To support better diagnosis and risk assessment in patients with coronary artery disease, the American College of Cardiology (ACC) Foundation—together with leading specialty and subspecialty societies—has released a 2023 update to the Appropriate Use Criteria (AUC). This comprehensive review focuses on the optimal use of stress tests and imaging modalities for the anatomical evaluation of chronic coronary artery disease (CAD), previously known as stable ischemic heart disease (SIHD).
The 2023 Guide to Appropriate Use Criteria of ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS for Detection and Risk Assessment in Chronic Coronary Artery Disease includes updated recommendations for radionuclide imaging, stress echocardiography, coronary artery calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD.
By América Torres
Key Changes in the 2023 Guide for Detection and Risk Assessment in Chronic Coronary Artery Disease
Like its previous version, this document provides a classification of test modalities side by side for a given clinical scenario. These classifications are not considered competitive rankings because, as of now, the availability of comparative evidence, patient variability, and the range of capabilities available in any given location are limited.
In general, the main changes in this version are:
- Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document that is still in development.
- Some clinical scenarios and tables were eliminated to simplify scenario selection. Additionally, the flow of tables has been reorganized so that all can be consulted by answering a limited number of clinical questions about the patient, starting with the status of their symptoms.
- Several clinical scenarios have been revised to incorporate changes in other documents, such as pretest probability assessment, assessment of atherosclerotic cardiovascular disease (ASCVD) risk, syncope, and others. ASCVD risk factors not considered in contemporary risk calculators have been added as modifiers for certain clinical scenarios.
Stress Testing Criteria for Coronary Artery Disease Based on Clinical Scenarios
As mentioned earlier, the purpose of this Guide is to outline the appropriate use of various invasive and non-invasive test modalities for the diagnosis and/or evaluation of chronic coronary artery disease (CCD) in clinical scenarios that include:
- Patients with ischemic symptoms: without prior tests (described in Table 1.1), with prior tests but without myocardial infarction (MI) or revascularization (described in Table 1.2), and with prior MI or revascularization (described in Table 1.3).
- Patients without ischemic symptoms: tests to assess the risk of ASCVD events (described in Table 2.1), and with prior MI or previous revascularization (described in Table 2.2).
- Patients seeking to initiate a physical exercise program or cardiac rehabilitation (described in Table 2.3).
- Patients with other cardiovascular conditions such as heart failure, arrhythmias, or syncope (described in Table 2.4).
Below is an overview of when treadmill stress tests and stress echocardiography are recommended, based on clinical scenarios in chronic coronary artery disease.
Table 1.1: Symptomatic Patients With No Known CCD and No Prior Testing
Clinical Scenario: Less-likely anginal symptoms, age <50 y and 0 or 1 CV risk factor. Tests: ECG Treadmill – May be appropriate. Echo Stress – Rarely Appropriate.
Clinical Scenario: Less-likely anginal symptoms, age 50 y or above and/or ≥ 2 CV risk factors. Tests: ECG Treadmill – May be appropriate. Echo Stress – May be appropriate.
Clinical Scenario: Likely anginal symptoms, age <50 y and 0 or 1 CV risk factor. Tests: ECG Treadmill/ Echo Stress – Appropriate.
Clinical Scenario: Likely anginal symptoms, age 50 y or above and/or ≥2 CV risk factors. Tests: ECG Treadmill/ Echo Stress – Appropriate.
CV risk factors: diabetes mellitus, smoking, family history of premature CAD, hypertension, dyslipidemia.
Table 1.2: Symptomatic Patients Without Known CCD and With Prior Testing*
The ECG Treadmill test may be appropriate in the following clinical scenarios:
- Abnormal ECG
- Coronary computed tomography angiography (CCTA) with no coronary artery disease (CAD); or up to 49% stenosis (Coronary Artery Disease (CAD)-Reporting and Data System (RADS): 0-2.
- CCTA with moderate stenosis 50%-69% (CAD-RADS 3).
- CCTA with severe stenosis ≥70% (CAD-RADS 4-5).
- Coronary artery calcium (CAC) score = 0 (CAC-DRS = 0) (CAC-DRS Coronary Artery Calcium Data and Reporting System).
- CAC score 1-99 (CAC-DRS 1).
- Invasive coronary angiography with intermediate severity and/or invasive physiological testing not done**
The ECG Treadmill test is appropriate in the following clinical scenarios:
- CCTA inconclusive (CAD-RADS N).
- CAC score 100-299 (CAC-DRS 2).
- CAC score ≥300 (CAC-DRS 3).
The Echo Stress test may be appropriate in the following clinical scenarios:
- Normal exercise stress test (ET).
- Inconclusive stress imaging.***
- CCTA with no CAD or up to 49% stenosis (CAD-RADS 0-2).
- CCTA with severe stenosis ≥ 70% (CAD-RADS 4-5).
- CAC score = 0 (CAC-DRS 0).
- CAC score 1-99 (CAC-DRS 1).
- Invasive coronary angiography with obstructive CAD and/or abnormal invasive physiological testing**
The Echo Stress test is appropriate in the following clinical scenarios:
- Abnormal ECG.
- Inconclusive ET.
- Abnormal ET.
- CCTA with moderate stenosis 50%-69% (CAD-RADS 3).
- CCTA inconclusive (CAD-RADS N)
- CAC score 100-299 (CAC-DRS 2).
- CAC score ≥300 (CAC-DRS 3).
- Invasive coronary angiography with intermediate severity and/or invasive physiological testing not done**
* Refers to sequential testing being done as part of a continued patient evaluation or application of recent testing results in the reevaluation of a patient.
** Refers to diagnostic angiography, not percutaneous coronary intervention.
*** Stress imaging could be SPECT (single-proton emission tomography), PET (positron emission tomography), echo o CMR (cardiac magnetic resonance).
Table 1.3: Symptomatic Patients With Prior MI or Revascularization
The ECG Treadmill test may be appropriate in the following clinical scenarios:
- Incomplete revascularization.
- Prior percutaneous coronary intervention (PCI), symptoms similar to prior ischemic episode and/or anginal symptoms
- Prior PCI, nonanginal symptoms.
- Prior coronary artery bypass graft (CABG), symptoms similar to prior ischemic episode and/or anginal symptoms.
- Prior CABG, nonanginal symptoms.
- Prior myocardial infarction (MI), no revascularization, symptoms similar to prior ischemic episode and/or anginal.
- Prior MI, no revascularization, nonanginal symptoms
The ECG Treadmill test is appropriate in the following clinical scenario:
- Prior to cardiac rehabilitation, coronary disease (no new or worsening symptoms).
The Echo Stress test may be appropriate in the following clinical scenarios:
- Prior PCI, nonanginal symptoms.
- Prior CABG, nonanginal symptoms.
- Prior MI, no revascularization, nonanginal symptoms.
- Prior to cardiac rehabilitation, coronary disease (no new or worsening symptoms)
The Echo Stress test is appropriate in the following clinical scenarios:
- Incomplete revascularization.
- Prior percutaneous coronary intervention (PCI), symptoms similar to prior ischemic episode and/or anginal symptoms.
- Prior CABG, symptoms similar to prior ischemic episode and/or anginal symptoms.
- Prior MI, no revascularization, symptoms similar to prior ischemic episode and/or anginal.
- Assessment of myocardial viability.
Table 2.1: Asymptomatic Patients Without Known ASCVD
The ECG Treadmill test may be appropriate in the following clinical scenarios:
- Borderline atherosclerotic cardiovascular disease (ASCVD) risk 5% to 7.5%.
- Borderline ASCVD risk 5% to 7.5% with risk-enhancing factors (Table C, page 2455 of the Guide).
- Intermediate ASCVD risk 7.5% to 20% with or without risk-enhancing factors (Table C, page 2455 of the Guide).
- High ASCVD risk >20%.
The Echo Stress test may be appropriate in the following clinical scenario:
- High ASCVD risk >20%.
Table 2.3: Asymptomatic Patients Undergoing Assessment of an Exercise Program or Cardiac Rehabilitation
The Exercise ECG is appropriate in the following scenarios:
- Prior to initiation of an unsupervised exercise program, with known chronic coronary disease (CCD).
- Prior to cardiac rehabilitation.
The Exercise ECG may be appropriate in the following scenario:
- Prior to initiation of an unsupervised exercise program, without known CCD.
The Echo Stress test may be appropriate in the following scenarios:
- Prior to initiation of an unsupervised exercise program, with known chronic coronary disease (CCD).
- Prior to cardiac rehabilitation.
When assessing cardiac health, selecting the appropriate test is essential for accurate evaluation and ensuring patient safety. Whether using Exercise ECG or Echo Stress tests, these tools help tailor the approach based on the presence of chronic coronary disease. At SCHILLER, we complement these clinical needs with advanced diagnostic solutions designed for early and precise detection of coronary artery disease (CAD).
Advanced Detection and Risk Assessment Tools for Coronary Artery Disease
At SCHILLER, we understand that accurate, early detection is critical in managing coronary artery disease (CAD). That’s why we’ve developed a portfolio of high-performance diagnostic solutions designed to support your clinical expertise and decision-making.
Our ECG systems, including the CARDIOVIT AT-102 G2 and CARDIOVIT FT-1, deliver precise, high-quality data for resting and routine examinations. For more complex evaluations, the CARDIOVIT CS-200 Excellence stress testing system offers advanced analytics and powerful algorithms for comprehensive risk assessment and functional diagnosis.
Comprehensive Stress Testing with CARDIOVIT CS-200 Excellence
For advanced cardiac stress testing—particularly in exercise-based cardiac assessments—the CARDIOVIT CS-200 Excellence is our most advanced stress testing system. Equipped with powerful analysis tools, customizable protocols, and support for up to 16-lead ECG, it enables comprehensive risk assessment and functional diagnostics in patients with suspected or known CAD. This powerful system combines robust performance, flexible reporting, and seamless connectivity to EMR/HIS platforms, making it an essential tool for comprehensive cardiac stress testing.
Watch the video to discover all the capabilities and advantages of the CARDIOVIT CS-200 Excellence and see how it can enhance your cardiac diagnostic workflow.
Complete Stress Testing Solutions
To create a comprehensive stress testing setup, the CARDIOVIT CS-200 Excellence can be easily paired with SCHILLER’s ergometers and the TMX-428 Treadmill, ensuring reliable performance and smooth integration throughout the diagnostic workflow. The TMX-428 Treadmill is designed for medical use, combining quiet operation with reliable performance. Its smooth, unobtrusive design makes it perfect for both hospital and office environments, enhancing patient comfort during stress testing.
For clinicians who prefer a cycling option or require greater versatility, the ERG 910 plus / ERG 911 plus Ergometer Bikes offer outstanding performance for both diagnostic and therapeutic applications. These cardiology-grade ergometers are compatible with all SCHILLER exercise EKG devices.
For stress echocardiography, SCHILLER offers the ERG 911 LS Stress Echocouch, ideal for patients with known or suspected coronary artery disease. It features a heart-level opening for easy ultrasound access and is designed for elderly and disabled patients. Fully compatible with most stress testing systems, it adjusts from 0° to 45° for optimal patient positioning.
Watch the videos to explore how our ergometers enhance precision and comfort in your cardiac stress testing procedures.
At SCHILLER, we believe that every heartbeat counts—and that starts with giving healthcare professionals the most advanced tools for accurate, early detection of coronary artery disease. From high-resolution ECG systems to powerful stress testing solutions and reliable ergometers, our technology is built to support your clinical decisions and improve patient outcomes.
Ready to experience the difference SCHILLER can make in your cardiac diagnostic workflow?
Frequently Asked Questions
1 What is the purpose of a stress testing system in coronary artery disease diagnosis?
A stress testing system evaluates how the heart functions under physical stress, helping detect coronary artery disease (CAD) by revealing abnormalities that may not appear during resting ECG. It allows clinicians to assess blood flow, heart rhythm, and overall cardiovascular function in response to exercise.
2 What features should a high-quality cardiac stress testing system include?
A reliable cardiac stress testing system should offer multi-lead ECG (ideally up to 16 leads), advanced diagnostic algorithms, customizable test protocols, and seamless integration with treadmills or ergometers. Compatibility with EMR/HIS systems is also essential for efficient workflow and data management.
3 How does the CARDIOVIT CS-200 Excellence support cardiac risk assessment?
The CARDIOVIT CS-200 Excellence Stress Test System enhances cardiac risk assessment by delivering high-resolution, real-time ECG data during exercise. With support for up to 16-lead ECG and advanced analytics, it helps clinicians identify ischemic changes and functional impairments in patients with suspected or confirmed CAD.