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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e415 CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text 1. There are stress test features in patients with prior CABG and presenting with stable chest pain that may indicate a high likelihood of severe ischemic heart disease such as stress electrocardiographic findings including 2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/VF, severe stress-induced left ventricular systolic dysfunction, stress-induced perfusion abnormalities involving ≥10% myocardium or stress-induced left ventricular dilation. In these patients with prior CABG and high-risk imaging features, referral for ICA is reasonable provided that these patients are amenable to and are candidates for coronary revascularization.1-7 Patients with prior CABG presenting with stable chest pain may have stress imaging features that are equivocal or nondiagnostic for the presence of myocardial ischemia. Equivocal or nondiagnostic stress tests may be a result of patient’s body habitus, inadequate or suboptimal heart rate, arrhythmias such as atrial fibrillation, left bundle branch block, or patient motion. In these patients, performing an ICA is reasonable when the angiographic findings have a high likelihood of impacting therapeutic decisions.1 2. Stable chest pain due to myocardial ischemia may occur in patients with prior CABG because of progression of atherosclerosis in the native coronary arteries or within the bypass grafts. Noninvasive stress imaging testing is reasonable in these patients to identify ischemic myocardial territories that will further guide revascularization for patients who are amenable to and are candidates for revascularization. Furthermore, stress imaging also assists in stratifying patients to determine the degree of likelihood for severe ischemic heart disease, which will assist in therapeutic decisions.8-10,12-14 CCTA has a great degree of accuracy with a sensitivity and specificity of detecting complete graft occlusions, 99% and 99%, respectively, when compared with the standard of ICA.15 Furthermore, CCTA was ideal in assessing bypass grafts attributable to the large size of these vessels, decreased vessel calcification and decreased motion of these vessels when compared with native coronary vessels, with successful evaluation of bypass grafts in 93% to 100% of patients.15 In patients who have stable chest pain and are previously known to have borderline graft stenosis or are suspected to have new graft stenosis, CCTA is useful for assessing graft patency but less robust for assessing native coronary vessel stenosis in this population because of high degree of nondiagnostic segments.8-15 5.2.2 Patients With Known Nonobstructive CAD Presenting With Stable Chest Pain Recommendations for Patients With Known Nonobstructive CAD Presenting With Stable Chest Pain Referenced studies that support the recommendations are summarized in Online Data Supplements 34 and 35. COR LOE Recommendations Index Diagnostic Testing Anatomic Testing 2a B-NR 1. For symptomatic patients with known nonobstructive CAD who have stable chest pain, CCTA is reasonable for determining atherosclerotic plaque burden and progression to obstructive CAD, and guiding therapeutic decision-making.1-7 2a B-NR 2. For patients with known coronary stenosis from 40% to 90% on CCTA, FFR can be useful for diagnosis of vessel-specific ischemia and to guide decision-making regarding the use of ICA.8-14 Stress Testing 2a C-LD 3. For patients with known extensive nonobstructive CAD with stable chest pain symptoms, stress imaging (PET/SPECT, CMR, or echocardiography) is reasonable for the diagnosis of myocardial ischemia.15-24 Synopsis For patients with known nonobstructive CAD (luminal narrowing 1%–49%), CCTA can be useful for detection of new or worsening obstructive stenosis, atherosclerotic disease progression, and identification of high-risk plaque features, such as low attenuation plaque or positive remodeling1,2,5-7,25 (Figure 13). Similarly, stress imaging is reasonable to detect myocardial ischemia and can help guide further management and treatment of ischemic burden.15-24 Irrespective of the test performed, an overarching goal of the evaluation of symptomatic patients with known nonobstructive CAD is to identify those who would benefit from intensification of preventive therapy, as defined by the 2018 cholesterol-lowering guidelines and the 2019 prevention guidelines.26-29 For this evaluation, the patient should be engaged in a process of shared decision-making before determining the final choice of the cardiac testing modality and in guiding the pathway for treatment decisions. Recommendation-Specific Supportive Text Anatomic Testing 1. Atherosclerosis is a progressive disease that worsens over time,1 with nonobstructive CAD Downloaded from http://ahajournals.org by on October 7, 2026