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CLINICAL STATEMENTS AND GUIDELINES Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 August 29, 2023 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline in the composite primary MACE (cardiovascular death, MI, hospitalization for unstable angina, HF, or resuscitated cardiac arrest) endpoint was observed at ∼3.3 years of follow-up. Angina symptoms improved in both the conservative and invasive treatment arms, although improvements were larger in the invasive arm, particularly with more frequent angina at baseline.48 Therefore, in patients with CCD with known anatomy and ongoing angina despite GDMT, early invasive angiography and revascularization should be considered to improve symptoms. Notably, secondary analyses of RCTs have reported no differences in major adverse cardiovascular outcomes in medical versus invasive medical treatment strategies in patient with CCD49 when stratified by ischemia severity on noninvasive testing. 3. The improved diagnostic accuracy of PET MPI is helpful in patients with known CAD. In a randomized trial of 322 symptomatic patients with known CAD, the presence of low- and high-risk stress PET findings was associated with lower and higher rates of ICA when compared with SPECT MPI (P=0.001).29 4 Observational studies of patients with CAD and stable chest pain have shown 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 (eg, medical therapy, revascularization, cardiac rehabilitation [CR]).26,30–32 5 Reduced MBFR reflects abnormalities of flow within the epicardial coronary arteries, microvasculature, or both, and independently predicts risk of major CAD events. Measurement of MBFR can be effectively accomplished using PET18,50,51 or CMR.15 Normal MBFR may be helpful in excluding high-risk anatomy, although global reduced levels (<2) may provide a better estimate of disease extent and severity. Nonobstructive CAD with reduced MBFR is more frequently observed in women.50 6 CCTA is accurate for the assessment of native vessel CAD and bypass graft patency with high accuracy (∼96%) and concordance (82% to >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.33–37 Other modalities may be considered in patients with CCD with smaller or more distal stents. Several controlled clinical trials have evaluated the concordance of fractional flow reserve (FFR)-CT with invasive FFR.52–55 Diagnostic sensitivity of FFR-CT compared with invasive FFR is high. 3.2 Risk Stratification and Relationship to Treatment Selection Recommendations for Risk Stratification and Relationship to Treatment Selection Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations Risk Stratification and Prognosis 1 B-NR 1 In patients with CCD, it is recommended that risk stratification incorporate all available information, including noninvasive, invasive, or both cardiovascular diagnostic testing results or use validated risk scores to classify patients as low (<1%), intermediate (1%-3%), or high (>3%) yearly risk for cardiovascular death or nonfatal MI.1–4 Relationship to Treatment 1 A 2. In patients with CCD, optimization of GDMT is recommended to reduce MACE.*5–7 1 A 3 In patients with CCD with newly reduced LV systolic function, clinical heart failure, or both, ICA is recommended to assess coronary anatomy and guide potential revascularization.8,9 3: No benefit A 4 In patients with CCD, ICA for risk stratification is not routinely recommended in patients without LV systolic dysfunction, heart failure, stable chest pain refractory to GDMT, and/or noninvasive testing suggestive of significant (>50%) left main disease.5–7,10,11 *Modified from the 2021 AHA/ACC/Multisociety Guideline for the Evaluation and Diagnosis of Chest Pain.12 Synopsis In patients with CCD, the results of noninvasive or invasive testing alone are insufficient to accurately risk stratify an individual’s annual future risk of future cardiovascular death or nonfatal MI.13 Clinicians should integrate cardiovascular test results with demographic, social, and medical variables (Table 5) and use validated risk prediction models (where available) to estimate the annual cardiovascular risk. Although multiple randomized trials have shown that routine revascularization does not lead to a reduction in MACE, a symptom and integrated risk assessment may help identify subsets of patients, such as those with persistent angina, reduced LV function or HF, who may benefit from routine revascularization.5-8,14 Recommendation-Specific Supportive Test 1 Noninvasive test results alone are insufficient to adequately risk stratify patients with CCD, and the additional information improves risk prediction.4 In an externally validated study of patients who underwent an exercise stress testing, the Duke Treadmill Score alone had a c-index of 0.62 for allcause death, but the addition of clinical variables into an integrated risk score improved discrimination (c-index=0.83) and reclassified 64% of lowrisk Duke Treadmill Score scores to intermediate or high risk.1 Externally validated risk scores lack Downloaded from http://ahajournals.org by on October 7, 2026