Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing: Difference between revisions

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{{Chronic stable angina}}
{{Chronic stable angina}}
{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; Smita Kohli, M.D.
{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; Smita Kohli, M.D.;{{AA}}


==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>==
==ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>==


===Noninvasive Testing for the Diagnosis of Obstructive CAD and Risk Stratification in Asymptomatic Patients (DO NOT EDIT)<ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>===
===Noninvasive Testing for the Diagnosis of Obstructive CAD and Risk Assessment Recommendations(DO NOT EDIT)<ref name="pmid12570960">{{cite journal| author=Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al.| title=ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 1 | pages= 159-68 | pmid=12570960 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12570960  }} </ref>===
====Advanced Testing: Resting and Stress Noninvasive Testing====
'''Resting Imaging to Assess Cardiac Structure and Function'''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Assessment of resting left ventricular (LV) systolic and diastolic ventricular function and evaluation for abnormalities of myocardium, heart valves, or pericardium are recommended with the use of Doppler echocardiography in patients with known or suspected IHD and a prior MI, pathological Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
 
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Assessment of cardiac structure and function with resting echocardiography may be considered in patients with hypertension or diabetes mellitus and an abnormal ECG. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Measurement of LV function with radionuclide imaging may be considered in patients with a prior MI or pathological Q waves, provided there is no need to evaluate symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. "([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:Lightcoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]


|-
| bgcolor="Lightcoral"|<nowiki>"</nowiki>'''1.''' Echocardiography, radionuclide imaging, CMR, and cardiac computed tomography are not recommended for routine assessment of LV function in patients with a normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="Lightcoral"|<nowiki>"</nowiki>'''2.''' Routine reassessment (>1 year) of LV function with technologies such as echocardiography radionuclide imaging, CMR, or cardiac computed tomography is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated.. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|}
'''Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment'''
:'''''Patients able to exercise'''''


{|class="wikitable"
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]


|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina exercise electrocardiography|Exercise ECG]] testing without an imaging modality in asymptomatic patients with possible [[myocardial ischemia]] on [[Chronic stable angina ambulatory ST segment monitoring|ambulatory ECG]] monitoring or with [[coronary calcification]] on [[Chronic stable angina electron beam tomography|EBCT]] but with the baseline [[ECG]] abnormalities listed under Class IIb1 above. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|}
 
{|class="wikitable"
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[Chronic stable angina exercise electrocardiography|Exercise ECG]] testing without an imaging modality in asymptomatic patients with an established diagnosis of [[CAD]] owing to prior [[MI]] or [[coronary angiography]]; however, testing can assess functional capacity and prognosis. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' [[Chronic stable angina exercise echocardiography|Exercise echocardiography]] or [[dobutamine]] [[echocardiography]] in asymptomatic patients with [[left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG . ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''4.''' [[Adenosine]] or [[dipyridamole]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] in asymptomatic patients who are able to exercise and who do not have [[left bundle-branch block]] or electronically paced ventricular rhythm. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' CMR with pharmacological stress is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG . "([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''5.''' Exercise myocardial perfusion imaging, [[Chronic stable angina exercise echocardiography|exercise echocardiography]], [[adenosine]] or [[dipyridamole]] myocardial perfusion imaging, or [[dobutamine]] [[echocardiography]] after [[Chronic stable angina exercise electrocardiography|exercise ECG]] testing in asymptomatic patients with a low-risk Duke treadmill score. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


Line 29: Line 68:


|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Chronic stable angina exercise electrocardiography|Exercise ECG]] testing without an imaging modality in asymptomatic patients with possible [[myocardial ischemia]] on [[Chronic stable angina ambulatory ST segment monitoring|ambulatory ECG]] ([[AECG]]) monitoring or with severe [[coronary calcification]] on [[Chronic stable angina electron beam tomography|EBCT]] in the absence of one of the following [[ECG]] abnormalities:
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' CCTA may be reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:Lightcoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
 
|-
| bgcolor="Lightcoral"|<nowiki>"</nowiki>'''1.''' Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG.. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|}
 
:'''''Patients unable to exercise'''''
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG.  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG . ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG . "([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C]])''<nowiki>"</nowiki>
|-
|}
'''''Regardless of patients ability to exercise'''''
{|class="wikitable"
|-
|-
| bgcolor="LemonChiffon"|'''a.''' Preexcitation ([[Wolff-Parkinson-White syndrome]]) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
|-
| bgcolor="LemonChiffon"|'''b.''' Electronically paced ventricular rhythm ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who have left bundle-branch block on ECG, regardless of ability to exercise to an adequate workload  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|'''c.''' More than 1 mm of [[ST depression]] at rest ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with SIHD who are being considered for revascularization of known coronary stenosis of unclear physiological significance  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|'''d.''' Complete [[left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Exercise perfusion imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] in asymptomatic patients with possible [[myocardial ischemia]] on [[Chronic stable angina ambulatory ST segment monitoring|ambulatory ECG]] monitoring or with severe [[coronary calcification]] on [[Chronic stable angina electron beam tomography|EBCT]] who are able to exercise and have one of the following baseline [[ECG]] abnormalities:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 
|-
|-
| bgcolor="LemonChiffon"|'''a.''' Preexcitation ([[Wolff-Parkinson-White syndrome]]) ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' CCTA can be useful for risk assessment in patients with SIHD who have an indeterminate result from functional testing . ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|'''b.''' More than 1 mm of [[ST depression]] at rest. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Adenosine]] or [[dipyridamole]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|myocardial perfusion imaging]] in patients with severe [[coronary calcification]] on [[Chronic stable angina electron beam tomography|EBCT]] but with one of the following baseline [[ECG]] abnormalities:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
 
|-
|-
| bgcolor="LemonChiffon"|'''a.''' Electronically paced ventricular rhythm ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress imaging or as an alternative to invasive coronary angiography when functional testing indicates a moderate- to high-risk result and knowledge of angiographic coronary anatomy is unknown. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|'''b.''' [[Left bundle-branch block]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Adenosine]] or [[dipyridamole]] [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|myocardial perfusion imaging]] or [[dobutamine]] [[echocardiography]] in patients with possible [[myocardial ischemia]] on [[Chronic stable angina ambulatory ST segment monitoring|ambulatory ECG]] monitoring or with [[coronary calcification]] on [[Chronic stable angina electron beam tomography|EBCT]] who are unable to exercise. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:Lightcoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
 
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' Exercise [[myocardial perfusion]] imaging or [[Chronic stable angina exercise echocardiography|exercise echocardiography]] after [[Chronic stable angina exercise electrocardiography|exercise ECG]] testing in asymptomatic patients with an intermediate-risk or high-risk Duke treadmill score. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="Lightcoral"|<nowiki>"</nowiki>'''1.''' A request to perform either a) more than 1 stress imaging study or b) a stress imaging study and a CCTA at the same time is not recommended for risk assessment in patients with SIHD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' [[Adenosine]] or [[dipyridamole]] myocardial perfusion imaging or [[dobutamine]] [[echocardiography]] after [[Chronic stable angina exercise electrocardiography|exercise ECG]] testing in asymptomatic patients with an inadequate [[Chronic stable angina exercise electrocardiography|exercise ECG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}


Latest revision as of 15:05, 31 October 2016

Chronic stable angina Microchapters

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Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing On the Web

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Risk calculators and risk factors for Chronic stable angina risk stratification in asymptomatic patients by noninvasive testing

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.;Aysha Anwar, M.B.B.S[3]

ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[1]

Noninvasive Testing for the Diagnosis of Obstructive CAD and Risk Assessment Recommendations(DO NOT EDIT)[1]

Advanced Testing: Resting and Stress Noninvasive Testing

Resting Imaging to Assess Cardiac Structure and Function

Class I
"1. Assessment of resting left ventricular (LV) systolic and diastolic ventricular function and evaluation for abnormalities of myocardium, heart valves, or pericardium are recommended with the use of Doppler echocardiography in patients with known or suspected IHD and a prior MI, pathological Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur (Level of Evidence: B)"
Class IIb
"1. Assessment of cardiac structure and function with resting echocardiography may be considered in patients with hypertension or diabetes mellitus and an abnormal ECG. (Level of Evidence: C)"
"2. Measurement of LV function with radionuclide imaging may be considered in patients with a prior MI or pathological Q waves, provided there is no need to evaluate symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur. "(Level of Evidence: C)"
Class III
"1. Echocardiography, radionuclide imaging, CMR, and cardiac computed tomography are not recommended for routine assessment of LV function in patients with a normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias. (Level of Evidence: C)"
"2. Routine reassessment (>1 year) of LV function with technologies such as echocardiography radionuclide imaging, CMR, or cardiac computed tomography is not recommended in patients with no change in clinical status and for whom no change in therapy is contemplated.. (Level of Evidence: C)"

Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment

Patients able to exercise
Class I
"1. Standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG (Level of Evidence: B)"
"2. The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing (Level of Evidence: B)"
Class IIa
"1. The addition of either nuclear MPI or echocardiography to standard exercise ECG testing is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG . (Level of Evidence: B)"
"2. CMR with pharmacological stress is reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG . "(Level of Evidence: B)"
Class IIb
"1. CCTA may be reasonable for risk assessment in patients with SIHD who are able to exercise to an adequate workload but have an uninterpretable ECG. (Level of Evidence: B)"
Class III
"1. Pharmacological stress imaging (nuclear MPI, echocardiography, or CMR) or CCTA is not recommended for risk assessment in patients with SIHD who are able to exercise to an adequate workload and have an interpretable ECG.. (Level of Evidence: C)"
Patients unable to exercise
Class I
"1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG. (Level of Evidence: B)"
Class IIa
"1. Pharmacological stress CMR is reasonable for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG . (Level of Evidence: B)"
"2. CCTA can be useful as a first-line test for risk assessment in patients with SIHD who are unable to exercise to an adequate workload regardless of interpretability of ECG . "(Level of Evidence:C)"

Regardless of patients ability to exercise

Class I
"1. Pharmacological stress with either nuclear MPI or echocardiography is recommended for risk assessment in patients with SIHD who have left bundle-branch block on ECG, regardless of ability to exercise to an adequate workload (Level of Evidence: B)"
"2. Either exercise or pharmacological stress with imaging (nuclear MPI, echocardiography, or CMR) is recommended for risk assessment in patients with SIHD who are being considered for revascularization of known coronary stenosis of unclear physiological significance (Level of Evidence: B)"
Class IIa
"1. CCTA can be useful for risk assessment in patients with SIHD who have an indeterminate result from functional testing . (Level of Evidence: C)"
Class IIb
"1. CCTA might be considered for risk assessment in patients with SIHD unable to undergo stress imaging or as an alternative to invasive coronary angiography when functional testing indicates a moderate- to high-risk result and knowledge of angiographic coronary anatomy is unknown. (Level of Evidence: C)"
Class III
"1. A request to perform either a) more than 1 stress imaging study or b) a stress imaging study and a CCTA at the same time is not recommended for risk assessment in patients with SIHD. (Level of Evidence: C)"

References

  1. ↑ 1.0 1.1 Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS; et al. (2003). "ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina)". J Am Coll Cardiol. 41 (1): 159–68. PMID 12570960.

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