AC Portal
Document Navigator

Asymptomatic Patient at Risk for Coronary Artery Disease

Variant: 1   Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transthoracic resting Usually Not Appropriate O
US echocardiography transthoracic stress Usually Not Appropriate O
Radiography chest Usually Not Appropriate ☢
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRA coronary arteries without IV contrast Usually Not Appropriate O
MRI heart function and morphology without and with IV contrast Usually Not Appropriate O
MRI heart function and morphology without IV contrast Usually Not Appropriate O
MRI heart function with stress without and with IV contrast Usually Not Appropriate O
MRI heart function with stress without IV contrast Usually Not Appropriate O
CT coronary calcium Usually Not Appropriate ☢☢☢
CTA coronary arteries with IV contrast Usually Not Appropriate ☢☢☢
SPECT or SPECT/CT MPI rest and stress Usually Not Appropriate ☢☢☢☢

Variant: 2   Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CT coronary calcium Usually Appropriate ☢☢☢
CTA coronary arteries with IV contrast May Be Appropriate ☢☢☢
US echocardiography transthoracic resting Usually Not Appropriate O
US echocardiography transthoracic stress Usually Not Appropriate O
Radiography chest Usually Not Appropriate ☢
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRA coronary arteries without IV contrast Usually Not Appropriate O
MRI heart function and morphology without and with IV contrast Usually Not Appropriate O
MRI heart function and morphology without IV contrast Usually Not Appropriate O
MRI heart function with stress without and with IV contrast Usually Not Appropriate O
MRI heart function with stress without IV contrast Usually Not Appropriate O
SPECT or SPECT/CT MPI rest and stress Usually Not Appropriate ☢☢☢☢

Variant: 3   Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CT coronary calcium May Be Appropriate ☢☢☢
CTA coronary arteries with IV contrast May Be Appropriate ☢☢☢
US echocardiography transthoracic resting Usually Not Appropriate O
US echocardiography transthoracic stress Usually Not Appropriate O
Radiography chest Usually Not Appropriate ☢
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRA coronary arteries without IV contrast Usually Not Appropriate O
MRI heart function and morphology without and with IV contrast Usually Not Appropriate O
MRI heart function and morphology without IV contrast Usually Not Appropriate O
MRI heart function with stress without and with IV contrast Usually Not Appropriate O
MRI heart function with stress without IV contrast Usually Not Appropriate O
SPECT or SPECT/CT MPI rest and stress Usually Not Appropriate ☢☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
A. CT Coronary Calcium
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
B. CTA Coronary Arteries
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
C. US Echocardiography Transthoracic Resting
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
D. US Echocardiography Transthoracic Stress
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
E. MRA Coronary Arteries
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
F. MRI Heart Function with Stress
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
G. MRI Heart Function and Morphology
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
H. Radiography Chest
Variant 1: Asymptomatic patient. Low risk for coronary artery disease. Initial imaging.
I. SPECT/CT MPI Rest and Stress
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
A. CT Coronary Calcium
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
B. CTA Coronary Arteries
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
C. US Echocardiography Transthoracic Resting
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
D. US Echocardiography Transthoracic Stress
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
E. MRA Coronary Arteries
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
F. MRI Heart Function and Morphology
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
G. MRI Heart Function with Stress
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
H. Radiography Chest
Variant 2: Asymptomatic patient. Intermediate risk for coronary artery disease. Initial imaging.
I. SPECT/CT MPI Rest and Stress
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
A. CT Coronary Calcium
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
B. CTA Coronary Arteries
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
C. US Echocardiography Transthoracic Resting
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
D. US Echocardiography Transthoracic Stress
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
E. MRA Coronary Arteries
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
F. MRI Heart Function with Stress
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
G. MRI Heart Function and Morphology
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
H. Radiography Chest
Variant 3: Asymptomatic patient. High risk for coronary artery disease. Initial imaging.
I. SPECT/CT MPI Rest and Stress
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information
References
1. Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation. 2000;102(25):3137-3147.
2. Greenland P, Alpert JS, Beller GA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2010;56(25):e50-103.
3. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 73(24):e285-e350, 2019 Jun 25.
4. Greenland P, Knoll MD, Stamler J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA. 2003;290(7):891-897.
5. Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2935-59.
6. Wilson SR, Lin FY, Min JK. Role of coronary artery calcium score and coronary CT angiography in the diagnosis and risk stratification of individuals with suspected coronary artery disease. Curr Cardiol Rep. 2011;13(4):271-279.
7. Perez de Isla L, Alonso R, Muniz-Grijalvo O, et al. Coronary computed tomographic angiography findings and their therapeutic implications in asymptomatic patients with familial hypercholesterolemia. Lessons from the SAFEHEART study. J. clin. lipidol.. 12(4):948-957, 2018 Jul - Aug.
8. Detrano R, Guerci AD, Carr JJ, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med 2008;358:1336-45.
9. American College of Radiology. ACR Appropriateness Criteria®: Acute Nonspecific Chest Pain—Low Probability of Coronary Artery Disease. Available at: https://acsearch.acr.org/docs/69401/Narrative/.
10. Shah AB, Kirsch J, Bolen MA, et al. ACR Appropriateness Criteria R Chronic Chest Pain-Noncardiac Etiology Unlikely-Low to Intermediate Probability of Coronary Artery Disease. Journal of the American College of Radiology. 15(11S):S283-S290, 2018 Nov.J. Am. Coll. Radiol.. 15(11S):S283-S290, 2018 Nov.
11. Akers SR, Panchal V, et al. ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease. J Am Coll Radiol. 2017 May;14(5S):S1546-1440(17)30141-2.
12. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 59(7):23C-30C, 1987 Mar 09.
13. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=164+&releaseId=2.
14. Joshi PH, Patel B, Blaha MJ, et al. Coronary artery Calcium predicts Cardiovascular events in participants with a low lifetime risk of Cardiovascular disease: The Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 246:367-73, 2016 Mar.
15. Hecht H, Blaha MJ, Berman DS, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. [Review]. J Cardiovasc Comput Tomogr. 11(2):157-168, 2017 Mar - Apr.
16. Dudum R, Dzaye O, Mirbolouk M, et al. Coronary artery calcium scoring in low risk patients with family history of coronary heart disease: Validation of the SCCT guideline approach in the coronary artery calcium consortium. J Cardiovasc Comput Tomogr. 2019 Mar 27.
17. Mitchell JD, Paisley R, Moon P, Novak E, Villines TC. Coronary Artery Calcium and Long-Term Risk of Death, Myocardial Infarction, and Stroke: The Walter Reed Cohort Study. JACC Cardiovasc Imaging. 11(12):1799-1806, 2018 12.
18. Carr JJ, Jacobs DR Jr, Terry JG, et al. Association of Coronary Artery Calcium in Adults Aged 32 to 46 Years With Incident Coronary Heart Disease and Death. JAMA Cardiol. 2(4):391-399, 2017 04 01.
19. Choi EK, Choi SI, Rivera JJ, et al. Coronary computed tomography angiography as a screening tool for the detection of occult coronary artery disease in asymptomatic individuals. J Am Coll Cardiol. 2008;52(5):357-365.
20. Heijenbrok-Kal MH, Fleischmann KE, Hunink MG. Stress echocardiography, stress single-photon-emission computed tomography and electron beam computed tomography for the assessment of coronary artery disease: a meta-analysis of diagnostic performance. Am Heart J 2007;154:415-23.
21. Song KD, Kim SM, Choe YH, et al. Integrated cardiac magnetic resonance imaging with coronary magnetic resonance angiography, stress-perfusion, and delayed-enhancement imaging for the detection of occult coronary artery disease in asymptomatic individuals. Int J Cardiovasc Imaging. 31 Suppl 1:77-89, 2015 Jun.
22. Weir-McCall JR, Fitzgerald K, Papagiorcopulo CJ, et al. Prevalence of unrecognized myocardial infarction in a low-intermediate risk asymptomatic cohort and its relation to systemic atherosclerosis. Eur Heart J Cardiovasc Imaging 2017;18:657-62.
23. Mordi IR, Badar AA, Irving RJ, Weir-McCall JR, Houston JG, Lang CC. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag 2017;13:427-37.
24. Kondos GT, Hoff JA, Sevrukov A, et al. Electron-beam tomography coronary artery calcium and cardiac events: a 37-month follow-up of 5635 initially asymptomatic low- to intermediate-risk adults. Circulation. 2003;107(20):2571-2576.
25. Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology. 2003;228(3):826-833.
26. Budoff MJ, Shaw LJ, Liu ST, et al. Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol. 2007;49(18):1860-1870.
27. Okwuosa TM, Greenland P, Ning H, Liu K, Lloyd-Jones DM. Yield of screening for coronary artery calcium in early middle-age adults based on the 10-year Framingham Risk Score: the CARDIA study. JACC Cardiovasc Imaging. 5(9):923-30, 2012 Sep.
28. Gibson AO, Blaha MJ, Arnan MK, et al. Coronary artery calcium and incident cerebrovascular events in an asymptomatic cohort. The MESA Study. JACC Cardiovasc Imaging. 7(11):1108-15, 2014 Nov.
29. Polonsky TS, McClelland RL, Jorgensen NW, et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA. 2010;303(16):1610-1616.
30. Erbel R, Mohlenkamp S, Moebus S, et al. Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall study. J Am Coll Cardiol. 2010;56(17):1397-1406.
31. Mulders TA, Taraboanta C, Franken LC, et al. Coronary artery calcification score as tool for risk assessment among families with premature coronary artery disease. Atherosclerosis. 245:155-60, 2016 Feb.
32. Nasir K, Rubin J, Blaha MJ, et al. Interplay of coronary artery calcification and traditional risk factors for the prediction of all-cause mortality in asymptomatic individuals. Circ Cardiovasc Imaging. 5(4):467-73, 2012 Jul.
33. Di Cesare E, Patriarca L, Panebianco L, et al. Coronary computed tomography angiography in the evaluation of intermediate risk asymptomatic individuals. Radiologia Medica. 123(9):686-694, 2018 Sep.
34. Picano E, Molinaro S, Pasanisi E. The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis. Cardiovasc Ultrasound 2008;6:30.
35. Cruz G, Atkinson D, Henningsson M, Botnar RM, Prieto C. Highly efficient nonrigid motion-corrected 3D whole-heart coronary vessel wall imaging. Magn Reson Med 2017;77:1894-908.
36. Moghari MH, Roujol S, Henningsson M, et al. Three-dimensional heart locator for whole-heart coronary magnetic resonance angiography. Magn Reson Med 2014;71:2118-26.
37. Schwitter J, Wacker CM, Wilke N, et al. MR-IMPACT II: Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary artery disease Trial: perfusion-cardiac magnetic resonance vs. single-photon emission computed tomography for the detection of coronary artery disease: a comparative multicentre, multivendor trial. Eur Heart J. 2013;34(10):775-781.
38. Hendel RC, Abbott BG, Bateman TM, et al. The role of radionuclide myocardial perfusion imaging for asymptomatic individuals. J Nucl Cardiol 2011;18:3-15.
39. Multimodality Writing Group for Stable Ischemic Heart Disease, Wolk MJ, Bailey SR, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. [Review]. J Card Fail. 20(2):65-90, 2014 Feb.
40. Sarwar A, Shaw LJ, Shapiro MD, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2(6):675-688.
41. Blaha MJ, Budoff MJ, DeFilippis AP, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet. 378(9792):684-92, 2011 Aug 20.
42. Cho I, Chang HJ, O Hartaigh B, et al. Incremental prognostic utility of coronary CT angiography for asymptomatic patients based upon extent and severity of coronary artery calcium: results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study.[Erratum appears in Eur Heart J. 2015 Dec 7;36(46):3287; PMID: 26063448]. Eur Heart J. 36(8):501-8, 2015 Feb 21.
43. Dedic A, Ten Kate GJ, Roos CJ, et al. Prognostic Value of Coronary Computed Tomography Imaging in Patients at High Risk Without Symptoms of Coronary Artery Disease. Am J Cardiol. 117(5):768-74, 2016 Mar 01.
44. Plank F, Friedrich G, Dichtl W, et al. The diagnostic and prognostic value of coronary CT angiography in asymptomatic high-risk patients: a cohort study. Open Heart. 1(1):e000096, 2014.
45. Min JK, Labounty TM, Gomez MJ, et al. Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals. Atherosclerosis. 232(2):298-304, 2014 Feb.
46. Muhlestein JB, Lappe DL, Lima JA, et al. Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial. JAMA. 312(21):2234-43, 2014 Dec 03.
47. Guaricci AI, Lorenzoni V, Guglielmo M, et al. Prognostic relevance of subclinical coronary and carotid atherosclerosis in a diabetic and nondiabetic asymptomatic population. Clin Cardiol. 41(6):769-777, 2018 Jun.
48. Halon DA, Lavi I, Barnett-Griness O, et al. Plaque Morphology as Predictor of Late Plaque Events in Patients With Asymptomatic Type 2 Diabetes: A Long-Term Observational Study. JACC Cardiovasc Imaging. 2018 May 11.
49. Beller E, Meinel FG, Schoeppe F, et al. Predictive value of coronary computed tomography angiography in asymptomatic individuals with diabetes mellitus: Systematic review and meta-analysis. [Review]. J Cardiovasc Comput Tomogr. 12(4):320-328, 2018 Jul - Aug.
50. Takx RA, Blomberg BA, El Aidi H, et al. Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging 2015;8.
51. Young LH, Wackers FJ, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study: a randomized controlled trial. JAMA. 2009;301(15):1547-1555.
52. Zellweger MJ, Maraun M, Osterhues HH, et al. Progression to overt or silent CAD in asymptomatic patients with diabetes mellitus at high coronary risk: main findings of the prospective multicenter BARDOT trial with a pilot randomized treatment substudy. JACC Cardiovasc Imaging. 7(10):1001-10, 2014 Oct.
53. Budoff MJ, Raggi P, Beller GA, et al. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient: The Imaging Council of the American College of Cardiology. [Review]. JACC Cardiovasc Imaging. 9(2):176-92, 2016 Feb.
54. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.
Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.