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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e414 CLINICAL STATEMENTS AND GUIDELINES revascularization.20,34,63-65 Patients with moderatesevere ischemia on PET (≥10% ischemic myocardium) treated with PCI reported an improvement in angina when compared with those treated medically.20 Prespecified substudies from therapeutic strategy trials for SIHD also evaluated the role of rest/stress nuclear MPI to assess residual ischemia severity among patients with known CAD who were treated with medical therapy alone or when combined with revascularization.1,2,14-18 Clinical trials of CMR have included subgroups with obstructive CAD, including 76% and 49% in the MR-IMPACT and MR-IMPACT2 studies, respectively, showing generally comparable diagnostic accuracy to stress SPECT MPI.23,24 Several large, multicenter registries reveal that stress CMR effectively risk stratifies patients with known CAD.27-30 In a multicenter registry of 2496 patients with a history of CAD, an abnormal stress CMR had a nearly 2-fold increased mortality hazard.27 From the SPINS Registry (Stress CMR Perfusion Imaging in the United States), patients with known CAD with MPI ischemia and scarring by late gadolinium enhancement had a relative hazard of 1.5 to 2.1 for CV death or nonfatal MI.30 Prognosis worsens for patients by the extent and severity of inducible wall motion abnormalities on stress echocardiography.66,67 Recent randomized trial evidence supports the role of stress echocardiography to guide clinical decision-making. From the ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy in Stable Angina) trial, there was a greater reduction in the stress echocardiographic wall motion score among patients with single-vessel CAD treated with PCI compared with placebo (P<0.0001).68 In a secondary analysis, there was an interaction between the baseline stress echocardiographic wall motion score and the efficacy of PCI for improved angina at 6 weeks of follow-up.69 That is, PCI-treated patients with a wall motion score ≥1 were more often angina-free compared with those in the placebo arm. 6. Evidence supports that the improved diagnostic accuracy of PET MPI is helpful in the patient with known CAD. In a randomized trial of 322 symptomatic patients with known CAD, the presence of lowand high-risk stress PET findings was associated with lower and higher rates of ICA when compared with SPECT MPI (P=0.001).37 In this trial, nearly 1 in 5 patients with low-risk SPECT MPI findings underwent ICA, a rate more than twice that of stress PET MPI. Based on such evidence, PET is preferable over SPECT when both are available. 7. Observational studies of patients with CAD and stable chest pain have demonstrated that exercise treadmill testing can be useful by evaluating the relation of symptoms to graded stress testing, thereby helping to confirm the diagnosis of angina pectoris; assessing symptom severity; and selecting appropriate management: medical therapy, revascularization, and/or cardiac rehabilitation.4,38-40 Secondary Diagnostic Testing: For the Assessment of Vascular Territory Flow or Vessel- Specific Ischemia 8. Measurement of MBFR, when reduced, reflects abnormalities of flow within the epicardial coronary arteries and/or microvasculature and independently predicts risk of major CAD events. This can be effectively accomplished using PET31,70,71 or CMR.28 Normal MBFR may be helpful in excluding high risk anatomy, although reduced levels may provide a better estimate of disease extent and severity. In the presence of nonobstructive CAD, reduced MBFR may signify coronary microvascular dysfunction, especially among women.70 5.2.1.1 Patients With Prior CABG Surgery With Stable Chest Pain Recommendations for Patients With Prior CABG Surgery With Stable Chest Pain COR LOE Recommendations 1 C-LD 1. In patients who have had prior CABG surgery presenting with stable chest pain whose noninvasive stress test results show moderateto-severe ischemia,1-7 or in those suspected to have myocardial ischemia with indeterminate/ nondiagnostic stress test, ICA is recommended for guiding therapeutic decision-making.1 2a C-LD 2. In patients who have had prior CABG surgery presenting with stable chest pain who are suspected to have myocardial ischemia, it is reasonable to perform stress imaging or CCTA to evaluate for myocardial ischemia or graft stenosis or occlusion.8-15 Synopsis In patients with prior CABG who have stable chest pain, it is important to assess medical therapies and optimize all guideline-directed therapies.1 ICA can be useful to guide therapeutic decision-making in those with frequent angina that has not improved with medical therapy.1-9 In those whose symptoms do improve after optimizing medical therapy, evaluation with stress testing can be useful to assess the degree of myocardial ischemia and determine which patients may benefit from coronary angiography.6,10 CCTA can also be used to detect graft patency but is often less robust for assessing native coronary vessel stenosis in those with prior CABG, because of high degree of nondiagnostic segments.8-15 Downloaded from http://ahajournals.org by on October 7, 2026