The following are key points to remember from the 2023 multimodality Appropriate Use Criteria (AUC) for the detection and risk assessment of chronic coronary disease (CCD):

1. This AUC document on CCD replaces its predecessor, the 2013 multimodality AUC for detection and risk assessment of stable ischemic heart disease (SIHD). CCD encompasses any manifestation of coronary artery disease other than active acute coronary syndrome, and patients with CCD may or may not be symptomatic. The shift in terminology from SIHD to CCD was previously recognized in the European Society of Cardiology 2019 guideline on chronic coronary syndromes, which emphasized the idea that atherosclerotic disease can progress even during clinically silent periods (Knuuti J, et al., Eur Heart J 2020;41:407-77).
2. In lieu of the terms “typical/definite angina” and “atypical/probable angina,” the current document uses “likely anginal” and “less-likely anginal,” to reflect the idea that patients can present with a range of symptoms.
3. The appropriateness tables are organized based on presence or absence of symptoms, as well as presence or absence of known CCD and prior cardiovascular testing.
4. Clinicians may choose to test asymptomatic patients for a number of reasons, including the following:
• Refinement of risk stratification in patients with borderline and intermediate atherosclerotic cardiovascular disease risk scores (coronary artery calcium scoring is considered appropriate, electrocardiogram [ECG] treadmill testing may be appropriate).
• Assessment of patients at high risk for silent ischemia (stress testing with nuclear, echocardiographic, or magnetic resonance imaging is considered appropriate).
• Initiation of an unsupervised exercise program in the absence of known CCD (no testing is considered appropriate, ECG treadmill testing may be appropriate, and other modalities are considered rarely appropriate).
• Evaluation of patients who underwent chest radiation therapy >5 years ago (all stress testing modalities and coronary artery calcium scoring may be appropriate).
5. As noted in prior AUC documents, more than one testing modality could be appropriate in any given clinical scenario. AUC do not attempt to rank modalities with regard to appropriateness. Cost and safety factor implicitly into the development of AUC, and local expertise and availability should always be considered in clinical decision-making.
6. The current CCD AUC does not cover preoperative risk assessment, as the 2013 SIHD AUC did. An upcoming AUC document will provide guidance on multimodality imaging in cardiovascular evaluation of patients undergoing nonurgent, noncardiac surgery.

Clinical Topics: Acute Coronary Syndromes, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angina Pectoris, Atherosclerosis, Coronary Artery Disease, Coronary Disease, Diagnostic Imaging, Echocardiography, Electrocardiography, Exercise Test, Magnetic Resonance Imaging, Myocardial Ischemia, Risk Assessment, Secondary Prevention, Tomography, X-Ray Computed

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