Perspective:

The following are 10 points to remember about this guideline summary:

1. The guidelines recommend that patients with chest pain should receive a thorough history and physical examination to assess the probability of ischemic heart disease (IHD) prior to additional testing.

2. A resting electrocardiogram (ECG) in patients without an obvious noncardiac cause of chest pain for risk assessment is recommended.

3. A standard exercise ECG is recommended 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.

4. An 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.

5. Pharmacologic stress with radionuclide myocardial perfusion imaging or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who are incapable of at least moderate physical functioning or with disabling comorbidity.

6. Assessment of resting left ventricular systolic and diastolic ventricular function and evaluating for abnormalities of myocardium, heart valves, or pericardium using Doppler echocardiography are indicated 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.

7. 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.

8. Patients with stable IHD who have survived sudden cardiac death or a potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk.

9. 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.

10. 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.