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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e409 CLINICAL STATEMENTS AND GUIDELINES

2a B-NR 10.	 For intermediate-high risk patients with stable chest pain after inconclusive CCTA, stress imaging is reasonable.13,14,20-23,40,71-76

2b C-EO 11.	 For intermediate-high risk patients with stable chest pain after a negative stress test but with high clinical suspicion of CAD, CCTA or ICA may be reasonable. Synopsis

The approach to the diagnostic evaluation of patients with no known CAD who are at intermediate to high risk (Figure 12) should be guided by the ability to achieve highquality imaging as well as local availability and expertise. Intermediate-high risk patients have modest rates of obstructive CAD (∼10%–20%) and risk of clinical events (∼1%–2% per year).1,5,8,77-80 CCTA is preferable in those <65 years of age and not on optimal preventive therapies, while stress testing may be advantageous in those

Figure 12. Clinical Decision Pathway for Patients With Stable Chest Pain and No Known CAD Test choice should be guided by local availability and expertise. *Test choice guided by patient’s exercise capacity, resting electrocardiographic abnormalities; CCTA preferable in those <65 years of age and not on optimal preventive therapies; stress testing favored in those ≥65 years of age (with a higher likelihood of ischemia). †High-risk CAD means left main stenosis ≥50%; anatomically significant 3-vessel disease (≥70% stenosis). CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; INOCA, ischemia and no obstructive CAD; PET, positron emission tomography; and SPECT, single-photon emission CT.

Recommendations for Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD (Continued) Sequential or Add-on Testing: What to Do if Index Test Results are Positive or Inconclusive (continued)

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