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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e413 CLINICAL STATEMENTS AND GUIDELINES

4.	 CCTA has been shown to be accurate for the assessment of native vessel CAD and bypass graft patency with high accuracy (∼96%) and concordance (82%–>93%) to ICA; it may also be useful to assess patency of proximal large stents (≥3 mm) if such information is known at the time of presentation.9-13 Several controlled clinical trials have evaluated the concordance of FFR-CT with invasive FFR.59-62 Diagnostic sensitivity of FFR-CT compared with invasive FFR is high.32,60

Stress Testing

5.	 Observational findings reveal that patients with moderate-severe ischemia on PET and SPECT MPI have an improved outcome with early coronary

Figure 13. Clinical Decision Pathway for Patients With Stable Chest Pain (or Equivalent) Symptoms With Prior MI, Prior Revascularization, or Known CAD on Invasive Coronary Angiography or CCTA, Including Those With Nonobstructive CAD Test choice should be guided by local availability and expertise. *Known CAD means prior MI, revascularization, known obstructive CAD, nonobstructive CAD. †High-risk CAD means left main stenosis ≥50%; or obstructive CAD with FFR-CT ≤0.80. ‡Test choice guided by the patient’s exercise capacity, resting electrocardiographic abnormalities. §Patients with prior CABG or stents >3.0 mm. Follow-up Testing and Intensification of GDMT Guided by Initial Test Results and Persistence / Worsening / Frequency of Symptoms and Shared Decision Making. CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; ECG, electrocardiogram; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography; iFR, instant wave-free ratio; INOCA, ischemia and no obstructive coronary artery disease; MI, myocardial infarction; MPI, myocardial perfusion imaging; PET, positron emission tomography; SIHD, stable ischemic heart disease; and SPECT, single-photon emission CT.

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