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Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful. * Modified from: Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007; 116:e418. Data modified from: Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 2003; 107:149. Recommendations for cardiac stress imaging as the initial test for diagnosis of coronary heart disease (CHD) in patients with chronic stable angina who are unable to exercise Class I 1. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with an intermediate pretest probability of CAD. 2. Adenosine or dipyridamole stress myocardial perfusion imaging or dobutamine echocardiography in patients with prior revascularization (either PTCA or CABG). Class IIb 1. Adenosine or dipyridamole stress myocardial perfusion imaging or dobutamine echocardiography in patients with a low or high probability of CAD in the absence of electronically paced ventricular rhythm or left bundle-branch block. 2. Adenosine or dipyridamole myocardial perfusion imaging in patients with a low or a high probability of CAD and one of the following baseline ECG abnormalities a. Electronically paced ventricular rhythm b. Left bundle-branch block ACC/AHA classification

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful. Data modified from: Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 2003; 107:149. Comparative advantages of stress echocardiography and stress radionuclide perfusion imaging in diagnosis of coronary heart disease Advantages of stress echocardiography 1. Higher specificity 2. Versatility - more extensive evaluation of cardiac anatomy and function 3. Greater convenience, efficacy, availability 4. Lower cost Advantages of stress perfusion imaging 1. Higher technical success rate 2. Higher sensitivity - especially for single vessel coronary disease involving the left circumflex 3. Better accuracy in evaluating possible ischemia when multiple resting left ventricular wall motion abnormalities are present 4. More extensive published data base - especially in evaluation of prognosis Reproduced with permission from: ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 2003; 107:149. Copyright © 2003 American College of Cardiology.

©2013 UpToDate ® Print Email ACC/AHA guideline summary: Exercise ECG testing without an imaging modality for the diagnosis of obstructive coronary heart disease (CHD) Class I - There is evidence and/or general agreement that exercise ECG testing for the diagnosis of CHD is indicated in patients with: •  An intermediate pretest probability of CHD based upon age, gender, and symptoms, including patients with complete right bundle branch block or less than 1 mm ST depression, in the absence of the exceptions listed in class IIb and class III. Class IIa - The weight of evidence or opinion is in favor of the usefulness of exercise ECG testing for the diagnosis of CHD in patients with: •  Suspected variant (vasospastic) angina. Class IIb - The usefulness of exercise ECG testing for the diagnosis of CHD is less well established in patients with: •  A high or low pretest probability of CHD. •  Digoxin therapy and less then 1 mm of ST segment depression at baseline. •  Electrocardiographic evidence of left ventricular hypertrophy and and less then 1 mm of ST segment depression at baseline. Class III - There is evidence and/or general agreement that exercise testing for risk assessment and prognosis in patients at intermediate or high probability of CHD is not useful in the following settings: •  Patients with the following baseline ECG abnormalities: 1. Preexcitation (Wolff-Parkinson-White) syndrome. 2. Electronically paced ventricular rhythm. 3. More than 1 mm of ST segment depression at rest. 4. Complete left bundle branch block. •  An established diagnosis of CHD due to prior myocardial infarction or coronary angiography. However, testing may be warranted in such patients to assess functional capacity and prognosis. Data from Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 2003; 107:149.