American College of Cardiology

GIBBONS ET AL., 2002 GUIDELINE UPDATE FOR EXERCISE TESTING
Circulation 2002;106:1883-1892

ACC/AHA 2002 Guideline Update for Exercise Testing—Summary Article

A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Excercise Testing Guidelines)

Committee Members
Raymond J. Gibbons, MD, FACC, Chair, Gary J. Balady, MD, FACC, J. Timothy Bricker, MD, FACC; Bernard R. Chaitman, MD, FACC, FAHA; Gerald F. Fletcher, MD, FACC, FAHA; Victor F. Froelicher, MD, FACC, FAHA; Daniel B. Mark, MD, MPH, FACC, FAHA; Ben D. McCallister, MD, FACC, FAHA; Aryan N. Mooss, MBBS, FACC, FAHA; Michael G. O'Reilly, MD, FACC; William L. Winters, Jr, MD, FACC, FAHA

Task Force Members
Raymond J. Gibbons, MD, FACC, FAHA, Chair; Elliott M. Antman, MD, FACC, FAHA, Vice Chair; Joseph S. Alpert, MD, FACC, FAHA; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA; Gabriel Gregoratos, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA; Richard O. Russell, MD, FACC, FAHA*; Sidney C. Smith, Jr, MD, FACC, FAHA

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or full revision is needed. This process gives priority to areas where major changes in text, and particularly recommendations, are mentioned on the basis of new understanding or evidence. Minor changes in verbiage and references are discouraged.

The ACC/AHA guidelines for exercise testing that were published in 1997 have now been updated. The full-text guidelines incorporating the updated material are available on the Internet (www.acc.org or www.americanheart.org) in both a version that shows the changes in the 1997 guidelines in strike-over (deleted text) and highlighting (new text) and a “clean” version that fully incorporates the changes.

This article describes the 10 major areas of change reflected in the update in a format that we hope can be read and understood as a stand-alone document. The table of contents from the full-length guideline indicates the location of these changes. Interested readers are referred to the full-length Internet version to completely understand the context of these changes. All new references appear in boldface type; all original references appear in normal type.

The ACC/AHA classifications, I, II, and III are used to summarize indications as follows:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
    IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
    IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.

In the original guideline, the committee did not rank the available scientific evidence in an A, B, or C fashion. The level of evidence is provided for the new recommendations appearing in the update. The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of patients or from careful analyses of nonrandomized studies or observational registries. A lower rank (C) was given when expert consensus was the primary basis for the recommendation.

The ACC/AHA Task Force on Practice Guidelines welcomes feedback on this update process and the format of this article. Please direct your comments to the Task Force c/o Dawn Phoubandith, American College of Cardiology or via e-mail (dphouban@acc.org).

Table of Contents:

Preamble

1. Introduction
   1. Exercise Testing Procedure
   2. General Overview
   3. Indications and Safety
   4. Equipment and Protocols
   5. Exercise End Points
   6. Interpretation of the Exercise Test
   7. Cost and Availability
   8. Clinical Context
      
      
2. Exercise Testing to Diagnose Obstructive Coronary Artery Disease
   1. Rationale
   2. Pretest Probability
   3. Diagnostic Characteristics and Test Performance
   4. Believability Criteria for Diagnostic Tests
   5. Diagnostic Accuracy of the Standard Exercise Test
   6. Cofounders of Stress ECG Interpretation (Modification I)
   7. ST-Segment Interpretation Issues
      
      
3. Risk Assessment and Prognosis in Patients With Symptoms or a Prior History of Coronary Artery Disease
   1. Risk Stratification: General Considerations
   2. Prognosis of Coronary Artery Disease: General Considerations
   3. Risk Stratification With the Exercise Test (Modifications II, III, IV)
   4. Use of Exercise Test Results in Patient Treatment
   
   
   
4. After Myocardial Infarction (Modification V)
   1. Exercise Test Logistics
   2. Risk Stratification and Prognosis
   3. Activity Counseling
   4. Cardiac Rehabilitation
   5. Summary
   
   
   
5. Exercise Testing Using Ventilatory Gas Analysis
   
   
6. Special Groups: Women, Asymptomatic Individuals, and Postrevascularization Patients
   1. Women
   2. Diagnosis of Coronary Artery Disease in the Elderly
   3. Exercise Testing in Asymptomatic Individuals Without Known CAD (Modifications VI, VII)
   4. Valvular Heart Disease (Modification VIII)
   5. Exercise Testing Before and After Revascularization
   6. Investigation of Heart Rhythm Disorders (Modification IX)
   7. Evaluation of Hypertension (Modification X)
      
      
7. Pediatric Testing: Exercise Testing in Children and Adolescents
   1. Differences Between Pediatric and Adult Testing
   2. Exercise Testing for Specific Pediatric and Congenital Cardiac Problems

Appendices

Staff and Acknowledgement

Tables and Figures

References

The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated as changes occur.

This document was approved by the American College of Cardiology Foundation Board of Trustees in July 2002 and by the American Heart Association Science Advisory and Coordinating Committee in June 2002. When citing this document, the American College of Cardiology Foundation and the American Heart Association would appreciate the following citation format: Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL Jr. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106:1883-1892.

Copies: This document is available on the World Wide Web sites of the ACC (www.acc.org) and the AHA (www.americanheart.org). A single copy of the complete guidelines is available by calling 800-253-4636 (US only) or writing the American College of Cardiology, Resource Center, 9111 Old Georgetown Road, Bethesda, MD 20814-1699. Ask for reprint No. 71-0231. To obtain a copy of the Executive Summary published in the October 1, 2002 issue of Circulation, ask for reprint No. 71-0232. To purchase additional reprints (specify version and reprint number): up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4426, fax 410-528-4264, or e-mail kbradle@lww.com.

*Former Task Force member during writing effort. (Circulation. 2002;106:1883-1892.) Circulation is available at http://www.circulationaha.org.

© 2002 by the American College of Cardiology Foundation and the American Heart Association, Inc.