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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

3 EVALUATION, DIAGNOSIS, AND RISK

STRATIFICATION

3.1 Diagnostic Evaluation

Recommendations for Diagnostic Evaluation Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

1 B-NR 1 In patients with CCD and a change in symptoms

or functional capacity that persists despite GDMT, stress positron emission tomography/single photon emission CT myocardial perfusion imaging (PET/ SPECT MPI), cardiovascular magnetic resonance (CMR) imaging, or stress echocardiography is recommended to detect the presence and extent of myocardial ischemia, estimate risk of major adverse cardiovascular events (MACE), and guide therapeutic decision-making.*1–23

1 B-R 2 In patients with CCD and a change in symptoms

or functional capacity that persists despite GDMT, invasive coronary angiography (ICA) is recommended for guiding therapeutic decision-making with the goal of improving anginal symptoms.*24–28

2a B-R 3 In patients with CCD and a change in symptoms

or functional capacity that persists despite 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.*29

2a B-NR 4 In patients with CCD and a change in symptoms

or functional capacity that persists despite GDMT, exercise treadmill testing can be useful to determine whether the symptoms are consistent with angina pectoris, assess the severity of symptoms, evaluate functional capacity, and guide management.*26,30–32

2a B-NR 5 In patients with CCD undergoing stress PET MPI

or stress CMR imaging, the addition of myocardial blood flow reserve (MBFR) can be useful to improve diagnostic accuracy and enhance risk stratification.*18–23

2a B-NR 6 In patients with CCD and a change in symptoms

or functional capacity that persists despite GDMT, and who have had previous coronary revascularization, coronary CT angiography (CCTA) is reasonable to evaluate bypass graft or stent patency (for stents ≥3 mm).*33–37

*Modified from the 2021 AHA/ACC/Multisociety Guideline for the Evaluation and Diagnosis of Chest Pain.38 Synopsis In patients with CCD, if there is an opportunity to do so, clinicians should first intensify GDMT and defer testing. In patients with CCD, assessing the severity of ischemia may be useful to guide clinical decision-making regarding the use of ICA and for intensification of preventive and anti-ischemic therapy. Imaging should be considered in those with new-onset or persistent stable chest pain. In patients with CCD and frequent angina or severe stressinduced ischemia, referral to ICA or CCTA is an option.26 For additional recommendations about known obstructive and nonobstructive CAD, suspected ischemia, ischemia with nonobstructive coronary arteries (INOCA), role of invasive testing, and revascularization, refer to the 2021 AHA/ACC chest pain guideline,38 the 2021 ACC/AHA/ SCAI revascularization guideline,39 as well as Section 6.1.2 (“Ischemia With Nonobstructive Coronary Arteries”) of this guideline. Additionally, cost–value considerations for diagnostic testing contained within the 2021 AHA/ACC chest pain guideline, Section 5.3, should be considered.38

Recommendation-Specific Supportive Text

1 Observational studies reveal that patients with

moderate to severe ischemia on PET and SPECT MPI have an improved outcome with early coronary revascularization.7,21,40–43 Clinical trials of CMR imaging that included subgroups of patients with obstructive CAD, showed comparable diagnostic accuracy to stress SPECT MPI.10,11 Several large, multicenter registries revealed that stress CMR imaging effectively risk stratifies patients with known CAD.14–17 In a multicenter registry of 2496 patients with a history of CAD, an abnormal stress CMR image was associated with a nearly 2-fold increased mortality hazard.14 Registry data also reported that patients with chest pain syndrome with ischemia by MPI and scarring by late gadolinium enhancement had a relative hazard of 1.5 to 2.1 for cardiovascular death or nonfatal MI.17 Prognosis worsens for patients by the extent and severity of inducible wall motion abnormalities on stress echocardiography.44,45 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 of Angioplasty in Stable Angina) trial, a secondary outcome was a greater reduction in the stress echocardiographic wall motion score among patients with single-vessel CAD treated with percutaneous coronary intervention (PCI) compared with placebo (P<0.0001).46 Patients with PCI and who have a wall motion score ≥1 were more often angina-free compared with those in the placebo arm. 2.	 Randomized trials of patients with CCD reveal

a pattern that ischemia-guided PCI results in an improvement in angina when compared with medical therapy alone.24-26,47,48 In the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical & Invasive Approaches) trial, 5179 patients with stable CAD and site-determined moderate-severe ischemia on stress testing (patients with ≥50% left main stenosis on CCTA, left ventricular ejection fraction [LVEF] <35%, and unacceptable angina on medical therapy were excluded) were randomized to invasive versus conservative care strategies.26 No difference

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