinoma	NA—chest x-ray presumably already performed, demonstrating lesion 8 or 9—if no baseline chest x-ray available	CT chest with or without contrast (including upper abdomen): 9—CT with contrast is preferred if there are no strong contraindications.
Blunt chest trauma—suspected aortic injury	9	CTA chest (noncoronary): 9 CT chest without contrast: 6—Useful to detect mediastinal hematoma when contrast contraindicated.

This table integrates information relevant to the practice of emergency medicine from multiple ACR Appropriateness Criteria topics, and does not represent all information included in these topics. Refer to the ACR website at www.acr.org/ac for the most current and complete version of the ACR Appropriateness Criteria®.”

Reprinted with permission of the American College of Radiology, Reston, VA. No other representation of this material is authorized without expressed, written permission from the American College of Radiology. Rating scale: 1, 2, 3: Usually not appropriate; 4, 5, 6: may be appropriate; 7, 8, 9: Usually appropriate.

From American College of Radiology. ACR appropriateness criteria. (Accessed at http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx) (Access date: 3-21-2011)