p.45 抽出テキスト

November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e412

CLINICAL STATEMENTS AND GUIDELINES 5.2.1. Patients With Obstructive CAD Who Present With Stable Chest Pain

Recommendations for Patients With Obstructive CAD Who Present With Stable Chest Pain Referenced studies that support the recommendations are summarized in Online Data Supplements 32 and 33.

COR LOE Recommendations

Index Diagnostic Testing

Anatomic Testing

1 A 1.	 For patients with obstructive CAD who have stable chest pain despite GDMT and moderatesevere ischemia, ICA is recommended for guiding therapeutic decision-making.1-4

1 A 2.	 For patients with obstructive CAD who have stable chest pain despite optimal GDMT, those referred for ICA without prior stress testing benefit from FFR or instantaneous wave free ratio.3,5-7

1 B-R 3.	 For symptomatic patients with obstructive CAD who have stable chest pain with CCTAdefined ≥50% stenosis in the left main coronary artery, obstructive CAD with FFR with CT ≤0.80, or severe stenosis (≥70%) in all 3 main vessels, ICA is effective for guiding therapeutic decision-making.4,8

2a B-NR 4.	 For patients who have stable chest pain with previous coronary revascularization, CCTA is reasonable to evaluate bypass graft or stent patency (for stents ≥3 mm).9-13 Stress Testing

1 B-NR 5.	 For patients with obstructive CAD who have stable chest pain despite optimal GDMT, stress PET/SPECT MPI, CMR, or echocardiography is recommended for diagnosis of myocardial ischemia, estimating risk of MACE, and guiding therapeutic decision-making.14-36

2a B-R 6.	 For patients with obstructive CAD who have stable chest pain despite optimal GDMT, when selected for rest/stress nuclear MPI, PET is reasonable in preference to SPECT, if available, to improve diagnostic accuracy and decrease the rate of nondiagnostic test results.37

2a B-NR 7.	 For patients with obstructive CAD who have stable chest pain despite GDMT, exercise treadmill testing can be useful to determine if the symptoms are consistent with angina pectoris, assess the severity of symptoms, evaluate functional capacity and select management, including cardiac rehabilitation.4,38-40

2a B-NR 8.	 For patients with obstructive CAD who have stable chest pain symptoms undergoing stress PET MPI or stress CMR, the addition of MBFR is useful to improve diagnosis accuracy and enhance risk stratification.31-36

Synopsis In patients with known CAD, physicians should opt to intensify GDMT first, if there is an opportunity to do so, and defer testing. In patients with a history of obstructive CAD, previous AMI, or previous coronary revascularization, assessing the severity of ischemia may be useful to guide clinical decision-making regarding the use of ICA and intensify preventive and anti-ischemic therapy. Imaging should be considered in those with new onset or persistent stable chest pain (Figure 13). In patients with frequent angina or severe stressinduced ischemia, referral to ICA or CCTA is an option.4 Among individuals with known obstructive CAD or ischemic heart disease who have stable symptoms, exercise treadmill testing may be useful for assessing functional capacity, assessing the type and severity of symptoms, and informing the role of coronary revascularization, cardiac rehabilitation, or anti-anginal therapy.4,38-40

Recommendation-Specific Supportive Text Anatomic Testing

1.	 SIHD randomized trials reveal a pattern that ischemia-guided percutaneous coronary intervention (PCI) results in an improvement in angina when compared with medical therapy alone.1-4,41 In the ISCHEMIA trial, a total of 5179 patients with stable CAD and site-determined moderate-severe ischemia on stress testing were randomized to invasive versus conservative care strategies.4 No difference in the composite primary MACE endpoint was observed at ∼3.3 years of follow-up. Patients presenting with daily, weekly, or monthly angina had a prompt and durable improvement in symptoms when randomized to invasive compared with conservative management.41 2.	 Coronary revascularization after identification of suspected lesion-specific ischemia (FFR ≤0.80 or instantaneous wave-free ratio ≤0.89) in obstructive CAD is associated with improved event-free survival compared with the use of PCI determined by anatomy alone.3,5,6,42 3.	 In a patient presenting with new or recurrent chest pain symptoms, progression of CAD (ie, new or worsening stenosis or more extensive nonobstructive atherosclerotic plaque) may be characterized using CCTA.43,44 Detection of nonobstructive CAD often results in prompt initiation and intensification of preventive and anti-ischemic therapies with CCTA.45-50 There is a high degree of concordance between CCTA- and ICA-determined obstructive CAD.33,51-55 CCTAdefined left main stenosis (nonobstructive and ≥50% stenosis) is associated with a high CAD event risk.56,57 Coronary revascularization confers a survival benefit among patients with left main CAD.58 From randomized trials, major clinical outcomes in patients with left main CAD are similar with CABG and PCI at near-term follow-up of 1 to 2 years, although repeat revascularization rates are higher after PCI.58

Downloaded from http://ahajournals.org by on October 7, 2026