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Clinical Guildelines

  1. Diagnosis of Patients With Stable Ischemic Heart Disease: Executive Summary of a Clinical Practice Guideline for Primary Care From the American College of Physicians/American College of Cardiology Foundation/American Heart Association/American Association for Thoracic Surgery/Preventive Cardiovascular Nurses Association/Society of Thoracic Surgeons
  2. Initial Cardiac Testing to Establish Diagnosis of IHD
  3. The organizations recommend that patients with chest pain should receive a thorough history and physical examination to assess the probability of IHD prior to additional testing (Grade: strong recommendation; low-quality evidence).
  4. The organizations recommend that choices regarding diagnostic and therapeutic options should be made through a process of shared decision making involving the patient and provider, explaining information about risks, benefits, and costs to the patient (Grade: strong recommendation; low-quality evidence).
  5. The organizations recommend that patients who present with acute angina must be categorized as stable or unstable; patients with unstable angina should be further categorized as high, moderate, or low risk (Grade: strong recommendation; low-quality evidence).
  6. The organizations recommend a resting electrocardiography (ECG) in patients without an obvious noncardiac cause of chest pain for risk assessment (Grade: strong recommendation; moderate-quality evidence).
  7. The organizations recommend standard exercise ECG for initial diagnosis in patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; high-quality evidence).
  8. The organizations recommend that exercise stress with radionuclide myocardial perfusion imaging or echocardiography should be used for patients with an intermediate to high pretest probability of IHD that have an uninterpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; moderate-quality evidence).
  9. The organizations recommend that pharmacologic stress with radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance imaging should not be used for patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; low-quality evidence).
  10. The organizations recommend that exercise stress with nuclear myocardial perfusion imaging should not be used as an initial test in low-risk patients who have an interpretable ECG and at least moderate physical functioning or no disabling comorbidity (Grade: strong recommendation; low-quality evidence).
  11. The organizations recommend pharmacologic stress with radionuclide myocardial perfusion imaging or echocardiography for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or with disabling comorbidity (Grade: strong recommendation; moderate-quality evidence).
  12. The organizations recommend that standard exercise ECG testing should not be used for patients that have an uninterpretable ECG or are incapable of at least moderate physical functioning or with disabling comorbidity (Grade: strong recommendation; low-quality evidence).
  13. The organizations recommend assessing resting left ventricular systolic and diastolic ventricular function and evaluating for abnormalities of myocardium, heart valves, or pericardium using Doppler echocardiography in patients with known or suspected IHD and a prior myocardial infarction, pathologic Q waves, symptoms or signs suggestive of heart failure, complex ventricular arrhythmias, or an undiagnosed heart murmur (Grade: strong recommendation; moderate-quality evidence).
  14. The organizations recommend that echocardiography, radionuclide imaging, cardiac magnetic resonance imaging, or cardiac computed tomography should not be used for routine assessment of left ventricular function in patients with a normal ECG, no history of myocardial infarction, no symptoms or signs suggestive of heart failure, and no complex ventricular arrhythmias (Grade: strong recommendation; low-quality evidence).
  15. The organizations recommend that routine reassessment (<1 year) of left ventricular function using technologies such as echocardiography radionuclide imaging, cardiac magnetic resonance imaging, or cardiac computed tomography should not be used in patients with no change in clinical status and for whom no change in therapy is contemplated (Grade: strong recommendation; low-quality evidence).
  16. Cardiac Stress Testing to Assess Risk in Patients With Known Stable IHD Who Are Able to Exercise
  17. The organizations recommend standard exercise ECG testing for risk assessment in patients who are able to exercise to an adequate workload and have an ECG that can be interpreted during exercise (Grade: strong recommendation; moderate-quality evidence).
  18. The organizations recommend the addition of either radionuclide myocardial perfusion imaging or echocardiography to standard exercise ECG testing for risk assessment, in patients with stable IHD who are able to exercise to an adequate workload but have an uninterpretable ECG not due to left bundle branch block or ventricular pacing (Grade: strong recommendation; moderate-quality evidence).
  19. The organizations recommend that pharmacologic stress imaging (radionuclide myocardial perfusion imaging, echocardiography, cardiac magnetic resonance imaging) or cardiac computed tomography angiography should not be used for risk assessment in patients with stable IHD who are able to exercise to an adequate workload and have an interpretable ECG (Grade: strong recommendation; low-quality evidence).
  20. Cardiac Stress Testing to Assess Risk in Patients With Known Stable IHD Who Are Unable to Exercise
  21. The organizations recommend pharmacologic stress with either radionuclide myocardial perfusion imaging or echocardiography for risk assessment in patients who are unable to exercise to an adequate workload regardless of interpretability of ECG (Grade: strong recommendation; moderate-quality evidence).
  22. Cardiac Stress Testing to Assess Risk in Patients With Stable IHD Regardless of Ability to Exercise
  23. The organizations recommend pharmacologic stress with either radionuclide myocardial perfusion imaging or echocardiography for risk assessment in patients with stable IHD who have left bundle branch block on ECG, regardless of ability to exercise to an adequate workload (Grade: strong recommendation; moderate-quality evidence).
  24. The organizations recommend either exercise or pharmacological stress with imaging (radionuclide myocardial perfusion imaging, echocardiography, or cardiac magnetic resonance) for risk assessment in patients being considered for revascularization of known coronary stenosis of unclear physiologic significance (Grade: strong recommendation; moderate-quality evidence).
  25. The organizations recommend that a) more than 1 stress imaging study or b) a stress imaging study and cardiac computed tomography angiography at the same time should not be used for risk assessment in patients with stable IHD (Grade: strong recommendation; low-quality evidence).
  26. Coronary Angiography as an Initial Testing Strategy to Assess Risk in Patients With Stable IHD
  27. The organizations recommend that patients with stable IHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia undergo coronary angiography to assess cardiac risk (Grade: strong recommendation; moderate quality-evidence).
  28. The organizations recommend that patients with stable IHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk assessment (Grade: strong recommendation; moderate quality-evidence).
  29. The organizations recommend that patients with stable IHD and clinical characteristics that indicate a high likelihood of severe IHD should undergo coronary angiography to assess cardiac risk (Grade: strong recommendation; low-quality evidence).
  30. Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing
  31. The organizations recommend that coronary arteriography should be used for risk assessment in patients with stable IHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk (Grade: strong recommendation; low-quality evidence).
  32. The organizations recommend that coronary angiography for risk assessment should not be utilized for stable IHD patients who elect not to undergo revascularization or who are not candidates for revascularization based on comorbidities or individual preferences (Grade: strong recommendation; moderate-quality evidence).
  33. The organizations recommend that coronary angiography should not be used to further assess risk in patients with stable IHD who have preserved left ventricular function (ejection fraction >50%) and low-risk criteria on noninvasive testing (Grade: strong recommendation; moderate-quality evidence).
  34. The organizations recommend that coronary angiography should not be used to assess risk in patients who are at low risk based upon clinical criteria and who have not undergone noninvasive risk testing (Grade: strong recommendation; low-quality evidence).
  35. The organizations recommend that coronary angiography should not be used to assess risk in asymptomatic patients with no evidence of ischemia on noninvasive testing (Grade: strong recommendation; low-quality evidence).

American College of Physicians