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©2013 UpToDate ® Print Email 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: 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. Recommendations for cardiac stress imaging as the initial test for diagnosis of coronary heart disease (CHD) in patients with chronic stable angina who are able to exercise Class I 1. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate pretest probability of CAD who have one of the following baseline ECG abnormalities: a. Pre-excitation (Wolff-Parkinson-White) syndrome b. More than 1 mm of ST depression at rest 2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with prior revascularization (either PTCA or CABG). 3. Adenosine or dipyridamole myocardial perfusion imaging in patients with an intermediate pretest probability of CAD and one of the following baseline ECG abnormalities: a. Electronically paced ventricular rhythm b. Left bundle-branch block 4. Dobutamine stress echocardiography in patients with an intermediate pretest probability of CAD and left bundle branch block.* Class IIb 1. Exercise myocardial perfusion imaging and exercise echocardiography in patients with a low or high probability of CAD who have one of the following baseline ECG abnormalities: a. Pre-excitation (Wolff-Parkinson-White) syndrome b. More than 1 mm of ST depression 2. Adenosine or dipyridamole myocardial perfusion imaging in patients with a low or high probability of CAD and one of the following baseline ECG abnormalities: a. Electronically paced ventricular rhythm b. Left bundle-branch block 3. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have one of the following: a. Digoxin use with <1 mm ST depression on the baseline ECG b. LVH with <1 mm ST depression on the baseline ECG

a. Electronically paced ventricular rhythm b. Left bundle-branch block 3. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have one of the following: a. Digoxin use with <1 mm ST depression on the baseline ECG b. LVH with <1 mm ST depression on the baseline ECG 4. Exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography as the initial stress test in a patient with a normal rest ECG who is not taking digoxin. 5. Exercise in patients with left bundle-branch block. ACC/AHA classification