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©2013 UpToDate ® Print Email ACC/AHA guideline summary: Exercise testing for risk assessment and prognosis in patients with an intermediate or high probability of coronary heart disease (CHD) Class I - 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 indicated in the following settings: •  As part of the initial evaluation in the absence of the exceptions listed in class IIb and class III. •  After a significant change in cardiac symptoms. Class IIb - The usefulness or efficacy is less well established for exercise testing for risk assessment and prognosis in patients at intermediate or high probability of CHD in the following settings: •  The following ECG abnormalities: 1. Preexcitation (Wolff-Parkinson-White) syndrome. 2. Electronically paced ventricular rhythm. 3. More than 1 mm of ST depression at rest. 4. Complete left bundle branch block. •  After cardiac catheterization to identify ischemia in the distribution of a coronary lesion of borderline severity. •  After revascularization in patients with a significant change in anginal pattern that is suggestive of ischemia. 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 setting: •  In the presence of severe comorbidity that is likely to limit life expectancy or prevent revascularization. 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.

©2013 UpToDate ® Print Email ACC/AHA guideline summary: Exercise testing for risk assessment and prognosis in patients with an intermediate or high probability of coronary heart disease (CHD) Class I - 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 indicated in the following settings: •  As part of the initial evaluation in the absence of the exceptions listed in class IIb and class III. •  After a significant change in cardiac symptoms. Class IIb - The usefulness or efficacy is less well established for exercise testing for risk assessment and prognosis in patients at intermediate or high probability of CHD in the following settings: •  The following ECG abnormalities: 1. Preexcitation (Wolff-Parkinson-White) syndrome. 2. Electronically paced ventricular rhythm. 3. More than 1 mm of ST depression at rest. 4. Complete left bundle branch block. •  After cardiac catheterization to identify ischemia in the distribution of a coronary lesion of borderline severity. •  After revascularization in patients with a significant change in anginal pattern that is suggestive of ischemia. 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 setting: •  In the presence of severe comorbidity that is likely to limit life expectancy or prevent revascularization. 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. ACC/AHA guideline summary: Cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise Class I - There is evidence and/or general agreement that cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise should be performed in the following manner:

ACC/AHA guideline summary: Cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise Class I - There is evidence and/or general agreement that cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise should be performed in the following manner: • Among patients who do not have left bundle branch block or an electronically paced ventricular rhythm but have either an abnormal ECG or are taking digoxin, exercise myocardial perfusion imaging (MPI) or exercise echocardiography to identify the extent, severity, and location of ischemia. • Among patients with left bundle branch block or an electronically paced ventricular rhythm, dipyridamole or adenosine MPI. • Among patients with left bundle branch block, dobutamine stress echocardiography.* • When assessing the functional significance of coronary lesions, exercise MPI or exercise echocardiography. Class IIb - The weight of evidence or opinion is less well established for the usefulness of cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise in the following setting: • Exercise echocardiography in the presence of left bundle branch block. • Exercise, dipyridamole, or adenosis MPI or exercise or dobutamine echocardiography in patients who have a normal rest ECG and are not taking digoxin. Class III - There is evidence and/or general agreement that cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise is not useful in in the following settings: • Exercise MPI in the presence of left bundle branch block. • Severe comorbidity that is likely to limit life expectation or prevent revascularization.

Class III - There is evidence and/or general agreement that cardiac stress imaging as the initial test for risk stratification of patients with chronic stable angina who are able to exercise is not useful in in the following settings: • Exercise MPI in the presence of left bundle branch block. • Severe comorbidity that is likely to limit life expectation or prevent revascularization. * 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 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. Copyright 2003 by the American College of Cardiology and American Heart Association, Inc.