From the Guidelines
Cardiologists should select between cardiac diagnostic and treatment options based on patient-specific factors including pretest probability of coronary artery disease (CAD), symptom severity, and risk stratification, with the most recent guidelines from the European Society of Cardiology (ESC) and American College of Cardiology (ACC) emphasizing a personalized approach based on comprehensive risk-benefit assessment. For initial diagnosis in patients with intermediate pretest probability of CAD, stress ECG is typically the first-line test due to its accessibility and low cost, though it has lower sensitivity and specificity compared to other modalities 1. CT coronary angiography is preferred for patients with low-intermediate pretest probability, offering excellent negative predictive value and anatomical visualization without invasiveness. Stress echocardiography is valuable for patients with intermediate-high pretest probability and when functional assessment of myocardial ischemia is needed. For treatment decisions, PCI (angioplasty with stenting) is generally indicated for single or two-vessel disease, acute coronary syndromes, or when immediate revascularization is needed 1. CABG is preferred for complex multi-vessel disease, left main coronary artery disease, or in diabetic patients with multi-vessel disease. The decision between PCI and CABG also considers anatomical complexity (measured by SYNTAX score), comorbidities, patient preference, and heart team consensus. Age, frailty, renal function, and bleeding risk further influence these decisions, with guidelines emphasizing a personalized approach based on comprehensive risk-benefit assessment rather than rigid criteria. According to the most recent guidelines, coronary CT angiography or stress CMR or their combined use are recommended to diagnose and risk stratify obstructive disease among symptomatic patients 1. Functional imaging tests are the exam of choice for risk assessment among patients with a prior CCS diagnosis who needs risk assessment (new/worsening symptoms or high clinical prognostic risk) 1. Stress imaging is recommended to look for inducible ischemia before coronary angiography among patients with suspected low-risk unstable angina 1. Coronary CT angiography should be considered as an alternative to coronary angiography among patients without prior history of coronary artery disease presenting with chest pain and having an inconclusive diagnostic assessment 1. Stress CMR may be performed following primary percutaneous coronary intervention (PCI) to assess residual ischemia and viability, and CMR should be considered when echocardiography is suboptimal, both in-hospital (after primary PCI) and after discharge, for the quantification of left ventricular function 1. Some key parameters that guide cardiologists in deciding between stress ECG, CT coronary angio, stress echo, PCI, and CABG include:
- Pretest probability of CAD
- Symptom severity
- Risk stratification
- Anatomical complexity (measured by SYNTAX score)
- Comorbidities
- Patient preference
- Heart team consensus
- Age
- Frailty
- Renal function
- Bleeding risk
- Left ventricular function
- Presence of diabetes
- Presence of prior cardiac surgery or coronary artery disease. These parameters are considered in the context of the most recent guidelines from the ESC and ACC, which emphasize a personalized approach to cardiac diagnosis and treatment.
From the Research
Parameters for Cardiologists to Decide on Diagnostic Tests and Procedures
The decision to use stress ECG, CT coronary angio, stress echo, PCI, or CABG depends on several parameters, including:
- Patient's symptoms and medical history 2, 3, 4, 5, 6
- Presence and severity of coronary artery disease (CAD) 2, 3, 4, 5
- Results of previous diagnostic tests, such as stress ECG or echocardiogram 3, 4, 5
- Patient's risk factors, such as diabetes, hypertension, and high cholesterol 2, 4
- Presence of other heart conditions, such as valvular heart disease or heart failure 2, 4
Diagnostic Tests
The following diagnostic tests are used to guide the decision:
- Stress ECG: used to evaluate patients with suspected CAD, especially those with atypical chest pain 3, 5, 6
- CT coronary angio: used to detect significant CAD and guide further treatment 5
- Stress echo: used to evaluate patients with suspected CAD, especially those with abnormal stress ECG results 2, 3, 4, 6
Procedures
The following procedures are considered based on the diagnostic test results:
- PCI: considered for patients with significant CAD and high-risk features 4, 6
- CABG: considered for patients with complex CAD, multiple vessel disease, or high-risk features 4, 6
Guidelines
The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) have published guidelines for the use of stress echocardiography, which include: