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Evidence review for CT and MRI indications for intervention

Heart valve disease presenting in adults: investigation and management

Evidence review F

NICE Guideline, No. 208

London: National Institute for Health and Care Excellence (NICE); .
ISBN-13: 978-1-4731-4301-2

1. Cardiac MRI and CT in determining the need for intervention

1.1. Review question

In adults with heart valve disease, what is the prognostic value and cost effectiveness of cardiac MRI and cardiac CT to determine the need for intervention?

1.1.1. Introduction

Cardiac MRI and cardiac CT are also used in patients with heart valve disease, for assessment of the left and right ventricle, for assessment of the aorta, to identify coexistent coronary disease, and also for assessment of heart valve disease severity. Consequently, it is important to define the prognostic value and cost effectiveness of cardiac MRI and cardiac CT to determine the need for intervention.

This review aims to assess which risk factors measured on cardiac CT or cardiac MRI indicate that intervention should be performed in different valve disease presentations.

1.1.2. Summary of the protocol

For full details see the review protocol in Appendix A.

Table 1. PICO characteristics of review question.

Table 1

PICO characteristics of review question.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Prognostic evidence

1.1.4.1. Included studies

A search was conducted for prospective and retrospective cohort studies investigating the prognostic value of various factors measured on cardiac CT or cardiac MRI to predict outcomes in those that received conservative management of valve disease and those that received surgical treatment of valve disease. The prognostic factors were different depending on the type of valve disease (e.g. aortic regurgitation or aortic stenosis) and full details are provided in the protocol.

Twenty-seven cohort studies were included in the review;6, 8, 9, 22, 40, 57, 62, 63, 84, 88, 94, 118, 123, 140, 152, 155, 158, 162, 187, 190, 191, 211–213, 225, 275, 291 these are summarised in Table 2 below. Evidence from these studies is summarised in Table 7–Table 10 below.

This included evidence from 22 studies for aortic stenosis, 2 studies for aortic regurgitation, 2 studies for mitral regurgitation and 1 study for functional tricuspid regurgitation.

The number of studies reporting each of the available prognostic factors within each stratum was as follows (note that some studies reported more than one prognostic factor):

  • Aortic stenosis: 5/10 pre-specified risk factors
    • Cardiac MRI
      –

      LVEF on cardiac MRI: 3 studies88, 123, 158

      –

      myocardial fibrosis on cardiac MRI: 10 studies6, 22, 57, 84, 88, 118, 123, 155, 187, 225

    • Cardiac CT:
      –

      coronary artery disease: 3 studies40, 152, 275

      –

      aortic valve area: 1 study62

      –

      aortic valve calcium score: 9 studies8, 9, 63, 94, 152, 162, 212, 275, 291

  • Aortic regurgitation: 1/8 pre-specified risk factors
    • Cardiac MRI
      –

      regurgitant fraction and regurgitant volume: 2 studies140, 191

  • Primary mitral regurgitation: 1/5 pre-specified risk factors
    • Cardiac MRI
      –

      regurgitant volume: 2 studies190, 213

  • Functional tricuspid regurgitation: 1/4 pre-specified risk factors
    • Cardiac MRI
      –

      right ventricular systolic function: 1 study211

No relevant clinical studies investigating the effects of any of the prespecified prognostic factors were identified for the following populations:

  • secondary mitral regurgitation
  • mitral stenosis.

Note that, although studies ideally would have performed at least some form of multivariate analysis or controlled for confounders through study design, for populations and prognostic factors where there was limited or no adjusted results available, univariate results were included in the review. This was assessed individually for each population and prognostic factor combination. Studies that had not included the prespecified confounders in their multivariate analysis were still included but they were downgraded for indirectness.

Due to limited available evidence directly matching the protocol, studies that had indirect populations or prognostic factors were included but downgraded for indirectness. For example, for many studies it was unclear whether the population represented those in whom there was uncertainty about whether intervention was indicated. For some prognostic factors, studies where all participants received intervention, and therefore had an indication for intervention prior to cardiac CT or MRI results, were included due to a lack of more direct evidence.

Similarly, there were some cases where prognostic factors did not exactly match the protocol and many studies reported outcomes that were a composite of different outcomes listed separately in the protocol. In several studies, outcomes for those treated medically and those treated surgically were combined within a single analysis, rather than analysing separately as was specified in the protocol.

No pooling was possible for most outcomes due to differences in population, prognostic factor definition, which also affected the referent (comparator) group that was used in studies, or outcome reported; however, pooling of three studies was possible for the outcome of all-cause mortality following aortic valve replacement for the myocardial fibrosis on cardiac MRI prognostic factor. Although there were differences in the variables that had been adjusted for as part of the multivariate analysis, two of the three studies had included the key confounder of age in this analysis. While the other study did not account for age, this variable was very similar between the two prognostic factor groups at baseline.

See also the study selection flow chart in Appendix A, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the prognostic evidence

Table 2. Summary of studies included in the evidence review.

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.6. Summary of the prognostic evidence

Aortic stenosis
Table 3. Clinical evidence summary: LVEF on cardiac MRI.

Table 3

Clinical evidence summary: LVEF on cardiac MRI.

Table 4. Clinical evidence summary: Myocardial fibrosis on cardiac MRI.

Table 4

Clinical evidence summary: Myocardial fibrosis on cardiac MRI.

Table 5. Clinical evidence summary: coronary artery disease on CT.

Table 5

Clinical evidence summary: coronary artery disease on CT.

Table 6. Clinical evidence summary: Aortic valve area on CT.

Table 6

Clinical evidence summary: Aortic valve area on CT.

Table 7. Clinical evidence summary: aortic valve calcium score on cardiac CT.

Table 7

Clinical evidence summary: aortic valve calcium score on cardiac CT.

Aortic regurgitation
Table 8. Clinical evidence summary: aortic regurgitant fraction or volume on cardiac MRI.

Table 8

Clinical evidence summary: aortic regurgitant fraction or volume on cardiac MRI.

Mitral regurgitation
Table 9. Clinical evidence summary: Mitral regurgitant volume on cardiac MRI.

Table 9

Clinical evidence summary: Mitral regurgitant volume on cardiac MRI.

Tricuspid regurgitation
Table 10. Clinical evidence summary: Right ventricular function on cardiac MRI.

Table 10

Clinical evidence summary: Right ventricular function on cardiac MRI.

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

No health economic studies were included.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

None.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Unit costs

Relevant unit costs are provided below to aid consideration of cost effectiveness.

ResourceUnit costsSource
Outpatient cardiac MRI without contrast£273NHS Reference Costs 2018–2019199
Outpatient cardiac MRI with post-contrast only£307NHS Reference Costs 2018–2019199
Outpatient cardiac MRI with pre and post contrast£392NHS Reference Costs 2018–2019199
Outpatient cardiac CT£194NHS Reference Costs 2018–2019199

1.1.11. Evidence statements

Effectiveness

See the summary of evidence in Table 7, Error! Reference source not found., Table 4, Table 5, Table 6, Table 3, Table 8, Table 9 and Table 10.

Economic
  • No relevant economic evaluations were identified.

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

All outcomes listed in the protocol were deemed critical and where possible they were assessed separately for groups that did not receive intervention (i.e. medically managed) and those that received an intervention (i.e. transcatheter or surgical intervention).

The following outcomes were pre-specified for each of these two treatment strategies:

  • Outcomes following no intervention (medical/conservative treatment):
    • Mortality
    • Hospital attendance/admission for heart failure or unplanned intervention
    • Reduced cardiac function
    • Symptom onset or symptom worsening (e.g. that led to surgery being required)

    Time-points selected for reporting of these outcomes were 1 and 5 years, where possible.

  • Outcomes following intervention (transcatheter or surgical treatment):
    • Mortality
    • Hospital admission for heart failure
    • Reduced cardiac function (echo or CMR parameters – for example LVEF <50%)
    • Return to normal LV volumes post-operatively based on echo or CMR as defined in the study
    • >20% reduction in LV volume post-operatively based on echo or CMR

    Time-points selected for reporting of these outcomes were 6 and 12 months, where possible.

The included evidence covered various types and presentations of valve disease, which were analysed as separate populations from the outset of the review. The evidence also covers a wide range of different risk factors pre-specified in the protocol. The number of outcomes reported therefore differs according to the type and presentation of valve disease and also the risk factor. Mortality was the most commonly reported outcome. Composite outcomes of two or more different outcomes listed in the protocol were also included.

Overall, most of the evidence was from populations that had been medically managed and censored at the time of surgery or need for surgery forming part of the outcome, though there were a number of studies that included medically and surgically treated patients in the same analysis and one study that looked solely at those that had received an intervention.

There was no evidence for the outcome of post-operative reduction in left ventricular volume.

1.1.12.2. The quality of the evidence
Strata and risk factors covered

No evidence was identified for the following population strata: mitral stenosis and secondary mitral regurgitation.

Some evidence was identified for all other strata specified in the protocol, although the number of risk factors covered for each varied. The number of risk factors covered by at least one study and outcome for each stratum was as follows (note that for many, some indirectness relative to the protocol was observed):

  • Aortic stenosis: 5/10 pre-specified risk factors
    • LVEF on cardiac MRI (3 studies)
    • myocardial fibrosis on cardiac MRI (10 studies)
    • coronary artery disease on CT (3 studies)
    • aortic valve area on CT (1 study)
    • aortic valve calcium score on CT (9 studies)
  • Aortic regurgitation: 1/8 pre-specified risk factors
    • regurgitant fraction and regurgitant volume on cardiac MRI (2 studies)
  • Primary mitral regurgitation: 1/5 pre-specified risk factors
    • regurgitant volume on cardiac MRI (2 studies)
  • Functional tricuspid regurgitation: 1/4 pre-specified risk factors
    • right ventricular systolic function on cardiac MRI (1 study)

Quality and limitations

The quality of the evidence was low to very low for most analyses. One outcome, reporting mortality under medical management in the section of evidence for aortic valve area measured on cardiac CT in adults with aortic stenosis was rated as moderate quality, with only minor risk of bias limitations. The main reason for downgrading in all studies was risk of bias, commonly because of limitations in the adjustment for confounding and statistical analysis – many studies did not perform multivariable analysis, while some studies that did use multivariable analysis the covariates included were unclear.

For many of the studies, indirectness relative to the protocol was also a reason for downgrading. For example, many studies only included people who already had an indication for surgery. In a few studies, outcome indirectness was considered to be present. This was because they had included medically and surgically treated patients in the analysis and had not adjusted for this or censored at the time of surgery, meaning separate outcomes were not available for those that did not receive intervention and those that received intervention. The committee agreed that despite this indirectness the evidence was important to include, while noting the limitations when discussing the findings. This was because they were aware of very few studies where CT or MRI were used strictly in those where the need for intervention was unclear and agreed that it is better to extrapolate from indirect evidence, when appropriate, than to rely on their experience alone.

Although some studies reported similar risk factors in similar populations, pooling was only performed in one analysis. This was because in all other cases there were differences between the studies in population, prognostic factor definition or the outcome reported.

Another limitation of the evidence was the size of the studies, with most including fewer than 300 participants. Therefore, the results were based on small populations and imprecision caused uncertainty in the true size of the effect.

It is important to note that although this review aims to assess which risk factors measured on cardiac CT or cardiac MRI indicate that intervention should be performed in various valve disease presentations, this is based on interpretation of outcomes with and without intervention. For example, if a particular risk factor appears to be associated with a worse outcome (e.g. higher mortality) on medical treatment compared to those without the risk factor, this may mean that intervention should be considered for those with this risk factor.

However, unless sufficient separate information is available for the same risk factor in populations that received medical treatment/conservative management and populations that received surgical treatment, it is difficult to be sure that surgery would improve the prognosis of those with the risk factor, as the risk factor could worsen the prognosis of all patients, regardless of whether medical treatment or intervention is selected. To make strong conclusions about whether intervention would improve the prognosis of people with particular risk factors, evidence comparing medical treatment and intervention within these subgroups would be required, which is not addressed by this review. However, the committee agreed that groups that experience poor outcomes following surgery are likely to experience even poorer outcomes if only medical management is provided, as these prognostic groups are associated with poorer outcome compared to those without the prognostic factor, regardless of which treatment is performed, although it was agreed that surgery would be a better option in these patients if suitable. Evidence of a prognostic factor being associated with a negative outcome following medical, transcatheter or surgical treatment was therefore used to support it as an indicator for intervention, as the committee agreed that intervention would improve outcomes compared to medical management for patients within these groups associated with poorer prognosis.

Based on a combination of the limitations reported above, all recommendations of indications for intervention were consider recommendations as there was insufficient evidence to support making offer recommendations. In addition, for some prognostic factors, although there was some evidence suggesting a role as a prognostic factor for worse outcome, the evidence was insufficient to make any active recommendation because of the low quality and uncertainty due to imprecise estimates.

Benefits and harms

The committee highlighted that all of the evidence was limited to showing whether the imaging parameters are associated with an adverse prognosis, but evidence about how intervention would impact this poor outcome is lacking.

Aortic stenosis
Left ventricular ejection fraction on cardiac MRI

Three small studies in people scheduled for aortic valve intervention or TAVI suggested a possible increased risk of mortality after intervention at an average of 2–4 years follow-up among those with baseline LVEF <50%, however, there was uncertainty in the effect estimates. Therefore, a research recommendation was made in this area (see Appendix K.3 for details).

Myocardial fibrosis on cardiac MRI

Ten studies investigated myocardial fibrosis, considering midwall fibrosis late gadolinium enhancement (LGE) pattern, any LGE pattern or any myocardial fibrosis in people with aortic stenosis. One study showed an increased risk of all-cause mortality at 2 years in those with midwall LGE pattern compared to no LGE on cardiac MRI and another study showed an increased risk of all-cause mortality at 10 years in those with severe fibrosis compared to no fibrosis on cardiac MRI. These same two studies also investigated infarct fibrosis LGE pattern compared to no LGE and mild fibrosis compared to no fibrosis on cardiac MRI, respectively. Although the direction of effect suggested an increased risk of poor outcomes for those with infarct fibrosis or with mild fibrosis compared to those with no fibrosis, there was large uncertainty around these effects and the size of the increased risk was smaller than for midwall or severe fibrosis.

Four small studies comparing those with and without late gadolinium enhancement or myocardial fibrosis on cardiac MRI reported composite outcomes, all of which included mortality. There was variation in the populations included as well as the outcome definitions. However, the majority suggested that myocardial fibrosis was associated with increased risk of a poor outcome. It was noted that the proportions of those with mid-wall fibrosis among those positive for LGE/fibrosis differed between the studies and was not always stated.

Four studies reported on outcomes after intervention. One pooled analysis showed an increased risk of all-cause mortality at approximately 3 years post intervention in those with late gadolinium enhancement on cardiac MRI at baseline assessment. Similarly, one of these studies also showed an increased risk of cardiovascular mortality post-intervention. One further study demonstrated that compared to a normal myocardium, diffuse myocardial fibrosis was associated with an increased risk of poor outcome after aortic valve replacement.

The experience of the committee was in line with these findings, as they were aware that myocardial fibrosis in general, not necessarily in aortic stenosis, is associated with a worse prognosis. Futhermore, myocardial fibrosis in people with aortic stenosis indicates early decompensation and the possible need for early intervention to stop progression, because midwall fibrosis cannot be reversed or improved by intervention. Midwall fibrosis was discussed as being seen to confer a particularly high need for intervention to avoid mortality. Therefore, based on the experience of the committee and the clinical evidence, it was agreed that follow-up should be enhanced in those with midwall fibrosis to check for symptoms and enable earlier aortic valve intervention to improve prognosis. It was noted that, cardiac MRI is indicated for various reasons, and this recommendation does not dictate if or when MRI should be performed, but rather advises on how to act upon the result of an MRI performed in a patient with aortic stenosis. Examples of enhanced follow up include review at shorter time intervals and / or referral for exercise echocardiography to unmask symptoms or other prognostic parameters that would indicate referral for surgery.

Coronary artery disease on cardiac CT

There was evidence from 2 patient cohorts showing a trend towards an increased risk of cardiac events or needing aortic valve intervention among those with coronary artery disease. However, there was uncertainty in the findings and insufficient evidence to inform a recommendation. The committee agreed not to prioritise this as an area for a research recommendation because coronary angiography is a more appropriate test.

Aortic valve area on cardiac CT

One study showed that an aortic valve area ≤1.2 cm2 predicted an increased risk of mortality under medical management, while there was no clear increased risk when the threshold was set as ≤1.0 cm2. This single study was insufficient evidence to inform a recommendation, especially as it conflicts with a larger body of evidence from echocardiography that an aortic valve area of ≤1.0 cm2 is the most useful prognostic indicator and because this threshold is not used in current practice. However, no research recommendation was made in this area because measurement of aortic valve area is established using echocardiography and the committee agreed measurement on CT was not a research priority. Recommendations about the use of aortic valve area measured on echocardiography have been made based on evidence in review D.

Aortic valve calcium score on cardiac CT

There was evidence from two studies that a high aortic valve calcium score (≥2065 AU in men and ≥1274 AU in women) is a predictor of poor outcome in terms of mortality under conservative management or death or need for aortic valve intervention during follow-up. Regarding post-operative outcomes, there was evidence from one study of a very large increase in risk of the composite outcome of all-cause mortality, stroke, myocardial infarction, heart failure or rehospitalisation for cardiac causes after TAVI and a large increased risk of rehospitalisation in those with a calcium score of >6000 HU. The committee noted that in low gradient aortic stenosis, a high calcium score or calcium density was not clearly associated with poor outcome after surgery, while this association was seen in bicuspid aortic stenosis. It was discussed that in the low-flow, low gradient population the evidence of those with higher calcium having a more positive prognosis after intervention could reflect the increased benefit of TAVI in this group and so favouring the use of calcium score to stratify for intervention. The committee acknowledged that there was currently insufficient evidence to specify precise CT calcium score thresholds that indicate referral. However, the committee agreed that the available evidence demonstrates that a higher aortic valve calcium score measured on cardiac CT is a marker for worse prognosis, which could be because it is an index of the severity of stenosis or a marker of more widespread vascular disease. This was supported by the knowledge and experience of the committee, who noted that a more calcified aortic valve is associated with more severe aortic stenosis. However, this does not apply in the same way to bicuspid aortic valves or rheumatic disease, because the mechanism of aortic stenosis is different and it would not be as relevant to monitor valve calcium. Therefore, the committee agreed that aortic valve calcium scoring is useful to assess the need for intervention in adults with symptomatic aortic stenosis of uncertain severity. This was because a high calcium score is likely to reflect more severe disease with a worse prognosis that, if symptomatic, may require intervention as in severe aortic stenosis the symptoms are more likely to be due to the heart valve disease. The committee agreed that this would also apply to those with low-flow, low gradient aortic stenosis because in their experience, calcium scoring is used to assess severity in these cases and the evidence did not reflect the appropriate population of those with uncertain severity.

Additionally, based on their expert opinion and the evidence of a worse prognosis after TAVI among those with a very high calcium score (large increased risk of rehospitalisation, or the composite of all-cause mortality, stroke, myocardial infarction, heart failure or rehospitalisation for cardiac causes in those with calcium score >6000 HU), the committee recommended that the amount and distribution of calcium in the aortic valve should be taken into account as part of the decision-making process between surgical and transcatheter intervention. This is because, for example, a very high calcium score may make TAVI a riskier procedure because surgical intervention provides a means to remove the excess calcium that is not possible with transcatheter intervention. In these cases surgical intervention may be considered in preference to TAVI. Regarding the distribution of the calcium, it was acknowledged that calcium in the left ventricular outflow tract may increase the risk of a TAVI procedure. It was agreed that this use of aortic valve calcium score was in line with current practice, as it is commonly used as a discriminator when deciding on the need for intervention. In conclusion, as the degree and distribution of calcium should be considered when deciding if TAVI is appropriate this was covered by recommendation 1.5.4.

Aortic regurgitation
Regurgitant fraction or volume on cardiac MRI

Two studies showed an increased risk of needing surgery among those with AR fraction >33 or ≥34% or AR volume >42 ml or ≥45 ml in asymptomatic moderate or severe AR. However, the committee noted that although the two studies used similar thresholds, the evidence was of low quality and while one showed a large effect the other showed a small effect size. Therefore, there was too much uncertainty in the predictive value of this parameter to make an active recommendation. Also, the threshold for referral or intervention is not well established in current practice and there was no evidence for regurgitant volume, which may also have prognostic value. Therefore, a research recommendation was made in this area (see Appendix K.1 for details).

A further research recommendation to assess the prognostic value of left ventricular ejection fraction measured on cardiac MRI was made due to no evidence being identified for this prognostic factor in this population (see Appendix K.2 for details).

Mitral regurgitation
Mitral regurgitant volume on cardiac MRI

Two studies showed a better prognosis among those with asymptomatic moderate or severe mitral regurgitation and a lower mitral regurgitant volume. Specifically, one study reported a reduced risk of developing an indication for surgery among those with mitral regurgitant volume ≤55 ml and the other showed that the risk of all-cause mortality or of developing an indication for surgery increases per 10 mL increase of mitral regurgitant volume on cardiac MRI. This evidence was insufficient to support any recommendations that may change practice because it was rated at low quality, only one used dichotomous analysis to inform what threshold may be suitable as an indicator and MRI is not commonly requested for this patient group in current practice. Therefore, a research recommendation was made in this area (see Appendix K.1 for details). This research recommendation also covered regurgitant fraction on cardiac MRI as no evidence was identified for this variable in mitral regurgitation.

A further research recommendation to assess the prognostic value of left ventricular ejection fraction measured on cardiac MRI was made due to no evidence being identified for this prognostic factor in this population (see Appendix K.2 for details).

Tricuspid regurgitation
Right ventricular function on cardiac MRI

One small study found an increased risk of cardiac death after surgery for tricuspid regurgitation in those with reduced right ventricular function as measured by a higher right ventricular end systolic volume index or a lower right ventricular ejection fraction.

The same trend was seen for the outcome of post-operative cardiac events, although the size of the increased risk was smaller and the uncertainty in the effect was greater than for the mortality outcome. However, this evidence of very low quality was insufficient to support any recommendations.

Due to this limited evidence for right ventricular function in the prognosis of tricuspid regurgitation, a research recommendation was made to assess the prognostic value of right ventricular ejection fraction measured on cardiac MRI (see Appendix K.4 for details).

1.1.12.3. Cost effectiveness and resource use

There was no published evidence of cost effectiveness. The committee were presented with the unit costs of cardiac MRI and cardiac CT.

Three consensus recommendations in line with current practice were made to consider aortic valve calcium scoring and distribution and mid-wall fibrosis when determining the need of reintervention in adults with aortic stenosis. The committee agreed that there was not enough robust evidence to specify levels of threshold of calcium score. High aortic valve calcium score was found to be associated with poor prognosis. Hence, the committee recommended to evaluate the need of intervention taking into account the score of aortic valve calcium measured on cardiac CT when the severity of aortic stenosis is uncertain. This could increase the number of interventions performed on patients who can better benefit from it, leading to better health outcomes. The cost effectiveness of CT in this population is uncertain and therefore the committee made a weak ‘consider’ recommendation for CT scanning in this patient group.

The committee aknowledged that aortic calcium score was an important factor in deciding whether to consider TAVI or a surgery as the degree and distribution of calcium in the aortic valve may increase the risk of a TAVI procedure. Hence, the committee recommended to take into account those factors when deciding the appropriate intervention. However, the economic modelling of TAVI – see Evidence Report H – did not show TAVI to be cost effective in surgically operable patients.

1.1.13. Recommendations supported by this evidence review

This evidence review supports recommendations 1.3.4–1.3.6 and 4 research recommendations on cardiac MRI to determine the need for intervention.

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Appendices

Appendix B. Literature search strategies

Heart valve disease – search strategy 4 – Cardiac CT and cardiac MRI indications for intervention

This literature search strategy was used for the following review:

  • In adults with heart valve disease, what is the prognostic value and cost effectiveness of cardiac MRI and cardiac CT to determine the need for intervention?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.196

For more information, please see the Methodology review published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy (PDF, 323K)

B.2. Health Economics literature search strategy (PDF, 306K)

Appendix G. Health economic study selection

Download PDF (260K)

Appendix H. Economic evidence tables

None

Appendix I. Health economic model

None.

Appendix J. Excluded studies

Clinical studies

Download PDF (429K)

Health Economic studies

Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2004 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.

None.

Final

Evidence reviews underpinning recommendations 1.3.4 to 1.3.6 and research recommendations in the NICE guideline

These evidence reviews were developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Copyright © NICE 2021.
Bookshelf ID: NBK589171PMID: 36780402

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