From the Guidelines
The current algorithm for suspected coronary artery disease (CAD) begins with a thorough clinical assessment, including medical history, risk factor evaluation, and physical examination, followed by estimation of the pre-test likelihood of obstructive CAD using the Risk Factor-weighted Clinical Likelihood model, as recommended by the 2024 ESC guidelines 1. The clinical assessment should include a detailed evaluation of cardiovascular risk factors, medical history, and symptom characteristics, as well as consideration of symptoms like chest pain triggered by emotional stress, dyspnea or dizziness on exertion, pain in the arms, jaw, neck, or upper back, or fatigue as potential angina equivalents 1. The pre-test likelihood of obstructive CAD should be estimated using the Risk Factor-weighted Clinical Likelihood model, and additional clinical data, such as examination of peripheral arteries, resting ECG, resting echocardiography, and presence of vascular calcifications on previously performed imaging tests, should be used to adjust the estimate yielded by the model 1. For patients with a very low (≤5%) pre-test likelihood of obstructive CAD, deferral of further diagnostic tests should be considered, while for those with a low (>5%–15%) pre-test likelihood, coronary artery calcium scoring (CACS) should be considered to reclassify subjects and identify more individuals with very low (≤5%) CACS-weighted clinical likelihood 1. Non-invasive anatomical imaging tests, such as coronary computed tomography angiography (CCTA), are recommended for patients with suspected CAD and low or moderate (>5%–50%) pre-test likelihood of obstructive CAD, to diagnose obstructive CAD and estimate the risk of major adverse cardiac events (MACE) 1. Stress echocardiography is recommended for patients with suspected CAD and moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, to diagnose myocardial ischemia and estimate the risk of MACE 1. The selection of the initial non-invasive diagnostic test should be based on pre-test likelihood of obstructive CAD, other patient characteristics that influence the performance of non-invasive tests, and local expertise and availability, as recommended by the 2024 ESC guidelines 1. Medical therapy typically includes antiplatelet agents, statins, and anti-anginal medications, as well as risk factor modification, including blood pressure control, diabetes management, smoking cessation, weight management, and regular physical activity 1. Overall, the stepwise approach allows for appropriate risk stratification and targeted interventions while minimizing unnecessary invasive procedures in low-risk patients.
From the Research
Current Algorithm for Suspected Coronary Artery Disease
The current algorithm for suspected coronary artery disease involves several steps, including:
- Clinical risk stratification using chest pain history, risk factor profile, and noninvasive stress test results 2
- Noninvasive stress testing, such as standard exercise treadmill testing or stress imaging, to assess the risk of coronary artery disease 3, 4
- Coronary angiography for high-risk patients to confirm the diagnosis and guide treatment 2
- Optimal medical therapy for all patients with coronary artery disease, including those with uncontrolled symptoms or high risk for adverse outcomes 2
- Coronary artery revascularization with percutaneous coronary intervention or coronary artery bypass graft surgery for patients with uncontrolled symptoms or high risk for adverse outcomes 2
Noninvasive Stress Testing
Noninvasive stress testing is a crucial component of the algorithm, with the goal of risk stratification 3, 4. The choice of stress test depends on the patient's ability to exercise and the presence of other medical conditions. Standard exercise treadmill testing is the initial procedure of choice for patients with a normal or near-normal resting electrocardiogram who are capable of adequate exercise 3, 4. Stress imaging is recommended for patients with prior revascularization, uninterpretable electrocardiograms, or inability to adequately exercise 3, 4.
Comparison of Diagnostic Tests
A systematic review and meta-analysis compared the clinical effectiveness of coronary computed tomography angiography (CCTA) with functional stress testing for patients with suspected coronary artery disease 5. The results showed that CCTA was associated with a reduced incidence of myocardial infarction, but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. However, CCTA was not associated with a reduction in mortality or cardiac hospitalizations 5. Another study found that stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than a treat-all strategy only if statin cost exceeded $3.16/pill or if testing increased adherence from <22% to >75% 6.