ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease


This manuscript summarizes multisocietal recommendations for appropriate use of diagnostic tests for detection and risk assessment in suspected stable ischemic heart disease. The purpose of this document is to update existing appropriate use criteria using contemporary data, for the use of exercise electrocardiography (ECG), stress radionuclide imaging (RNI), stress echo, stress cardiac magnetic resonance (CMR), calcium scoring, coronary computed tomography angiography (CCTA), and invasive coronary angiography. The following are several key points from these recommendations:

  1. This document presents potential diagnostic tests for common indications using a side-by-side rating system, and denotes tests as Appropriate, May Be Appropriate, or Rarely Appropriate.
  2. In symptomatic patients with suspected ischemic heart disease, pretest probability, ability to exercise, and ECG interpretability guide selection of appropriate tests. For example, exercise ECG is appropriate in patients with an interpretable ECG who are able to exercise and who have low or intermediate pretest probability of coronary artery disease (CAD). Stress RNI and stress echo are appropriate in the majority of categories, while stress CMR, CCTA, and invasive angiography are appropriate in selected categories.
  3. In asymptomatic patients, the only test graded appropriate is exercise ECG in patients with high CAD risk who are able to exercise and with an interpretable ECG.
  4. Multiple imaging tests may be appropriate in patients with newly diagnosed heart failure, while specific tests may be appropriate for the evaluation of selected arrhythmias. Exercise ECG, stress RNI, or stress echo are appropriate in patients with syncope and intermediate to high risk of CAD.
  5. It may be appropriate to perform sequential tests in patients with an abnormal or uncertain primary study, with secondary testing utilizing a different approach from the primary test.
  6. For asymptomatic patients or those with stable symptoms, follow-up testing is not regarded as appropriate in any scenarios. In patients with new or worsening symptoms, multiple tests are graded as appropriate depending on the scenario.
  7. Following revascularization, multiple tests are graded appropriate in symptomatic patients. Among asymptomatic patients after revascularization, testing is only graded as appropriate in patients with incomplete revascularization in whom additional revascularization is feasible.
  8. For preoperative assessment prior to noncardiac surgery, the only scenarios graded as appropriate are assessment of patients with poor or unknown functional capacity planned for vascular surgery with at least one clinical risk factor, kidney transplant, or renal transplant.
  9. In patients planning to start exercise or initiate cardiac rehabilitation, only exercise ECG testing is graded as appropriate.

Keywords: Kidney Transplantation, Coronary Artery Disease, Follow-Up Studies, Echocardiography, Stress, Syncope, Calcium, Coronary Angiography, Tomography, Heart Failure, Risk Assessment, Magnetic Resonance Spectroscopy, Exercise Test

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