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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e397 CLINICAL STATEMENTS AND GUIDELINES

2.	 ICA is an effective means for diagnosing obstructive CAD and guiding the use of coronary revascularization. For the intermediate-risk patients with a previous history of CAD, ICA is reasonable for patients presenting with frequent weekly or daily symptoms or for those already on GDMT as well as those with high-risk CAD (left main or proximal left anterior descending or multivessel CAD). 3.	 For patients with previous anatomic testing that revealed nonobstructive CAD, CCTA has been shown to effectively document progressive CAD, including more extensive atherosclerotic plaque or the presence of high-risk plaque features or new obstructive stenosis ≥50%.9-11,24 Patients in this category also include those patients with a previous CAC scan (or those for whom coronary artery calcification was

Figure 10. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With Known CAD Test choice should be guided by local availability and expertise. *Known CAD is prior MI, revascularization, known obstructive or nonobstructive CAD on invasive or CCTA. †If extensive plaque is present a high-quality CCTA is unlikely to be achieved, and stress testing is preferred ‡Obstructive CAD includes prior coronary artery bypass graft/percutaneous coronary intervention. §High-risk CAD means left main stenosis ≥50%; anatomically significant 3-vessel disease (≥70% stenosis). ‖FFR-CT turnaround times may impact prompt clinical care decisions. ACS indicates acute coronary syndrome; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission CT.

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