By América Torres
As part of their commitment to review and refine the Appropriate Use Criteria (AUC), the American College of Cardiology (ACC) Foundation and key specialty and subspecialty societies conducted a review of the appropriate use of stress tests and AUC for the anatomical evaluation of chronic coronary artery disease (CCD), formerly known as stable ischemic heart disease (SIHD).
The 2023 Guide to Appropriate Use Criteria of ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS for detection and risk assessment in chronic coronary artery disease is an update of the previous criteria published for radionuclide imaging, stress echocardiography, calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD.
Key Changes in the 2023 Guide for Detection and Risk Assessment in Chronic Coronay Artery Disease
Like its previous version, this document provides a classification of test modalities side by side for a given clinical scenario. These classifications are not considered competitive rankings because the availability of comparative evidence, patient variability, and the range of capabilities available in any given location are limited.
In general, the main changes in this version are:
- Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document still in development.
- Some clinical scenarios and tables were eliminated to simplify scenario selection. Additionally, the flow of tables has been reorganized so that all can be consulted by answering a limited number of clinical questions about the patient, starting with the status of their symptoms.
- Several clinical scenarios have been revised to incorporate changes in other documents, such as pretest probability assessment, atherosclerotic cardiovascular disease (ASCVD) risk assessmen, syncope, and others. ASCVD risk factors not considered in contemporary risk calculators have been added as modifiers for specific clinical scenarios.
As mentioned earlier, the purpose of this Guide is to outline the appropriate use of various invasive and non-invasive test modalities for the diagnosis and/or evaluation of chronic coronary artery disease (CCD) in clinical scenarios that include:
- Patients with ischemic symptoms: without prior tests (described in Table 1.1), with prior tests but without myocardial infarction (MI) or revascularization (described in Table 1.2), and with prior MI or revascularization (described in Table 1.3).
- Patients without ischemic symptoms: tests to assess the risk of ASCVD events (described in Table 2.1), and with prior MI or previous revascularization (described in Table 2.2).
- ·Patients seeking to initiate a physical exercise program or cardiac rehabilitation (described in Table 2.3).
- ·Patients with other cardiovascular conditions such as heart failure, arrhythmias, or syncope (described in Table 2.4).
Below is a brief summary of some of the criteria for using treadmill stress tests and stress echocardiography tests in their clinical scenarios.
Table1.1: Symptomatic Patients With No Known CCD and No Prior Testing
Clinical Scenario: Less-likely anginal symptoms, age <50 y and 0 or 1 CV risk factor. Tests: ECG Treadmill – May be appropriate. Echo Stress - Rarely Appropriate.
Clinical Scenario: Less-likely anginal symptoms, age 50 y or above and/or ≥ 2 CV risk factors. Tests: ECG Treadmill – May be appropriate. Echo Stress – May be appropriate.
Clinical Scenario: Likely anginal symptoms, age <50 y and 0 or 1 CV risk factor. Tests: ECG Treadmill/ Echo Stress – Appropriate.
Clinical Scenario: Likely anginal symptoms, age 50 y or above and/or ≥2 CV risk factors. Tests: ECG Treadmill/ Echo Stress – Appropriate.
CV risk factors: diabetes mellitus, smoking, family history of premature CAD, hypertension, dyslipidemia.
Table 1.2: Symptomatic Patients Without Known CCD and With Prior Testing*
The ECG Treadmill test may be appropriate in the following clinical scenarios:
- Abnormal ECG
- Coronary computed tomography angiography (CCTA) with no coronary artery disease (CAD); or up to 49% stenosis (Coronary Artery Disease (CAD)-Reporting and Data System (RADS): 0-2.
- CCTA with moderate stenosis 50%-69% (CAD-RADS 3).
- CCTA with severe stenosis ≥70% (CAD-RADS 4-5).
- Coronary artery calcium (CAC) score = 0 (CAC-DRS = 0) (CAC-DRS Coronary Artery Calcium Data and Reporting System).
- CAC score 1-99 (CAC-DRS 1).
- Invasive coronary angiography with intermediate severity and/or invasive physiological testing not done**
The ECG Treadmill test is appropriate in the following clinical scenarios:
- CCTA inconclusive (CAD-RADS N).
- CAC score 100-299 (CAC-DRS 2).
- CAC score ≥300 (CAC-DRS 3).
The Echo Stress test may be appropriate in the following clinical scenarios:
- Normal exercise stress test (ET).
- Inconclusive stress imaging.***
- CCTA with no CAD or up to 49% stenosis (CAD-RADS 0-2).
- CCTA with severe stenosis ≥ 70% (CAD-RADS 4-5).
- CAC score = 0 (CAC-DRS 0).
- CAC score 1-99 (CAC-DRS 1).
- Invasive coronary angiography with obstructive CAD and/or abnormal invasive physiological testing**
The Echo Stress test is appropriate in the following clinical scenarios:
- Abnormal ECG.
- Inconclusive ET.
- Abnormal ET.
- CCTA with moderate stenosis 50%-69% (CAD-RADS 3).
- CCTA inconclusive (CAD-RADS N)
- CAC score 100-299 (CAC-DRS 2).
- CAC score ≥300 (CAC-DRS 3).
- Invasive coronary angiography with intermediate severity and/or invasive physiological testing not done**
* Refers to sequential testing being done as part of a continued patient evaluation or application of recent testing results in the reevaluation of a patient.
** Refers to diagnostic angiography, not percutaneous coronary intervention.
*** Stress imaging could be SPECT (single-proton emission tomography), PET (positron emission tomography), echo o CMR (cardiac magnetic resonance).
Table 1.3 Symptomatic Patients With Prior MI or Revascularization
The ECG Treadmill test may be appropriate in the following clinical scenarios:
- Incomplete revascularization.
- Prior percutaneous coronary intervention (PCI), symptoms similar to prior ischemic episode and/or anginal symptoms
- Prior PCI, nonanginal symptoms.
- Prior coronary artery bypass graft (CABG), symptoms similar to prior ischemic episode and/or anginal symptoms.
- Prior CABG, nonanginal symptoms.
- Prior myocardial infarction (MI), no revascularization, symptoms similar to prior ischemic episode and/or anginal.
- Prior MI, no revascularization, nonanginal symptoms
The ECG Treadmill test is appropriate in the following clinical scenario:
- Prior to cardiac rehabilitation, coronary disease (no new or worsening symptoms).
The Echo Stress test may be appropriate in the following clinical scenarios:
- Prior PCI, nonanginal symptoms.
- Prior CABG, nonanginal symptoms.
- Prior MI, no revascularization, nonanginal symptoms.
- Prior to cardiac rehabilitation, coronary disease (no new or worsening symptoms)
The Echo Stress test is appropriate in the following clinical scenarios:
- Incomplete revascularization.
- Prior percutaneous coronary intervention (PCI), symptoms similar to prior ischemic episode and/or anginal symptoms.
- Prior CABG, symptoms similar to prior ischemic episode and/or anginal symptoms.
- Prior MI, no revascularization, symptoms similar to prior ischemic episode and/or anginal.
- Assessment of myocardial viability.
Table 2.1: Asymptomatic Patients Without Known ASCVD
The ECG Treadmill test may be appropriate in the following clinical scenarios:
- Borderline atherosclerotic cardiovascular disease (ASCVD) risk 5% to 7.5%.
- Borderline ASCVD risk 5% to 7.5% with risk-enhancing factors (Table C, page 2455 of the Guide).
- Intermediate ASCVD risk 7.5% to 20% with or without risk-enhancing factors (Table C, page 2455 of the Guide).
- High ASCVD risk >20%.
The Echo Stress test may be appropriate in the following clinical scenario:
- High ASCVD risk >20%.
Table 2.3: Asymptomatic Patients Undergoing Assessment of an Exercise Program or Cardiac Rehabilitation
The Exercise ECG is appropriate in the following scenarios:
- Prior to initiation of an unsupervised exercise program, with known chronic coronary disease (CCD).
- Prior to cardiac rehabilitation.
The Exercise ECG may be appropriate in the following scenario:
- Prior to initiation of an unsupervised exercise program, without known CCD.
The Echo Stress test may be appropriate in the following scenarios:
- Prior to initiation of an unsupervised exercise program, with known chronic coronary disease (CCD).
- Prior to cardiac rehabilitation.
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