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Diagnostic Testing in Cardiology TABLE 1, Diagnostic Testing for Coronary Artery Disease Diagnostic Test Utility Advantages Limitations Exercise Stress Testing Exercise ECG lnitial diagnostic test in most Data acquired on exercise Not usefulwhen baseline ECG is patients suspected of having capacity, blood pressure and abnormal (LVH, LBBB, paced CAD heart rate response, and rhythm, preexcitation, >1 -mm provoked symptoms ST-segment depression) Stress Recommended when baseline Exercise data acquired along lmage quality is suboptimal in echocardiog raphy ECG findings are abnormal or with wall motion images to some patients but can be when information on a particular assess for ischemia improved with microbubble area of myocardium at risk is contrast needed Allows evaluation of valve function and pulmonary lmage interpretation is difficult pressures when baseline wall motion abnormalities are present Relatively portable and less costly than nuclear protocols Diagnostic accuracy decreases with single-vessel disease or Entire study is completed in <1 h t delayed stress image acquisition SPECT myocardial Recommended when baseline Gating (image acquisition Attenuation artifacts can be perfusion imaging ECG findings are abnormalor coordinated with the cardiac caused by breast tissue or when information on a particular cycle); use o{ higher-energy diaphragm interference; area of myocardium at risk is agents, such as technetium; and attenuation correction and needed techniques used to correct for software programs can improve attenuation provide improved image interpretation With LBBB, conduction delay in specificity the septum may cause false- Radiation exposure positive abnormalities; Late reperfusion imaging allows vasodilator stress can improve evaluation of myocardial viability the accuracy of perfusion if thallium is used imaging Pharmacologic Stress Testing Dobutamine Recommended in patients who Because the patient is supine, Contraindications are severe echocardiography cannot exercise or when images are acquired baseline hypertension, unstable information on an area of continuously, allowing the test to angina, severe tachyarrhythmias, myocardium at risk is needed be stopped as soon as ischemia hypertrophic cardiomyopathy, is evident severe aortic stenosis, and large aortic aneurysm Stepwise increases in dobutamine dose allow staged assessment o{ wall motion abnormalities Vasod ilator myoca rdial Recommended in patients who Vasodilator stress testing may Contraindications a re active perfusion imaging cannot exercise minimize effect of B-blockade on bronchospastic airway disease, (adenosi ne, perfusion defect size theophylline use, sick sinus Minimizes septal abnormalities syndrome, hypotension, and high- dipyridamole, frequently seen with myocardial lmaging with vasodilator stress degree AV block regadenoson) perfusion imaging in patients can be performed sooner after with LBBB myocardial infarction Theophylline and caffeine must be withheld 12-24 h bef ore the test Adenosine or dipyridamole may cause chest pain, dyspnea, or flushing Radiation exposure Dobutamine Recommended in patients who Has sensitivity and specificity Contraindications are severe myocardial perfusion cannot exercise and have similar to those of exercise or baseline hypertension, unstable imaging contraindications to vasodilator vasodilator perfusion imaging for angina, severe tachyarrhythmias, stress diagnosis of myocardial ischemia hypertrophic card iomyopathy, severe aortic stenosis, and large Recommended when aortic aneurysm information on an area of myocardium at risk is needed Radiation exposure (Continued on the ne* page)

TABLE 1, Diagnostic Testing for Coronary Artery Disease Diagnostic Test Utility Advantages Limitations Exercise Stress Testing Exercise ECG lnitial diagnostic test in most Data acquired on exercise Not usefulwhen baseline ECG is patients suspected of having capacity, blood pressure and abnormal (LVH, LBBB, paced CAD heart rate response, and rhythm, preexcitation, >1 -mm provoked symptoms ST-segment depression) Stress Recommended when baseline Exercise data acquired along lmage quality is suboptimal in echocardiog raphy ECG findings are abnormal or with wall motion images to some patients but can be when information on a particular assess for ischemia improved with microbubble area of myocardium at risk is contrast needed Allows evaluation of valve function and pulmonary lmage interpretation is difficult pressures when baseline wall motion abnormalities are present Relatively portable and less costly than nuclear protocols Diagnostic accuracy decreases with single-vessel disease or Entire study is completed in <1 h t delayed stress image acquisition SPECT myocardial Recommended when baseline Gating (image acquisition Attenuation artifacts can be perfusion imaging ECG findings are abnormalor coordinated with the cardiac caused by breast tissue or when information on a particular cycle); use o{ higher-energy diaphragm interference; area of myocardium at risk is agents, such as technetium; and attenuation correction and needed techniques used to correct for software programs can improve attenuation provide improved image interpretation With LBBB, conduction delay in specificity the septum may cause false- Radiation exposure positive abnormalities; Late reperfusion imaging allows vasodilator stress can improve evaluation of myocardial viability the accuracy of perfusion if thallium is used imaging Pharmacologic Stress Testing Dobutamine Recommended in patients who Because the patient is supine, Contraindications are severe echocardiography cannot exercise or when images are acquired baseline hypertension, unstable information on an area of continuously, allowing the test to angina, severe tachyarrhythmias, myocardium at risk is needed be stopped as soon as ischemia hypertrophic cardiomyopathy, is evident severe aortic stenosis, and large aortic aneurysm Stepwise increases in dobutamine dose allow staged assessment o{ wall motion abnormalities Vasod ilator myoca rdial Recommended in patients who Vasodilator stress testing may Contraindications a re active perfusion imaging cannot exercise minimize effect of B-blockade on bronchospastic airway disease, (adenosi ne, perfusion defect size theophylline use, sick sinus Minimizes septal abnormalities syndrome, hypotension, and high- dipyridamole, frequently seen with myocardial lmaging with vasodilator stress degree AV block regadenoson) perfusion imaging in patients can be performed sooner after with LBBB myocardial infarction Theophylline and caffeine must be withheld 12-24 h bef ore the test Adenosine or dipyridamole may cause chest pain, dyspnea, or flushing Radiation exposure Dobutamine Recommended in patients who Has sensitivity and specificity Contraindications are severe myocardial perfusion cannot exercise and have similar to those of exercise or baseline hypertension, unstable imaging contraindications to vasodilator vasodilator perfusion imaging for angina, severe tachyarrhythmias, stress diagnosis of myocardial ischemia hypertrophic card iomyopathy, severe aortic stenosis, and large Recommended when aortic aneurysm information on an area of myocardium at risk is needed Radiation exposure (Continued on the ne* page) 4

Diagnostic Testing in CardiologY TABLE 1 . Diagnostic Testing for Coronary Artery Disease (Continued) Diagnostic Test utility Advantages Limitations PET/CT Provides best perfusion images Study duration is shorter and Not widely available in patients with increased BMI radiation dose is lowerthan with More expensive than other conventional myocardial imaging modalities Provides data on myocardial perfusion imaging perfusion, function, and viability Used with pharmacologic stress Absolute myocardial blood flow only (no exercise protocol) can be measured Radiation exposure Can be combined with CAC scori ng

PET/CT Provides best perfusion images Study duration is shorter and Not widely available in patients with increased BMI radiation dose is lowerthan with More expensive than other conventional myocardial imaging modalities Provides data on myocardial perfusion imaging perfusion, function, and viability Used with pharmacologic stress Absolute myocardial blood flow only (no exercise protocol) can be measured Radiation exposure Can be combined with CAC scori ng Dobutamine or Provides excellent spatial Accurate test for myocardial Some patients experience adenosine CMR resolution for visualization of wall ischemia or viability claustrophobia imaging motion abnormalities during May be contraindicated in patients dobutamine infusion with an older pacemaker, CD, or I

Dobutamine or Provides excellent spatial Accurate test for myocardial Some patients experience adenosine CMR resolution for visualization of wall ischemia or viability claustrophobia imaging motion abnormalities during May be contraindicated in patients dobutamine infusion with an older pacemaker, CD, or I ldentifies perfusion abnormalities other implanted device during adenosine infusion with Certain gadolinium-based gadolinium as contrast agent contrast agents are Provides data on infarction and contraindicated in patients with viability using gadolinium CKD" contrast Sinus rhythm and a slower heart ldentifies anomalous coronary rate are needed for improved artery origin image quality Limited avail and Other Tests Coronary angiography Provides anatomic diagnosis of Can be combined with functional lnvasive the presence and severity of assessment of coronary stenosis Risks associated with vascular access CAD (FFR, IFR) and radiocontrast exposure (kidney Allows for evaluation of coronary Percutaneous revascularization dysfunaion, allergy, bleeding) anatomy can be performed after Radiation exposure diagnostic study CAC scoring May inform preventive treatment CAC scores are predictive of Does not provide data on decisions for patients with cardiovascular risk in selected coronary luminal narrowing intermediate or borderline 10-y patients risk for cardiovascular events Radiation exposure

ldentifies perfusion abnormalities other implanted device during adenosine infusion with Certain gadolinium-based gadolinium as contrast agent contrast agents are Provides data on infarction and contraindicated in patients with viability using gadolinium CKD" contrast Sinus rhythm and a slower heart ldentifies anomalous coronary rate are needed for improved artery origin image quality Limited avail and Other Tests Coronary angiography Provides anatomic diagnosis of Can be combined with functional lnvasive the presence and severity of assessment of coronary stenosis Risks associated with vascular access CAD (FFR, IFR) and radiocontrast exposure (kidney Allows for evaluation of coronary Percutaneous revascularization dysfunaion, allergy, bleeding) anatomy can be performed after Radiation exposure diagnostic study CAC scoring May inform preventive treatment CAC scores are predictive of Does not provide data on decisions for patients with cardiovascular risk in selected coronary luminal narrowing intermediate or borderline 10-y patients risk for cardiovascular events Radiation exposure Coronary CT Useful for selected patients with Coronary artery vessel lumen and Requires high-resolution (64-slice) angiography intermediate risk for CAD atherosclerotic lesions can be CT instruments visualized in detail ldentifies anomalous coronary Does not provide detailed images a rteries of distal vessel anatomy Catheterization will be needed if intervention is planned Ability to quantify lesion severity can be limited by significant calcification or presence of coronary stent Radiation and radiocontrast exposure AV=atrioventricular;CAC=coronaryarterycacium;CAD=coronaryarterydisease;CKD=chronickidneydisease;CMR=cardiacmagneticresonance;FFR=fractionalflow

Coronary CT Useful for selected patients with Coronary artery vessel lumen and Requires high-resolution (64-slice) angiography intermediate risk for CAD atherosclerotic lesions can be CT instruments visualized in detail ldentifies anomalous coronary Does not provide detailed images a rteries of distal vessel anatomy Catheterization will be needed if intervention is planned Ability to quantify lesion severity can be limited by significant calcification or presence of coronary stent Radiation and radiocontrast exposure AV=atrioventricular;CAC=coronaryarterycacium;CAD=coronaryarterydisease;CKD=chronickidneydisease;CMR=cardiacmagneticresonance;FFR=fractionalflow emission CT.

Coronary CT Useful for selected patients with Coronary artery vessel lumen and Requires high-resolution (64-slice) angiography intermediate risk for CAD atherosclerotic lesions can be CT instruments visualized in detail ldentifies anomalous coronary Does not provide detailed images a rteries of distal vessel anatomy Catheterization will be needed if intervention is planned Ability to quantify lesion severity can be limited by significant calcification or presence of coronary stent Radiation and radiocontrast exposure AV=atrioventricular;CAC=coronaryarterycacium;CAD=coronaryarterydisease;CKD=chronickidneydisease;CMR=cardiacmagneticresonance;FFR=fractionalflow emission CT. "Group I gadolinium based contrast agents are contraindicated in patients with end stage kidney disease or estimated glomerular filtration rate less than 30 mUmin/1.73 m'. Group ll gadolinium-based contrast agents are not contraindicated in patients with CKD. There are insufficient data to make a recommendation for group lll gadolinium-based contrast agents in patients with CKD.

"Group I gadolinium based contrast agents are contraindicated in patients with end stage kidney disease or estimated glomerular filtration rate less than 30 mUmin/1.73 m'. Group ll gadolinium-based contrast agents are not contraindicated in patients with CKD. There are insufficient data to make a recommendation for group lll gadolinium-based contrast agents in patients with CKD. and symptoms. Stress testing is most effectively used in symptoms, often yields false positive results, potentially patients with an intermediate pretest probability of CAD (10% resulting in unnecessary testing, inaccurate diagnoses, and to 90'7,), in whom a positive test result significantly increases harms. In patients with a high pretest probabiliry invasive disease likelihood and a negative test result significantly angiography rather than stress testing is appropriate. decreases likelihood. Stress testing in persons with a low Assessment of the patient's ability to exercise is important likelihood of disease, such as young patients with atypical in determining the most appropriate stress test. Exercise ECG 5

Diagnostic Testing in Cardiology is the initial test of choice in patients with normal findings on patient has exerted maximal effort, requests to stop. or expe baseline ECG. If there are baseline ECG abnormalities (e.g., riences significant symptoms (angina or light headedness). ST segment depression >1 mm. Ieft bundle branch block. left The test also should be stopped for exertional hypotension, ventricular hypertrophy. paced rhythnl, or preexcitation). significant hypertension (>200i 110 mnr Hg). ST-segment ele ST segment changes induced u/ith exercise are not specific fbr vation or significant ST-segment depression. or significant CAD. Stress testing with adjunctive imaging or anatomic arrhythmias. assessment with coronary CTA is indicated in these instances. Ischemia is identified on exercise ECG b1' the develop The decision to \,\,ithhold cardiac medications. such as ment of horizontal or downsloping ST segment depression of nitrates and p blockers, before stress testing should be indi at least 1 nrm occurring 80 milliseconds after the J poirrt vidualized. In patients who are undergoing exercise stress (Figure l). ST segment depression cannot localize ischemia or testing to diagnose CAD, cardiac medications that impair heart identi['the culprit coronary artery. Exercise induced h1'po rate response (p btockers) should be withheld fbr at least tension or absence ofblood pressure augmentation can indi 2,1 hours before testir.rg because these agents may lead to an cate signifi cant obstructive disease. inadequate peak heart rate. If the purpose of the stress test is Erercise stress testing additionalll' provides prognostic to evaluate symptoms, determine efficacy oltherapy, or deter value in patients with known or suspected CAD. Exercise mine prognosis in a patient with kno\ 11 CAD, then patients capacit)'is a pouerful predictor of,outcomes: indir,iduals una should continue their cardioactive medication regimen. ble to achieve 5 metabolic equivalents. or the first stage of a Bruce protocol, have higher all-cause mortaliR: Heart rate Exercise ECG recovery after cessation ofexercise pror,ides incremental prog Stress testing to evaluate for CAD should always be performed nostic information. A heart rate drop of less than 12 min in the with exercise unless exercise is contraindicated or the patient first minute after exercise termination is associated r,r,ith is unable. Exercise stress testing protocols use treadmill or higher mortality. Information obtained from erercise stress bicycle ergometry to increase workload in a stepr,r,ise manner. testing also may be used in risk prediction models. The Duke which allows adequate time fbr development of maximal Treadmill Score incorporates duration of exercise. de'u'elop- metabolic demand. A standard Bruce protocol increases the ment of symptoms. and degree of ST segment depression speed and grade of the treadmill e."ery 3 minutes. Achieving to calculate 5-year all cause mortalin in patients \vithout B5'1, of the age predicted maximal heart rate is adequate for known CAD. identifying obstructive CAD; honever. patients should exer cise until limited by symptoms. Because heart rate and blood Stress Testing With Adjunctive Imaging pressure are the major determinants of myocardial oxygen ln patients with obstructive CAD. reduced blood flow and demand, achieving a rate pressure product (heart rate x sys myocardial ischemia result in a progression of myocardial tolic blood pressure) of at least 25,000 is considered an ade abnormalities, termed the ischemic cascade. Initiallll ischemia quate workload. Stress testing should be terminated when the induces changes in perfusion. follor,r,ed b1' diastolic and (at a

is the initial test of choice in patients with normal findings on patient has exerted maximal effort, requests to stop. or expe baseline ECG. If there are baseline ECG abnormalities (e.g., riences significant symptoms (angina or light headedness). ST segment depression >1 mm. Ieft bundle branch block. left The test also should be stopped for exertional hypotension, ventricular hypertrophy. paced rhythnl, or preexcitation). significant hypertension (>200i 110 mnr Hg). ST-segment ele ST segment changes induced u/ith exercise are not specific fbr vation or significant ST-segment depression. or significant CAD. Stress testing with adjunctive imaging or anatomic arrhythmias. assessment with coronary CTA is indicated in these instances. Ischemia is identified on exercise ECG b1' the develop The decision to \,\,ithhold cardiac medications. such as ment of horizontal or downsloping ST segment depression of nitrates and p blockers, before stress testing should be indi at least 1 nrm occurring 80 milliseconds after the J poirrt vidualized. In patients who are undergoing exercise stress (Figure l). ST segment depression cannot localize ischemia or testing to diagnose CAD, cardiac medications that impair heart identi['the culprit coronary artery. Exercise induced h1'po rate response (p btockers) should be withheld fbr at least tension or absence ofblood pressure augmentation can indi 2,1 hours before testir.rg because these agents may lead to an cate signifi cant obstructive disease. inadequate peak heart rate. If the purpose of the stress test is Erercise stress testing additionalll' provides prognostic to evaluate symptoms, determine efficacy oltherapy, or deter value in patients with known or suspected CAD. Exercise mine prognosis in a patient with kno\ 11 CAD, then patients capacit)'is a pouerful predictor of,outcomes: indir,iduals una should continue their cardioactive medication regimen. ble to achieve 5 metabolic equivalents. or the first stage of a Bruce protocol, have higher all-cause mortaliR: Heart rate Exercise ECG recovery after cessation ofexercise pror,ides incremental prog Stress testing to evaluate for CAD should always be performed nostic information. A heart rate drop of less than 12 min in the with exercise unless exercise is contraindicated or the patient first minute after exercise termination is associated r,r,ith is unable. Exercise stress testing protocols use treadmill or higher mortality. Information obtained from erercise stress bicycle ergometry to increase workload in a stepr,r,ise manner. testing also may be used in risk prediction models. The Duke which allows adequate time fbr development of maximal Treadmill Score incorporates duration of exercise. de'u'elop- metabolic demand. A standard Bruce protocol increases the ment of symptoms. and degree of ST segment depression speed and grade of the treadmill e."ery 3 minutes. Achieving to calculate 5-year all cause mortalin in patients \vithout B5'1, of the age predicted maximal heart rate is adequate for known CAD. identifying obstructive CAD; honever. patients should exer cise until limited by symptoms. Because heart rate and blood Stress Testing With Adjunctive Imaging pressure are the major determinants of myocardial oxygen ln patients with obstructive CAD. reduced blood flow and demand, achieving a rate pressure product (heart rate x sys myocardial ischemia result in a progression of myocardial tolic blood pressure) of at least 25,000 is considered an ade abnormalities, termed the ischemic cascade. Initiallll ischemia quate workload. Stress testing should be terminated when the induces changes in perfusion. follor,r,ed b1' diastolic and (at a BASELINE MA.Y ST Lsd Lad EXERCISE STAGE I 49 tfo ST @ l0ooa\' ST E'(ERCISE ST AGE d 116 Dpo ST @ loEoEV ST 0O:0O 1.0 8085 po!r, Slopc 9:29 10.8 80os portJ Sl+c

BASELINE MA.Y ST Lsd Lad EXERCISE STAGE I 49 tfo ST @ l0ooa\' ST E'(ERCISE ST AGE d 116 Dpo ST @ loEoEV ST 0O:0O 1.0 8085 po!r, Slopc 9:29 10.8 80os portJ Sl+c I I v4 F 4.1 oE a!?. {. \t1 0.9 \t4 0.? -l.t a\t 1.9 vl t.0 -{, rv -3.5 4.3 r0. 0.: 4.1 -0.3 03 0.8 -l.l

v4 F 4.1 oE a!?. {. \t1 0.9 \t4 0.? -l.t a\t 1.9 vl t.0 -{, rv -3.5 4.3 r0. 0.: 4.1 -0.3 03 0.8 -l.l ----|*- e11- v5 al1- I v2 r5 {.3 43 0.3 4.3 4.2 1.6 0, {:0.3 -1.9 0.J 0t 0t --t. I -ll

----|*- e11- v5 al1- I v2 r5 {.3 43 0.3 4.3 4.2 1.6 0, {:0.3 -1.9 0.J 0t 0t --t. I -ll trI a\T v! v6 Itr r1T v, \'6 0.5 0.4 l.t 0.1 -1.9 -:.,1 -:.r -:.0 O,I {l 0.1 4.2 -0.8 49 {t -l 0 tIGURE 1. ECGrecordedatbaseline(/eft) andduring(rght) exercisestresstesting.Thepresenceof 2mmdownslopingST-segmentdepressionsinleadsl, ll, Ill,andaVF and leads V3 through Vu during exercise is diagnostic of ischemia but does not localize specific vascular distribution. 6

Diagnostic Testing in Cardiology TABLE 2. lnterpretation of Stress Testing With exercise or dobutamine because of the potential for false lmaging Results positive septal perfusion abnormalities. Stress SPECT Stress Echoc ardiographA At Rest After Stressor tnterpretation Exercise stress echocardiography provides information on Normal Normal Normal ischemia, hemodynamic significance of valvular abnormali- Normal Perfusion defect Stress-induced ties, and pulmonary pressures during exercise. Exercise is myocardial ischemia performed with supine or upright bicycle ergometry which Perfusion Same perfusion lnfarct or hibernating allows for continuous imaging, or with a treadmill protocol, defea defect myocardium which requires acquisition of poststress images within Normal LV dilation Small or no distinct zone 90 seconds. The development of new wall motion abnormali- of ischemia, possible ties indicates ischemia in the visualized territory. Resting wall balanced ischemia or multivessel CAD motion abnormalities that do not improve at peak exercise may indicate infarcted or hibernating myocardium (chronic Stress Echocardiography but potentially reversible ischemic dysfunction). At Rest After Stressor lnterpretation With pharmacologic stress echocardiography, dobu Normal Normal Normal tamine is progressively infused (up to 40 pg/kg/min) to achieve Normal Wall motion Stress-induced 85% of age predicted maximal heart rate. Atropine is adminis- abnormality myocardial ischemia tered ifthe target heart rate is not achieved. The sensitivity of Regional wall Same regional lnfarct or hibernating stress echocardiography may be reduced in the setting of motion wall motion myocardium abnormalities abnormalities baseline wall motion abnormalities, systolic dysfunction, or single vessel disease. Normal LV dilation Small or no distinct zone of ischemia, possible balanced ischemia or Myocardial Perfusion lmaging and Viability Testing multivessel CAD Myocardial perfusion imaging (MPI), also known as nuclear CAD = coronary artery disease; LV = left ventricular; SPECT = single photon stress testing, uses dif'ferences in myocardial blood flow to emission Cl detect ischemia. In SPECT MPI, a radiotracer is injected at rest and at peak exercise/vasodilation, and the radiotracer is taken later stage) systolic dysfunction, ECG changes, and lastly, up by the myocardium relative to blood flow. Rest images are angina. The addition of imaging studies to stress testing compared with images obtained after stress. Perfusion defects increases diagnostic sensitivity by detecting earlier signs of observed after stress indicate flor.r, limiting CAD (Figure 2). and localizing ischemia. Stress testing with imaging is indicated in patients with an inability to exercise, baseline ECG abnormalities that limit interpretation of the exercise ECG, or indeterminate findings on the exercise ECG. Depending on the modality used, stress testing with imaging compares wall motion, perfusion, and/ or metabolism at baseline and after stress (Table 2). Imaging with SPECT, PET, or CMR can be used to detect reduced myo- cardial perfusion as early evidence of ischemia. Systolic dys- function, indicated by wall motion abnormalities during stress, can be detected by echocardiography or CMR imaging. Imaging choice should consider characteristics of the patient and modalify as well as local availabilily and expertise (see Table 1). Exercise is preferred over pharmacologic stressors. Dobutamine, like exercise, increases myocardial oxygen demand and elicits ischemia because of insufficient perfusion to the affected myocardium. Vasodilators, such as dipyrida- mole, regadenoson, and adenosine, produce hyperemia and a F I G UR E 2. Selected images from a nuclear perfusion single-photon emission CI flow disparity between myocardium supplied by unobstructed stress study. Normal perfusion is indicated by orange to white coloring, whereas poor perfusion is indicated by purple to blue coloring. Short-axis views (/) of the heart with vessels and myocardium supplied by stenotic vessels because stres (top row) and alresl(boftom row) show a radiotracer defect in the septal, anterior, of the inability of the distal vasculature to dilate further. In and inferior walls that is filled on the rest images. Long-axis views (8) demonstrate patients with left bundle branch block undergoing myocardial anterior, apical, and inferior filling defects with stres (top row) that is perfused at rest perfusion imaging, vasodilator induced stress is preferred to (bottom row). These findings are consistent with reversible myocardial ischemia.

TABLE 2. lnterpretation of Stress Testing With exercise or dobutamine because of the potential for false lmaging Results positive septal perfusion abnormalities. Stress SPECT Stress Echoc ardiographA At Rest After Stressor tnterpretation Exercise stress echocardiography provides information on Normal Normal Normal ischemia, hemodynamic significance of valvular abnormali- Normal Perfusion defect Stress-induced ties, and pulmonary pressures during exercise. Exercise is myocardial ischemia performed with supine or upright bicycle ergometry which Perfusion Same perfusion lnfarct or hibernating allows for continuous imaging, or with a treadmill protocol, defea defect myocardium which requires acquisition of poststress images within Normal LV dilation Small or no distinct zone 90 seconds. The development of new wall motion abnormali- of ischemia, possible ties indicates ischemia in the visualized territory. Resting wall balanced ischemia or multivessel CAD motion abnormalities that do not improve at peak exercise may indicate infarcted or hibernating myocardium (chronic Stress Echocardiography but potentially reversible ischemic dysfunction). At Rest After Stressor lnterpretation With pharmacologic stress echocardiography, dobu Normal Normal Normal tamine is progressively infused (up to 40 pg/kg/min) to achieve Normal Wall motion Stress-induced 85% of age predicted maximal heart rate. Atropine is adminis- abnormality myocardial ischemia tered ifthe target heart rate is not achieved. The sensitivity of Regional wall Same regional lnfarct or hibernating stress echocardiography may be reduced in the setting of motion wall motion myocardium abnormalities abnormalities baseline wall motion abnormalities, systolic dysfunction, or single vessel disease. Normal LV dilation Small or no distinct zone of ischemia, possible balanced ischemia or Myocardial Perfusion lmaging and Viability Testing multivessel CAD Myocardial perfusion imaging (MPI), also known as nuclear CAD = coronary artery disease; LV = left ventricular; SPECT = single photon stress testing, uses dif'ferences in myocardial blood flow to emission Cl detect ischemia. In SPECT MPI, a radiotracer is injected at rest and at peak exercise/vasodilation, and the radiotracer is taken later stage) systolic dysfunction, ECG changes, and lastly, up by the myocardium relative to blood flow. Rest images are angina. The addition of imaging studies to stress testing compared with images obtained after stress. Perfusion defects increases diagnostic sensitivity by detecting earlier signs of observed after stress indicate flor.r, limiting CAD (Figure 2). and localizing ischemia. Stress testing with imaging is indicated in patients with an inability to exercise, baseline ECG abnormalities that limit interpretation of the exercise ECG, or indeterminate findings on the exercise ECG. Depending on the modality used, stress testing with imaging compares wall motion, perfusion, and/ or metabolism at baseline and after stress (Table 2). Imaging with SPECT, PET, or CMR can be used to detect reduced myo- cardial perfusion as early evidence of ischemia. Systolic dys- function, indicated by wall motion abnormalities during stress, can be detected by echocardiography or CMR imaging. Imaging choice should consider characteristics of the patient and modalify as well as local availabilily and expertise (see Table 1). Exercise is preferred over pharmacologic stressors. Dobutamine, like exercise, increases myocardial oxygen demand and elicits ischemia because of insufficient perfusion to the affected myocardium. Vasodilators, such as dipyrida- mole, regadenoson, and adenosine, produce hyperemia and a F I G UR E 2. Selected images from a nuclear perfusion single-photon emission CI flow disparity between myocardium supplied by unobstructed stress study. Normal perfusion is indicated by orange to white coloring, whereas poor perfusion is indicated by purple to blue coloring. Short-axis views (/) of the heart with vessels and myocardium supplied by stenotic vessels because stres (top row) and alresl(boftom row) show a radiotracer defect in the septal, anterior, of the inability of the distal vasculature to dilate further. In and inferior walls that is filled on the rest images. Long-axis views (8) demonstrate patients with left bundle branch block undergoing myocardial anterior, apical, and inferior filling defects with stres (top row) that is perfused at rest perfusion imaging, vasodilator induced stress is preferred to (bottom row). These findings are consistent with reversible myocardial ischemia. 7

Diagnostic Testing in Cardiology TABLE 3. lnterpretation of Myocardial Viability Cardiouascular Magnetic Resononce lmaging Study Results CMR imaging may be used with dobutamine to assess r,r'all SPECT Viabitity Testing motion abnormalities or with vasodilators to assess perfusion. lnitial Study Rest Study Interpretation It is commonll'performed to evaluate the degree of infarction. (at Rest) Repeated After ViabiliR' can be determined by evaluating the extent of m1,o- 4-24 h (With cardial fibrosis within the left ventricle. Measures of right and Thallium) left ventricular function can be obtained u'ith gating. CMR Perfusion defect Perfusion defect Fixed defea: imaging is limited by operator expertise. length of tinte for infara, no viability image acquisition. and availability. Perfusion defect Reperfusion of Viable area myocardium XEY POIilIS PETViability Testing r Cardiac stress testing is best used in patients with an intermediate pretest probability of coronary artery Baseline Metabolism lnterpretation disease. Perfusion defea Metabolically Viable active myocardium o Exercise ECG is the preferred stress test in patients who Echocardiographic Viability Testing can exercise and have normal findings on a baseline ECG, because exercise provides additional prognostic Baseline Response to lnterpretation Dobutamine information on functional capacity and hemodynamic response. Wall motion Low dose: Biphasic response abnormality improvement of indicates viable . Stress testing with imaging is indicated in patients with function myocardium an inability to exercise, contraindications to exercise. Higher dose: baseline ECG abnormalities that preclude interpretation worsening of of exercise ECC results, or indeterminate findings on function exercise ECG. SPECT = sing e photon emiss on CT

TABLE 3. lnterpretation of Myocardial Viability Cardiouascular Magnetic Resononce lmaging Study Results CMR imaging may be used with dobutamine to assess r,r'all SPECT Viabitity Testing motion abnormalities or with vasodilators to assess perfusion. lnitial Study Rest Study Interpretation It is commonll'performed to evaluate the degree of infarction. (at Rest) Repeated After ViabiliR' can be determined by evaluating the extent of m1,o- 4-24 h (With cardial fibrosis within the left ventricle. Measures of right and Thallium) left ventricular function can be obtained u'ith gating. CMR Perfusion defect Perfusion defect Fixed defea: imaging is limited by operator expertise. length of tinte for infara, no viability image acquisition. and availability. Perfusion defect Reperfusion of Viable area myocardium XEY POIilIS PETViability Testing r Cardiac stress testing is best used in patients with an intermediate pretest probability of coronary artery Baseline Metabolism lnterpretation disease. Perfusion defea Metabolically Viable active myocardium o Exercise ECG is the preferred stress test in patients who Echocardiographic Viability Testing can exercise and have normal findings on a baseline ECG, because exercise provides additional prognostic Baseline Response to lnterpretation Dobutamine information on functional capacity and hemodynamic response. Wall motion Low dose: Biphasic response abnormality improvement of indicates viable . Stress testing with imaging is indicated in patients with function myocardium an inability to exercise, contraindications to exercise. Higher dose: baseline ECG abnormalities that preclude interpretation worsening of of exercise ECC results, or indeterminate findings on function exercise ECG. SPECT = sing e photon emiss on CT Visualization of the Coronary Anatomy Regions with fixed defects can indicate infarcted or hibernat Anatomic assessment of the epicardial coronary arteries can ing myocardium, and viability assessment can help distin be performed with noninvasive coronary CTA or invasive lngi guish between the two (Table 3). Gated images can provide an ography. Both tests require administration of contrast agents assessment of left ventricular systolic function. and expose the patient to radiation. Abilit),to interpret CTA SPECT imaging also can quantify the extent and severity can be limited in patients u'ith extensive calcification and of disease. providing additional prognostic information. High small distal arteries. risk features, such as multiple regions of hypoperfusion, In select symptomatic patients. CTA is another option fbr reduction or lack ofaugmentation in poststress ejection frac ruling out CAD. ln the PROMISE trial. 10,000 symptomatic tion, transient cavity dilatation, and wall motion abnormali patients suspected of having CAD were evaluated r.t,ith an ini ties. are associated with a worse prognosis. tial strate$/ of either anatomic testing n'ith CTA or functional Technetium based MPI has higher sensitivity and speci- testing. In patients n,ith an intermediate pretest probabilitl'of ficity than thallium-based studies and provides belter image CAD, the composite cardiovascular event rate r\Ias lor,r' (<1'll, quality. Technetium based agents bind to the mitochondria, per year) in both groups, and outcomes (death. ml,ocardial allowing for delayed imaging. In contrast, thallium uptake infarction, hospitalization for unstable angina. or major proce requires active metabolism, which can be useful in assessing dural complication) at 2 years did not differ betvreen groups. myocardial viability. Coronary CTA also may play a role in the evaluation of Cardiac PET provides excellent diagnostic and prognostic acute chest pain in the emergency department. CTA is appro information for patients known or suspected to have CAD. PET priate in patients suspected of having an acute aortic syn provides better temporal and spatial resolution than does drome or coronary embolism. CTA may be helpful in patients SPECT, which is helpful in patients with obesity or nondiag- with low or intermediate likelihood of non ST elevation nostic SPECT results. CT may be used with PET to provide acute coronary syndrome who have a lou, TIMI risk score. information on the presence of coronary artery calcification. negatire troponin assay. or nonischemic findings on ECG. It PET radiotracers have a short half'-life, resulting in lower radia also may be useful in patients with an equivocal diagnosis ol tion exposure and necessitating the use of vasodilators. non ST elevation acute coronary s)'ndrome u'ho have an Vasodilator stress allows for assessment of peak stress ejection equivocal initial troponin level or single troponin elevation fraction, quantification of absolute myocardial blood flow and without further symptoms of acute coronary syndrome or in evaluation of myocardial metabolism. The utility of PET in patients who have ischemic symptoms that resolved hours cardiac patients is limited by availability of the technologz. before undergoing testing. Caref'ul consideration of patient

Visualization of the Coronary Anatomy Regions with fixed defects can indicate infarcted or hibernat Anatomic assessment of the epicardial coronary arteries can ing myocardium, and viability assessment can help distin be performed with noninvasive coronary CTA or invasive lngi guish between the two (Table 3). Gated images can provide an ography. Both tests require administration of contrast agents assessment of left ventricular systolic function. and expose the patient to radiation. Abilit),to interpret CTA SPECT imaging also can quantify the extent and severity can be limited in patients u'ith extensive calcification and of disease. providing additional prognostic information. High small distal arteries. risk features, such as multiple regions of hypoperfusion, In select symptomatic patients. CTA is another option fbr reduction or lack ofaugmentation in poststress ejection frac ruling out CAD. ln the PROMISE trial. 10,000 symptomatic tion, transient cavity dilatation, and wall motion abnormali patients suspected of having CAD were evaluated r.t,ith an ini ties. are associated with a worse prognosis. tial strate$/ of either anatomic testing n'ith CTA or functional Technetium based MPI has higher sensitivity and speci- testing. In patients n,ith an intermediate pretest probabilitl'of ficity than thallium-based studies and provides belter image CAD, the composite cardiovascular event rate r\Ias lor,r' (<1'll, quality. Technetium based agents bind to the mitochondria, per year) in both groups, and outcomes (death. ml,ocardial allowing for delayed imaging. In contrast, thallium uptake infarction, hospitalization for unstable angina. or major proce requires active metabolism, which can be useful in assessing dural complication) at 2 years did not differ betvreen groups. myocardial viability. Coronary CTA also may play a role in the evaluation of Cardiac PET provides excellent diagnostic and prognostic acute chest pain in the emergency department. CTA is appro information for patients known or suspected to have CAD. PET priate in patients suspected of having an acute aortic syn provides better temporal and spatial resolution than does drome or coronary embolism. CTA may be helpful in patients SPECT, which is helpful in patients with obesity or nondiag- with low or intermediate likelihood of non ST elevation nostic SPECT results. CT may be used with PET to provide acute coronary syndrome who have a lou, TIMI risk score. information on the presence of coronary artery calcification. negatire troponin assay. or nonischemic findings on ECG. It PET radiotracers have a short half'-life, resulting in lower radia also may be useful in patients with an equivocal diagnosis ol tion exposure and necessitating the use of vasodilators. non ST elevation acute coronary s)'ndrome u'ho have an Vasodilator stress allows for assessment of peak stress ejection equivocal initial troponin level or single troponin elevation fraction, quantification of absolute myocardial blood flow and without further symptoms of acute coronary syndrome or in evaluation of myocardial metabolism. The utility of PET in patients who have ischemic symptoms that resolved hours cardiac patients is limited by availability of the technologz. before undergoing testing. Caref'ul consideration of patient 8

Diagnostic Testing in Cardiology f'actors is essential to avoid additional unnecessary testing, lmY P0t 1{r potential harms, and unnecessary costs. . The absence of coronary artery calcification is associated Invasive coronary angiography provides two dimensional with a low risk for cardiovascular events. images of the coronary vessel Iumen through the injection of nonionic contrast material using long, thin (<2-mm) catheters percutaneously. The femoral or radial artery is used to obtain Risks of Diagnostic Testing for arterial access, and radiation exposure is required. Invasive Coronary Artery Disease angiography should be considered in highly symptomatic Cardiac diagnostic testing carries risks related to exerciser expo patients with abnormal findings on stress testing, selected sure to pharmacologic stress testing agents, radiation, or contrast patients with acute coronary syndrome, and patients with agents; and vascular access for invasive procedures. Additionally, ischemic symptoms refractory to medical therapy. inappropriate initial testing may lead to unnecessary down- FFR, when added to angiography or CTA, measures the stream testing with added physical and flnancial costs. hemodynamic significance of a lesion and helps determine the There is a very small risk fbr myocardial infarction or need for intervention. FFR is the ratio ofblood flow distal to death (1/2500 patients) with exercise stress testing. Absolute the stenosis to blood flow proximal to the stenosis at maximal contraindications to exercise include unstable angina or acute t'low. It is typically measured during cardiac catheterization myocardial inflarction, uncontrolled arrhythmias, decompen- by placing a pressure wire across the stenosis and inducing sated heart failure, acute pulmonary embolism or deep venous conditions of maximal hyperemia, usually with adenosine. thrombosis, acute pericarditis or myocarditis, acute aortic lnstantaneous wave free ratio is a similar invasive functional dissection, and symptomatic severe aortic stenosis. Relative assessment ofcoronary stenoses that does not utilize vasodila contraindications are left main coronary artery stenosis, tor administration. FFR CT is an FDA approved noninvasive hypertrophic cardiomyopathy with severe obstruction, elec- diagnostic test that provides both anatomic and functional trolyte abnormalities, high degree atrioventricular block, and coronary data; it has higher specificity for the diagnosis of significant arrhythmias. obstructive CAD than does CTA alone. FFR CT is performed Side effects of vasodilator stress agents (most commonly, using computational fluid dynamics on CT derived data sets. adenosine and regadenoson) include chest pain, headache, Limited availabiliff of FFR CT and potential delays in analysis and flushing. Atrioventricular block and bronchospasm also affect its use in patients with acute symptoms. may occur. Theophylline may be given after testing to reverse these effects. Vasodilator stress testing is contraindicated in XEY POIl{I patients with reactive airways disease with active wheezing, . Coronary angiography and CT angiography (ClA) pro- systolic blood pressure of less than 90 mm Hg, sick sinus syn vide anatomic infbrmation regarding the extent and drome, or high degree atrioventricular block. severity ofcoronary artery disease; however, the diag SPECT, PET, CAC scoring, coronary CTA. and coronary nostic value of CTA may be limited in cases of extensive angiography all expose the patient to radiation. The level of calcification. radiation exposure depends on the procedure, equipment, choice ofradiopharmaceutical agent and dose, operator tech Coronary Artery Calcium Scoring nique, and patient characteristics (e.g., body size). Calcification of the coronary arteries is indicative ol ath- Contrast agents used in invasive angiography, coronary erosclerosis and may be quantified with CT. Although CAC CTA, and CMR imaging also pose a risk to the patient. Rarely, scoring provides infbrmation regarding the burden of dis CMR imaging that requires gadolinium contrast may cause ease, it cannot determine the degree of obstruction. CAC nephrogenic systemic fibrosis in patients with end stage kid measurement has been used for diagnosis and risk assess ney disease (see MKSAP 19 Nephrology). lodinated contrast ment in both symptomatic and asymptomatic patients. material used in CT or angiography may result in acute kidney Assessment ol CAC in asymptomatic patients should be injury. Microbubble contrast agents are used to enhance the limited to those at intermediate cardiovascular risk and to endocardial borders in echocardiography and rarely can cause select patients at borderline risk in whom CAC results may hypersensitivity reactions. influence primary prevention therapy (see MKSAP 19 Coronary angiography can be complicated by vascular Ceneral Internal Medicine l). CAC score also is incorpo- access problems, bleeding complications, coronary artery dis rated in the MESA Risk Score to predict 10 year coronary section, aortic dissection, and plaque disruption or thrombus heart disease risk (www.mesa nhlbi.org/MESACHDRisk/ leading to peripheral emboli, stroke, or myocardial infarction. MesaRiskScore/RiskScore.aspx). Femoral artery access can be complicated by retroperitoneal CAC scores are categorized as follows: 0, no disease; 1 to hemorrhage, which should be suspected in patients with 99. mild disease; 100 to 400, moderate disease; and greater hypotension, back or flank pain, and/or a drop in hemoglobin than 400, severe disease. Normal reference values depend on level. Pseudoaneurysms at the arterial puncture sites occur age, ethnicity, and sex. The absence ofCAC is associated with more commonly with f'emoral artery access and may manifest a low risk for cardiovascular events. as a large hematoma or new bruit at the access site.

f'actors is essential to avoid additional unnecessary testing, lmY P0t 1{r potential harms, and unnecessary costs. . The absence of coronary artery calcification is associated Invasive coronary angiography provides two dimensional with a low risk for cardiovascular events. images of the coronary vessel Iumen through the injection of nonionic contrast material using long, thin (<2-mm) catheters percutaneously. The femoral or radial artery is used to obtain Risks of Diagnostic Testing for arterial access, and radiation exposure is required. Invasive Coronary Artery Disease angiography should be considered in highly symptomatic Cardiac diagnostic testing carries risks related to exerciser expo patients with abnormal findings on stress testing, selected sure to pharmacologic stress testing agents, radiation, or contrast patients with acute coronary syndrome, and patients with agents; and vascular access for invasive procedures. Additionally, ischemic symptoms refractory to medical therapy. inappropriate initial testing may lead to unnecessary down- FFR, when added to angiography or CTA, measures the stream testing with added physical and flnancial costs. hemodynamic significance of a lesion and helps determine the There is a very small risk fbr myocardial infarction or need for intervention. FFR is the ratio ofblood flow distal to death (1/2500 patients) with exercise stress testing. Absolute the stenosis to blood flow proximal to the stenosis at maximal contraindications to exercise include unstable angina or acute t'low. It is typically measured during cardiac catheterization myocardial inflarction, uncontrolled arrhythmias, decompen- by placing a pressure wire across the stenosis and inducing sated heart failure, acute pulmonary embolism or deep venous conditions of maximal hyperemia, usually with adenosine. thrombosis, acute pericarditis or myocarditis, acute aortic lnstantaneous wave free ratio is a similar invasive functional dissection, and symptomatic severe aortic stenosis. Relative assessment ofcoronary stenoses that does not utilize vasodila contraindications are left main coronary artery stenosis, tor administration. FFR CT is an FDA approved noninvasive hypertrophic cardiomyopathy with severe obstruction, elec- diagnostic test that provides both anatomic and functional trolyte abnormalities, high degree atrioventricular block, and coronary data; it has higher specificity for the diagnosis of significant arrhythmias. obstructive CAD than does CTA alone. FFR CT is performed Side effects of vasodilator stress agents (most commonly, using computational fluid dynamics on CT derived data sets. adenosine and regadenoson) include chest pain, headache, Limited availabiliff of FFR CT and potential delays in analysis and flushing. Atrioventricular block and bronchospasm also affect its use in patients with acute symptoms. may occur. Theophylline may be given after testing to reverse these effects. Vasodilator stress testing is contraindicated in XEY POIl{I patients with reactive airways disease with active wheezing, . Coronary angiography and CT angiography (ClA) pro- systolic blood pressure of less than 90 mm Hg, sick sinus syn vide anatomic infbrmation regarding the extent and drome, or high degree atrioventricular block. severity ofcoronary artery disease; however, the diag SPECT, PET, CAC scoring, coronary CTA. and coronary nostic value of CTA may be limited in cases of extensive angiography all expose the patient to radiation. The level of calcification. radiation exposure depends on the procedure, equipment, choice ofradiopharmaceutical agent and dose, operator tech Coronary Artery Calcium Scoring nique, and patient characteristics (e.g., body size). Calcification of the coronary arteries is indicative ol ath- Contrast agents used in invasive angiography, coronary erosclerosis and may be quantified with CT. Although CAC CTA, and CMR imaging also pose a risk to the patient. Rarely, scoring provides infbrmation regarding the burden of dis CMR imaging that requires gadolinium contrast may cause ease, it cannot determine the degree of obstruction. CAC nephrogenic systemic fibrosis in patients with end stage kid measurement has been used for diagnosis and risk assess ney disease (see MKSAP 19 Nephrology). lodinated contrast ment in both symptomatic and asymptomatic patients. material used in CT or angiography may result in acute kidney Assessment ol CAC in asymptomatic patients should be injury. Microbubble contrast agents are used to enhance the limited to those at intermediate cardiovascular risk and to endocardial borders in echocardiography and rarely can cause select patients at borderline risk in whom CAC results may hypersensitivity reactions. influence primary prevention therapy (see MKSAP 19 Coronary angiography can be complicated by vascular Ceneral Internal Medicine l). CAC score also is incorpo- access problems, bleeding complications, coronary artery dis rated in the MESA Risk Score to predict 10 year coronary section, aortic dissection, and plaque disruption or thrombus heart disease risk (www.mesa nhlbi.org/MESACHDRisk/ leading to peripheral emboli, stroke, or myocardial infarction. MesaRiskScore/RiskScore.aspx). Femoral artery access can be complicated by retroperitoneal CAC scores are categorized as follows: 0, no disease; 1 to hemorrhage, which should be suspected in patients with 99. mild disease; 100 to 400, moderate disease; and greater hypotension, back or flank pain, and/or a drop in hemoglobin than 400, severe disease. Normal reference values depend on level. Pseudoaneurysms at the arterial puncture sites occur age, ethnicity, and sex. The absence ofCAC is associated with more commonly with f'emoral artery access and may manifest a low risk for cardiovascular events. as a large hematoma or new bruit at the access site. 9

Diagnostic Testing in Cardiology I(EV POITIT o Vasodilator stress testing is contraindicated in patients with reactive airways disease with active wheezing, sys tolic blood pressure of less than 90 mm Hg, sick sinus syndrome, or high degree atrioventricular block. Diagnostic Testing for Structural Heart Disease Diagnostic testing for structural heart disease should be consid ered in patients with suggestive history and physical examina- tion findings, such as a grade 316 or higher systolic murmur, a late or holosystolic murmul a diastolic or continuous murmur, or a murmur with accompanying symptoms. Repeat imaging is indicated in patients with structural heart disease when there is F IG U R E 3. Transesophageal echocardiogram showing an absence of thrombus a change in the clinical presentation. tunctional status, or exam in the left atrial appendage (LAA). The transducer is posteraor t0 the heart, and the ination findings; routine surveillance imaging is guided by left atrium (LA) and LAA (arow) are more easily seen than with transthoraci( lesion severity (see Valvular Heart Disease). Imaging modalities echocardiography. LV = left ventricle.

Diagnostic Testing for Structural Heart Disease Diagnostic testing for structural heart disease should be consid ered in patients with suggestive history and physical examina- tion findings, such as a grade 316 or higher systolic murmur, a late or holosystolic murmul a diastolic or continuous murmur, or a murmur with accompanying symptoms. Repeat imaging is indicated in patients with structural heart disease when there is F IG U R E 3. Transesophageal echocardiogram showing an absence of thrombus a change in the clinical presentation. tunctional status, or exam in the left atrial appendage (LAA). The transducer is posteraor t0 the heart, and the ination findings; routine surveillance imaging is guided by left atrium (LA) and LAA (arow) are more easily seen than with transthoraci( lesion severity (see Valvular Heart Disease). Imaging modalities echocardiography. LV = left ventricle. to evaluate for structural heart disease are listed in Table 4. The mainstay of noninvasive imaging fbr structural heart identifies cardiac amyloidosis due to misfolded transthyretin abnormalities is transthoracic echocardiography (TTE). TTE proteins (ATTR), with a specificity greater than 99'1,. evaluates right and left chamber size. thickness. and function. f,EY POIXIS including wall motion. TTE also provides information on val . The mainstay of noninvasive imaging for structural vular patholory (including endocarditis), diastolic function, heart abnormalities is transthoracic echocardiography, hemodynamics, and the pericardium. TTE can be used rt,ith which is used to evaluate patients'*'ith valvular abnor intravenous agitated saline contrast. normally cleared by the malities. congenital heart disease. pericardial disease, or pulmonary circulation, to document the presence of an intra- ventricular dysfunction. cardiac shunt. Dobutamine infusion during TTE may be used in patients with low gradient aortic stenosis in the setting of . ggm-Technetium pyrophosphate scintigraphy can be reduced ejection fraction to help diflerentiate between severe used to differentiate between amyloid subtypes and guide patient management. aortic stenosis and pseud<lstenosis. Transesophageal echocardiography (TEE) is commonly used to evaluate for inf'ective endocarditis and its complica- tions (e.g., abscess). TEE also may be used to better visualize Diagnostic Testing for valvular pathologr, particularly when surgical or percutaneous Cardiac Arrhythmias intervention is plannedr to evaluate specilic structures that The initial study in patients llith palpitations. pres)'ncope. or cannot be well visualized on TTE (e.g., prosthetic heart valves) syncope when an arrhythmia is suspected should be 12 lead or in patients with poor transthoracic imaging; to ev:rlurrte resting ECG. The ECC may show evidence o1'preexcitation. acute aortic abnormalities: and to rule out left atrial thrombus ectopic rhythms. atrioventricular block. or intraventricular befbre cardioversion (Figure 3). TEE requires moderate seda conduction delay, providing insight into the cause of the tion and placement of the probe in the distal esophagus and symptoms. Echocardiography should be perfbrmed in ptltients stomach. Contraindications include esophageal strictures or suspected of having structural heart disease. active esophageal varices. Esophageal injury. including perfb The intermittent and fleeting nature of'arrhllhmias can ration and bleeding, is a potential complication. make diagnosis difficult. Diagnostic studies are selected on the CMR imaging can be used for evaluation of myocardial basis of symptom frequency and the duration and timing of the and pericardial disease, including inflammatory or infiltrative recording (Table 5). [f symptoms occur daill: a 2.1- or 1B hour processes. CMR is particularly useful in diagnosing hyper ambulatory ECG monitor (Holter monitor) ma1'be used. Long trophic cardiomyopathy when there is eccentric or apical term ambulatory ECC monitors can be worn fbr up to 30 days hypertrophy that is diflicult to visualize on echocardiography. if symptoms are less fiequent. lntiequent s),mptomatic e\ents Although cardiac amyloidosis can be diagnosed with may be captured $,ith an external patient triggered event echocardiography or CMR imaging, 99m technetium pyro recorder if the event lasts long enough for the patient to trigger phosphate scintigraphy (eetrlTc-PYP) has re emerged as a useful the device. A looping event recorder captures seleral seconds of means fbr diflerentiating between amyloid subtypes, which the ECG signal befbre the device is triggered: it is useful for guides patient management. eemTc PYP imaging specifically (Text continued on page 13)

to evaluate for structural heart disease are listed in Table 4. The mainstay of noninvasive imaging fbr structural heart identifies cardiac amyloidosis due to misfolded transthyretin abnormalities is transthoracic echocardiography (TTE). TTE proteins (ATTR), with a specificity greater than 99'1,. evaluates right and left chamber size. thickness. and function. f,EY POIXIS including wall motion. TTE also provides information on val . The mainstay of noninvasive imaging for structural vular patholory (including endocarditis), diastolic function, heart abnormalities is transthoracic echocardiography, hemodynamics, and the pericardium. TTE can be used rt,ith which is used to evaluate patients'*'ith valvular abnor intravenous agitated saline contrast. normally cleared by the malities. congenital heart disease. pericardial disease, or pulmonary circulation, to document the presence of an intra- ventricular dysfunction. cardiac shunt. Dobutamine infusion during TTE may be used in patients with low gradient aortic stenosis in the setting of . ggm-Technetium pyrophosphate scintigraphy can be reduced ejection fraction to help diflerentiate between severe used to differentiate between amyloid subtypes and guide patient management. aortic stenosis and pseud<lstenosis. Transesophageal echocardiography (TEE) is commonly used to evaluate for inf'ective endocarditis and its complica- tions (e.g., abscess). TEE also may be used to better visualize Diagnostic Testing for valvular pathologr, particularly when surgical or percutaneous Cardiac Arrhythmias intervention is plannedr to evaluate specilic structures that The initial study in patients llith palpitations. pres)'ncope. or cannot be well visualized on TTE (e.g., prosthetic heart valves) syncope when an arrhythmia is suspected should be 12 lead or in patients with poor transthoracic imaging; to ev:rlurrte resting ECG. The ECC may show evidence o1'preexcitation. acute aortic abnormalities: and to rule out left atrial thrombus ectopic rhythms. atrioventricular block. or intraventricular befbre cardioversion (Figure 3). TEE requires moderate seda conduction delay, providing insight into the cause of the tion and placement of the probe in the distal esophagus and symptoms. Echocardiography should be perfbrmed in ptltients stomach. Contraindications include esophageal strictures or suspected of having structural heart disease. active esophageal varices. Esophageal injury. including perfb The intermittent and fleeting nature of'arrhllhmias can ration and bleeding, is a potential complication. make diagnosis difficult. Diagnostic studies are selected on the CMR imaging can be used for evaluation of myocardial basis of symptom frequency and the duration and timing of the and pericardial disease, including inflammatory or infiltrative recording (Table 5). [f symptoms occur daill: a 2.1- or 1B hour processes. CMR is particularly useful in diagnosing hyper ambulatory ECG monitor (Holter monitor) ma1'be used. Long trophic cardiomyopathy when there is eccentric or apical term ambulatory ECC monitors can be worn fbr up to 30 days hypertrophy that is diflicult to visualize on echocardiography. if symptoms are less fiequent. lntiequent s),mptomatic e\ents Although cardiac amyloidosis can be diagnosed with may be captured $,ith an external patient triggered event echocardiography or CMR imaging, 99m technetium pyro recorder if the event lasts long enough for the patient to trigger phosphate scintigraphy (eetrlTc-PYP) has re emerged as a useful the device. A looping event recorder captures seleral seconds of means fbr diflerentiating between amyloid subtypes, which the ECG signal befbre the device is triggered: it is useful for guides patient management. eemTc PYP imaging specifically (Text continued on page 13) 10

Diagnostic Testing in Cardiology TABLE 4. Diagnostic Testing for Structural Heart Disease Diagnostic Test Major lndications Advantages Limitations Transthoracic Heart failure Accurate diagnosis of structural Operator-dependent data acquisition; echocardiography heart disease and its severity interpretation requires expertise Cardiomyopathy Ouantitation of LV size . nd function, Variability in instrumentation Valvular disease pulmonary pressures, valve function, lmage quality limits diagnosis in Congenital heart disease and intracardiac shunts some patients (COPD, large body Pulmonary hypertension Widely available, portable, fast habitus)

TABLE 4. Diagnostic Testing for Structural Heart Disease Diagnostic Test Major lndications Advantages Limitations Transthoracic Heart failure Accurate diagnosis of structural Operator-dependent data acquisition; echocardiography heart disease and its severity interpretation requires expertise Cardiomyopathy Ouantitation of LV size . nd function, Variability in instrumentation Valvular disease pulmonary pressures, valve function, lmage quality limits diagnosis in Congenital heart disease and intracardiac shunts some patients (COPD, large body Pulmonary hypertension Widely available, portable, fast habitus) Aortic disease May require microbubble contrast agents Pericardial disease Transesophageal Endocarditis High-quality images, especially of Requires esophageal intubation, echoca rd iog ra phy posterior cardiac structures typically with moderate sedation Prosthetic valve dysfunction Most accurate test for evaluation of Evaluation of embolic source endocarditis, prosthetic valves, and Aortic disease left atrial thrombus Left atrialthrombus

Aortic disease May require microbubble contrast agents Pericardial disease Transesophageal Endocarditis High-quality images, especially of Requires esophageal intubation, echoca rd iog ra phy posterior cardiac structures typically with moderate sedation Prosthetic valve dysfunction Most accurate test for evaluation of Evaluation of embolic source endocarditis, prosthetic valves, and Aortic disease left atrial thrombus Left atrialthrombus Th ree-dimensional Mitral valve disease lmproved tomographic imaging Adjunct to two-dimensional imaging echocardiography ASD (percutaneous ASD Used during cardiac procedures for Limited by availability and expertise closure) device placement Cardiac masses lmproved assessment of LV global/ regional systolic function Radionuclide Evaluation of LV systolic Ouantitative EF measurements Radiation exposure angiography (MUGA) function Accurate for serial LVEF measurements Provides no data on other cardiac (e.9., to evaluate for cardiotoxicity structures from chemotherapy) Cardiac catheterization Coronary artery disease Direct measurement of intracardiac lnvasive (left and right) pressures, gradients, and shunts Congenital heart disease Radiation and radiocontrast Contrast angiography provides exposure Valve assessment visualization of complex cardiac lmages are not tomographic, limiting Shunt assessment anatomy evaluation of complex three- Allows percutaneous intervention dimensional anatomy for structural heart disease Coronary CT Coronary artery disease Visualization of complex cardiac Radiation and radiocontrast exposure angiography anatomy Coronary anatomy assessment lmage acquisition improved with High-resolution tomographic images sinus rhythm and slower heart rate Congenital heart disease CMR imaging Congenital heart disease High-resolution tomographic Limited by availability and expertise imaging and blood-flow data Myocardial disease Patient claustrophobia (infiltrative disease, Ouantitative RVvolume and EF myocarditis, hypertrophic measurements May be contraindicated in patients cardiomyopathy) with an older pacemakel lCD, or No ionizing radiation or contrast other implanted devices RV cardiomyopathy (ARVC) material Certain gadolinium-based contrast Ouantitation of LV mass and Enables three-dimensional agents are contraindicated in function reconstruction of cardiac anatomy patients with CKD" Sinus rhythm and slower heart rate are needed for improved image quality Chest CT with contrast Aortic disease High-resolution tomographic images Radiation and radiocontrast exposure Cardiac masses Enables three-d imensional reconstruction of vascular structures Pericardial disease 99m-Technetium Amyloid transthyretin (ATTR) High specificity for ATTR amyloidosis Radiation exposure pyrophosphate cardiac amyloidosis scintigraphy ARVC = arrhythmogenic right ventricular cardiomyopathy; ASD = atrial septal defecU CKD = chronic kidney disease; CMR = cardiac magnetic resonance; EF = ejection fradion;

Th ree-dimensional Mitral valve disease lmproved tomographic imaging Adjunct to two-dimensional imaging echocardiography ASD (percutaneous ASD Used during cardiac procedures for Limited by availability and expertise closure) device placement Cardiac masses lmproved assessment of LV global/ regional systolic function Radionuclide Evaluation of LV systolic Ouantitative EF measurements Radiation exposure angiography (MUGA) function Accurate for serial LVEF measurements Provides no data on other cardiac (e.9., to evaluate for cardiotoxicity structures from chemotherapy) Cardiac catheterization Coronary artery disease Direct measurement of intracardiac lnvasive (left and right) pressures, gradients, and shunts Congenital heart disease Radiation and radiocontrast Contrast angiography provides exposure Valve assessment visualization of complex cardiac lmages are not tomographic, limiting Shunt assessment anatomy evaluation of complex three- Allows percutaneous intervention dimensional anatomy for structural heart disease Coronary CT Coronary artery disease Visualization of complex cardiac Radiation and radiocontrast exposure angiography anatomy Coronary anatomy assessment lmage acquisition improved with High-resolution tomographic images sinus rhythm and slower heart rate Congenital heart disease CMR imaging Congenital heart disease High-resolution tomographic Limited by availability and expertise imaging and blood-flow data Myocardial disease Patient claustrophobia (infiltrative disease, Ouantitative RVvolume and EF myocarditis, hypertrophic measurements May be contraindicated in patients cardiomyopathy) with an older pacemakel lCD, or No ionizing radiation or contrast other implanted devices RV cardiomyopathy (ARVC) material Certain gadolinium-based contrast Ouantitation of LV mass and Enables three-dimensional agents are contraindicated in function reconstruction of cardiac anatomy patients with CKD" Sinus rhythm and slower heart rate are needed for improved image quality Chest CT with contrast Aortic disease High-resolution tomographic images Radiation and radiocontrast exposure Cardiac masses Enables three-d imensional reconstruction of vascular structures Pericardial disease 99m-Technetium Amyloid transthyretin (ATTR) High specificity for ATTR amyloidosis Radiation exposure pyrophosphate cardiac amyloidosis scintigraphy ARVC = arrhythmogenic right ventricular cardiomyopathy; ASD = atrial septal defecU CKD = chronic kidney disease; CMR = cardiac magnetic resonance; EF = ejection fradion; "Group I gadolinium-based contrast agents are contraindicated in patients with end-stage kidney disease or estimated glomerular filtration rate less than 30 mUmin/1 .73 mr. Group ll gadolinium-based contrast agents are not contraindicated in patients with CKD. There is insufficient data to malu u recommendation for group lll gadolinium_based contrast agents in CKD.

"Group I gadolinium-based contrast agents are contraindicated in patients with end-stage kidney disease or estimated glomerular filtration rate less than 30 mUmin/1 .73 mr. Group ll gadolinium-based contrast agents are not contraindicated in patients with CKD. There is insufficient data to malu u recommendation for group lll gadolinium_based contrast agents in CKD. 11

Diagnostic Testing in Cardiology TABTE 5. Diagnostic Testing for Suspected or Known Cardiac Arrhythmias Diagnostic Test or Device lndications Advantages Limitations Resting ECG lnitial diagnostic test in all 12-lead ECG recorded during Most arrhythmias are patients the arrhythmia often identifies intermittent and not recorded the specific arrhythmia on resting ECG Continuous ambulatory ECG Short-term: Frequent (at least Records every beat for 24 h, Short-term: Not helpful when (Holter monitor) daily) asymptomatic or 48 h, or up to 30 d for later arrhythmia occurs infrequently; symptomatic arrhythmias for ana lysis ECG leads limit patient 24- and 4B-h monitors activities (24- and 48-h Patient log allows correlation monitors) Long-term: lnfrequent with symptoms asym ptomatic or sym ptomatic Long-term:Adhesive Recorded data may be arrhythmias for monitoring up attachment to chest; detection transmitted to central to30d of rhythm abnormalities that monitoring service for rapid are asymptomatic or not notification clinically significant Exercise ECG Arrhyth mias provoked by Allows diagnosis of exercise- Physician supervision needed exercise related arrhythmias during testing Allows assessment of impact of Most arrhythmias are not arrhythmia on blood pressure exercise related and symptoms Patient-triggered event I nfrequent symptomatic Small, pocket-sized recorder Symptomatic arrhyth mias must recorder arrhythmias that last >1 '2 min is held to the chest when last long enough for patient to symptoms are present activate the device Recorded data may be Arrhythmia onset is not recorded transmitted to central Not use{ul for syncope or monitoring service for rapid extremely brief arrhythmias notification Looping event recorder lnfrequent, brief symptomatic Continuous ECG signal is ECG leads limit patient (wearable) arrhythmias recorded (with the previous activities 30 s to 2 min saved)when the Syncope Used for 1-4 wk in most cases patient activates the recording mode Device records only when activated by patient Arrhythmia onset is recorded Looping event recorder Very i nfrequent asymptomatic Long-term continuous ECG lnvasive procedure with minor (implantable) or symptomatic arrhythmias monitori ng with patient- ri sks (e.g., infrequent syncope) triggered or heart rate- Device is functionalfor 1 3 y tri g gered episode stora ge (device may need to be Specific heart rate or ORS explanted) parameters can be setto initiate recording of data

TABTE 5. Diagnostic Testing for Suspected or Known Cardiac Arrhythmias Diagnostic Test or Device lndications Advantages Limitations Resting ECG lnitial diagnostic test in all 12-lead ECG recorded during Most arrhythmias are patients the arrhythmia often identifies intermittent and not recorded the specific arrhythmia on resting ECG Continuous ambulatory ECG Short-term: Frequent (at least Records every beat for 24 h, Short-term: Not helpful when (Holter monitor) daily) asymptomatic or 48 h, or up to 30 d for later arrhythmia occurs infrequently; symptomatic arrhythmias for ana lysis ECG leads limit patient 24- and 4B-h monitors activities (24- and 48-h Patient log allows correlation monitors) Long-term: lnfrequent with symptoms asym ptomatic or sym ptomatic Long-term:Adhesive Recorded data may be arrhythmias for monitoring up attachment to chest; detection transmitted to central to30d of rhythm abnormalities that monitoring service for rapid are asymptomatic or not notification clinically significant Exercise ECG Arrhyth mias provoked by Allows diagnosis of exercise- Physician supervision needed exercise related arrhythmias during testing Allows assessment of impact of Most arrhythmias are not arrhythmia on blood pressure exercise related and symptoms Patient-triggered event I nfrequent symptomatic Small, pocket-sized recorder Symptomatic arrhyth mias must recorder arrhythmias that last >1 '2 min is held to the chest when last long enough for patient to symptoms are present activate the device Recorded data may be Arrhythmia onset is not recorded transmitted to central Not use{ul for syncope or monitoring service for rapid extremely brief arrhythmias notification Looping event recorder lnfrequent, brief symptomatic Continuous ECG signal is ECG leads limit patient (wearable) arrhythmias recorded (with the previous activities 30 s to 2 min saved)when the Syncope Used for 1-4 wk in most cases patient activates the recording mode Device records only when activated by patient Arrhythmia onset is recorded Looping event recorder Very i nfrequent asymptomatic Long-term continuous ECG lnvasive procedure with minor (implantable) or symptomatic arrhythmias monitori ng with patient- ri sks (e.g., infrequent syncope) triggered or heart rate- Device is functionalfor 1 3 y tri g gered episode stora ge (device may need to be Specific heart rate or ORS explanted) parameters can be setto initiate recording of data Mobile cardiac outpatient Continuous outpatient ECG Auto-trig gered and patient- ECG leads limit patient telemetry recording for precise triggered capture of arrhythmic activities unless a patch device quantification or capture of events is used rare arrhythmia Up to 96 h of retrievable Resource intensive memory Some patch models connect wirelessly to a mobile phone

Mobile cardiac outpatient Continuous outpatient ECG Auto-trig gered and patient- ECG leads limit patient telemetry recording for precise triggered capture of arrhythmic activities unless a patch device quantification or capture of events is used rare arrhythmia Up to 96 h of retrievable Resource intensive memory Some patch models connect wirelessly to a mobile phone Electrophysiology study lnducing, identifying, and Origin and mechanism of an lnvasive procedure with some clarifying the mechanism o{ arrhythmia can be precisely risk arrhythmia as well as potential defined Some arrhythmias may not be treatment (catheter a blation) inducible, particularly i{ the Catheter ablation of the abnormal heart rhythm or patient is sedated implantation of a cardiac electronic device (e.9., pacemaker or cardioverter- defibrillator) may be performed concomitantly 12

Coronary Artery Disease syncope or presyncope associated with arrhyhmias. An o Duration implanted loop recorder may be warranted in patients with o Aggra\ating factors (exertion. anrietl'. meals) very infiequent events. . Relieving factors Exercise stress testing frequer.rtly is used in patients with o Associated symptoms (shortness of breath. nausea. clil suspected or known arrhythmia to evaluate for chronotropic phoresis) incompetence. ischemia, and exercise induced arrhy'thmia. Most patients do not require invasive electrophysiologr Some demographic groups. including u'ot,'.tctt rti-tti testing. Electrophysiology testing may be indicated in patients patients \\'ith diabetes mellitus. may present onll'u'itl-r iln l.licril in rn hom the diagnosis remains indeterminate or in settings in s)'mptoms. including exertional d1'spnea. nausea. or e\aKqci- which catheter based intenentions mav be needed to treat ated fatigue. refractory arrhyhmias. The physical examin:rtion includes an eraluation oi tilt cardiovascular system and a search for findings su&qcstills I(EY POIlIT conditions that mimic angina, including heart f.ailure. pr-rlmo o The initial study in patients with palpitations, presyn- nary hypertension, valvular heart disease (particularll aortic cope, or syncope when an arrhythmia is suspected stenosis), and hypertrophic cardiomyopathy should be 12-lead resting ECG. The first step in diagnostic testing is to determine the pretcst probability (or likelihood) of coronary artery diseasc' ((..\i))

syncope or presyncope associated with arrhyhmias. An o Duration implanted loop recorder may be warranted in patients with o Aggra\ating factors (exertion. anrietl'. meals) very infiequent events. . Relieving factors Exercise stress testing frequer.rtly is used in patients with o Associated symptoms (shortness of breath. nausea. clil suspected or known arrhythmia to evaluate for chronotropic phoresis) incompetence. ischemia, and exercise induced arrhy'thmia. Most patients do not require invasive electrophysiologr Some demographic groups. including u'ot,'.tctt rti-tti testing. Electrophysiology testing may be indicated in patients patients \\'ith diabetes mellitus. may present onll'u'itl-r iln l.licril in rn hom the diagnosis remains indeterminate or in settings in s)'mptoms. including exertional d1'spnea. nausea. or e\aKqci- which catheter based intenentions mav be needed to treat ated fatigue. refractory arrhyhmias. The physical examin:rtion includes an eraluation oi tilt cardiovascular system and a search for findings su&qcstills I(EY POIlIT conditions that mimic angina, including heart f.ailure. pr-rlmo o The initial study in patients with palpitations, presyn- nary hypertension, valvular heart disease (particularll aortic cope, or syncope when an arrhythmia is suspected stenosis), and hypertrophic cardiomyopathy should be 12-lead resting ECG. The first step in diagnostic testing is to determine the pretcst probability (or likelihood) of coronary artery diseasc' ((..\i)) Coronary Artery Disease (Table 6). A baseline resting ECG is required to eraiuate tbr ot'tg r ing ischemia and to guide the choice of stress test (Figure +1. Stress testing is most useful in patients $'ith an ir.rtemtedi.iic Stable Angina Pectoris probabiliry* of CAD; houever. u'hen the pretest probabilir,\ ot'C.\i) Diagnosis and Evaluation is high. testing may provide prognostic infbrmation. Other ctiirg Stable angina pectoris is reproducible angina (discon.rfort or noses sl-rould be pursued in patiellts u'ith normal stress test finci pressure of the chest, neck, or arms) of at least 2 months'dura ings. lf stress testingyields abnormal results. additional er,aluation tion that is precipitated by a stable level of exertion or emotional should be considered (see Diagnostic Testing in Cardiolog'). stress and is relieved with rest. Unstable angina is new onset angina or angina occurring at a relatively low level of exefiion. I(EY POIf,TS occurring at rest. or accelerating in fiequency or severity. r Stable angina is characterized by reproducible chest dis Unstable angina is associated u,ith increased short term risk for comfbrt precipitated by exertion or emotional stress acute myocardial infarction (Ml). without appreciable worsening over a period of at least The evaluation of angina includes a focused history elicit 2 months. ing information on the follort,ing anginal characteristics: o The initial evaluation of angina includes a locused his o Qualit! tory eliciting qualiry location, radiation. and duration o Location ofangina; aggravating and relieving factors; and associ ated symptoms. o Radiation

Coronary Artery Disease (Table 6). A baseline resting ECG is required to eraiuate tbr ot'tg r ing ischemia and to guide the choice of stress test (Figure +1. Stress testing is most useful in patients $'ith an ir.rtemtedi.iic Stable Angina Pectoris probabiliry* of CAD; houever. u'hen the pretest probabilir,\ ot'C.\i) Diagnosis and Evaluation is high. testing may provide prognostic infbrmation. Other ctiirg Stable angina pectoris is reproducible angina (discon.rfort or noses sl-rould be pursued in patiellts u'ith normal stress test finci pressure of the chest, neck, or arms) of at least 2 months'dura ings. lf stress testingyields abnormal results. additional er,aluation tion that is precipitated by a stable level of exertion or emotional should be considered (see Diagnostic Testing in Cardiolog'). stress and is relieved with rest. Unstable angina is new onset angina or angina occurring at a relatively low level of exefiion. I(EY POIf,TS occurring at rest. or accelerating in fiequency or severity. r Stable angina is characterized by reproducible chest dis Unstable angina is associated u,ith increased short term risk for comfbrt precipitated by exertion or emotional stress acute myocardial infarction (Ml). without appreciable worsening over a period of at least The evaluation of angina includes a focused history elicit 2 months. ing information on the follort,ing anginal characteristics: o The initial evaluation of angina includes a locused his o Qualit! tory eliciting qualiry location, radiation. and duration o Location ofangina; aggravating and relieving factors; and associ ated symptoms. o Radiation TABLE 6. Pretest Likelihood of Coronary Artery Disease in Symptomatic Patients According to Age and Sex' Pretest Likelihood Nonanginal Chest Painb Atypical Angina' Typical Anginad Age (v) Men Women Men Women Men Women 30 39 4 2 34 12 76 26 40-49 13 3 51 22 8l 55 50-59 20 7 65 31 93 t3 60 69 27 14 72 51 94 B6

TABLE 6. Pretest Likelihood of Coronary Artery Disease in Symptomatic Patients According to Age and Sex' Pretest Likelihood Nonanginal Chest Painb Atypical Angina' Typical Anginad Age (v) Men Women Men Women Men Women 30 39 4 2 34 12 76 26 40-49 13 3 51 22 8l 55 50-59 20 7 65 31 93 t3 60 69 27 14 72 51 94 B6 'Each value represents the percentage with s gnrficant coronary anery disease on catheterization. "Nonanglnal chest pain has one or none of the components of typical angrna. 'Atypical angl na has two of the three components of typica I angi na. Reproduced with permission from F hn SD, Gardin JM, Abrams J, et al; Amer can College of Cardiology Foundat on.2A12 ACCF/ANNACP/AATS/PCNAJSCA /STS gu oelrne i.ri College of Cardiology Foundation and the Amelcan Hean Association, lnc. Published by Elsevier lnc. Ail rights reserued. 13