AC Portal
Document Navigator

Chronic Chest Pain-High Probability of Coronary Artery Disease

Variant: 1   Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transthoracic stress Usually Appropriate O
Arteriography coronary Usually Appropriate ☢☢☢
MRI heart function with stress without and with IV contrast Usually Appropriate O
MRI heart function with stress without IV contrast Usually Appropriate O
CTA coronary arteries with IV contrast Usually Appropriate ☢☢☢
Rb-82 PET/CT MPI rest and stress Usually Appropriate ☢☢☢☢
SPECT or SPECT/CT MPI rest and stress Usually Appropriate ☢☢☢☢
US echocardiography transthoracic resting May Be Appropriate O
MRI heart function and morphology without and with IV contrast May Be Appropriate O
CT coronary calcium May Be Appropriate ☢☢☢
US echocardiography transesophageal Usually Not Appropriate O
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 IV contrast Usually Not Appropriate O
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
CTA triple rule out Usually Not Appropriate ☢☢☢
Nuclear medicine ventriculography Usually Not Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US echocardiography transthoracic stress Usually Appropriate O
Arteriography coronary Usually Appropriate ☢☢☢
MRI heart function and morphology without and with IV contrast Usually Appropriate O
MRI heart function with stress without and with IV contrast Usually Appropriate O
MRI heart function with stress without IV contrast Usually Appropriate O
CTA coronary arteries with IV contrast Usually Appropriate ☢☢☢
Rb-82 PET/CT MPI rest and stress Usually Appropriate ☢☢☢☢
SPECT or SPECT/CT MPI rest and stress Usually Appropriate ☢☢☢☢
US echocardiography transthoracic resting May Be Appropriate (Disagreement) O
MRI heart function and morphology without IV contrast May Be Appropriate O
CT heart function and morphology with IV contrast May Be Appropriate ☢☢☢☢
US echocardiography transesophageal Usually Not Appropriate O
MRA coronary arteries without and with IV contrast Usually Not Appropriate O
MRA coronary arteries without IV contrast Usually Not Appropriate O
CT coronary calcium Usually Not Appropriate ☢☢☢
CTA chest with IV contrast Usually Not Appropriate ☢☢☢
CTA triple rule out Usually Not Appropriate ☢☢☢
Nuclear medicine ventriculography Usually Not Appropriate ☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
A. Arteriography Coronary
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
B. CT Coronary Calcium
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
C. CT Heart Function and Morphology
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
D. CTA Chest
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
E. CTA Triple Rule Out
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
F. CTA Coronary Arteries
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
G. MRA Coronary Arteries Without and With IV Contrast
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
H. MRA Coronary Arteries Without IV Contrast
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
I. MRI Heart Function and Morphology Without and With IV Contrast
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
J. MRI Heart Function and Morphology Without IV Contrast
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
K. MRI Heart Function with Stress Without and With IV Contrast
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
L. MRI Heart Function with Stress Without IV Contrast
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
M. Nuclear Medicine Ventriculography
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
N. Rb-82 PET/CT Heart
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
O. SPECT or SPECT/CT MPI Rest and Stress
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
P. US Echocardiography Transesophageal
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
Q. US Echocardiography Transthoracic Resting
Variant 1: Chronic chest pain; high probability of coronary artery disease. No known ischemic heart disease. Initial imaging.
R. US Echocardiography Transthoracic Stress
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
A. Arteriography Coronary
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
B. CT Coronary Calcium
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
C. CT Heart Function and Morphology
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
D. CTA Chest
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
E. CTA Triple Rule Out
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
F. CTA Coronary Arteries
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
G. MRA Coronary Arteries Without and With IV Contrast
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
H. MRA Coronary Arteries Without IV Contrast
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
I. MRI Heart Function and Morphology Without and With IV Contrast
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
J. MRI Heart Function and Morphology Without IV Contrast
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
K. MRI Heart Function with Stress Without and With IV Contrast
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
L. MRI Heart Function with Stress Without IV Contrast
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
M. Nuclear Medicine Ventriculography
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
N. Rb-82 PET/CT Heart
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
O. SPECT or SPECT/CT MPI Rest and Stress
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
P. US Echocardiography Transesophageal
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
Q. US Echocardiography Transthoracic Resting
Variant 2: Chronic chest pain; high probability of coronary artery disease. Known ischemic heart disease with no prior definitive treatment. Initial imaging.
R. US Echocardiography Transthoracic 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

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
1. Di Fiore DP, Beltrame JF. Chest pain in patients with 'normal angiography': could it be cardiac?. [Review]. Int. j. evid.-based healthc.. 11(1):56-68, 2013 Mar.
2. Beache GM, Mohammed TH, Hurwitz Koweek LM, et al. ACR Appropriateness Criteria R Acute Nonspecific Chest Pain-Low Probability of Coronary Artery Disease. Journal of the American College of Radiology. 17(11S):S346-S354, 2020 Nov.J. Am. Coll. Radiol.. 17(11S):S346-S354, 2020 Nov.
3. 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.
4. McKavanagh P, Lusk L, Ball PA, et al. A comparison of Diamond Forrester and coronary calcium scores as gatekeepers for investigations of stable chest pain. Int J Cardiovasc Imaging. 29(7):1547-55, 2013 Oct.
5. Versteylen MO, Joosen IA, Shaw LJ, Narula J, Hofstra L. Comparison of Framingham, PROCAM, SCORE, and Diamond Forrester to predict coronary atherosclerosis and cardiovascular events. J Nucl Cardiol. 18(5):904-11, 2011 Oct.
6. Wasfy MM, Brady TJ, Abbara S, et al. Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by computed tomographic angiography. Am J Cardiol 2012;109:998-1004.
7. Fordyce CB, Newby DE, Douglas PS. Diagnostic Strategies for the Evaluation of Chest Pain: Clinical Implications From SCOT-HEART and PROMISE. [Review]. Journal of the American College of Cardiology. 67(7):843-52, 2016 Feb 23.J Am Coll Cardiol. 67(7):843-52, 2016 Feb 23.
8. Alderman EL, Corley SD, Fisher LD, et al. Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff. J Am Coll Cardiol 1993;22:1141-54.
9. Chen SL, Xu B, Chen JB, et al. Diagnostic accuracy of quantitative angiographic and intravascular ultrasound parameters predicting the functional significance of single de novo lesions. Int J Cardiol 2013;168:1364-9.
10. Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol. 2010;55(25):2816-2821.
11. Tinana A, Mintz GS, Weissman NJ. Volumetric intravascular ultrasound quantification of the amount of atherosclerosis and calcium in nonstenotic arterial segments. Am J Cardiol 2002;89:757-60.
12. 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.
13. Wang X, Le EPV, Rajani NK, et al. A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques. Open Heart 2019;6:e000945.
14. Budoff MJ, Mayrhofer T, Ferencik M, et al. Prognostic Value of Coronary Artery Calcium in the PROMISE Study (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). Circulation. 136(21):1993-2005, 2017 Nov 21.
15. Gottlieb I, Miller JM, Arbab-Zadeh A, et al. The absence of coronary calcification does not exclude obstructive coronary artery disease or the need for revascularization in patients referred for conventional coronary angiography. J Am Coll Cardiol 2010;55:627-34.
16. Lubbers M, Dedic A, Coenen A, et al. Calcium imaging and selective computed tomography angiography in comparison to functional testing for suspected coronary artery disease: the multicentre, randomized CRESCENT trial. Eur Heart J. 2016;37(15):1232-1243.
17. Schenker MP, Dorbala S, Hong EC, et al. Interrelation of coronary calcification, myocardial ischemia, and outcomes in patients with intermediate likelihood of coronary artery disease: a combined positron emission tomography/computed tomography study. Circulation 2008;117:1693-700.
18. George RT, Arbab-Zadeh A, Miller JM, et al. Computed tomography myocardial perfusion imaging with 320-row detector computed tomography accurately detects myocardial ischemia in patients with obstructive coronary artery disease. Circ Cardiovasc Imaging 2012;5:333-40.
19. Bettencourt N, Chiribiri A, Schuster A, et al. Direct comparison of cardiac magnetic resonance and multidetector computed tomography stress-rest perfusion imaging for detection of coronary artery disease. J Am Coll Cardiol 2013;61:1099-107.
20. Cury RC, Kitt TM, Feaheny K, et al. A randomized, multicenter, multivendor study of myocardial perfusion imaging with regadenoson CT perfusion vs single photon emission CT. J Cardiovasc Comput Tomogr 2015;9:103-12 e1-2.
21. George RT, Arbab-Zadeh A, Miller JM, et al. Adenosine stress 64- and 256-row detector computed tomography angiography and perfusion imaging: a pilot study evaluating the transmural extent of perfusion abnormalities to predict atherosclerosis causing myocardial ischemia. Circ Cardiovasc Imaging 2009;2:174-82.
22. George RT, Mehra VC, Chen MY, et al. Myocardial CT perfusion imaging and SPECT for the diagnosis of coronary artery disease: a head-to-head comparison from the CORE320 multicenter diagnostic performance study. Radiology 2014;272:407-16.
23. Magalhaes TA, Kishi S, George RT, et al. Combined coronary angiography and myocardial perfusion by computed tomography in the identification of flow-limiting stenosis - The CORE320 study: An integrated analysis of CT coronary angiography and myocardial perfusion. J Cardiovasc Comput Tomogr. 2015;9(5):438-445.
24. Mano Y, Anzai T, Yoshizawa A, Itabashi Y, Ohki T. Role of non-electrocardiogram-gated contrast-enhanced computed tomography in the diagnosis of acute coronary syndrome. Heart & Vessels. 30(1):1-8, 2015 Jan.Heart Vessels. 30(1):1-8, 2015 Jan.
25. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724-1732.
26. Meijboom WB, Meijs MF, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52(25):2135-2144.
27. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359(22):2324-2336.
28. Schlattmann P, Schuetz GM, Dewey M. Influence of coronary artery disease prevalence on predictive values of coronary CT angiography: a meta-regression analysis. Eur Radiol 2011;21:1904-13.
29. Haase R, Schlattmann P, Gueret P, et al. Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data. BMJ. 365:l1945, 2019 06 12.
30. Arbab-Zadeh A, Miller JM, Rochitte CE, et al. Diagnostic accuracy of computed tomography coronary angiography according to pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) International Multicenter Study. J Am Coll Cardiol 2012;59:379-87.
31. Abdulla J, Abildstrom SZ, Gotzsche O, Christensen E, Kober L, Torp-Pedersen C. 64-multislice detector computed tomography coronary angiography as potential alternative to conventional coronary angiography: a systematic review and meta-analysis. Eur Heart J 2007;28:3042-50.
32. The SCOT-HEART investigators. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. The Lancet 2015;385:2383-91.
33. Koo BK, Erglis A, Doh JH, et al. Diagnosis of ischemia-causing coronary stenoses by noninvasive fractional flow reserve computed from coronary computed tomographic angiograms. Results from the prospective multicenter DISCOVER-FLOW (Diagnosis of Ischemia-Causing Stenoses Obtained Via Noninvasive Fractional Flow Reserve) study. J Am Coll Cardiol 2011;58:1989-97.
34. Taylor CA, Fonte TA, Min JK. Computational fluid dynamics applied to cardiac computed tomography for noninvasive quantification of fractional flow reserve: scientific basis. J Am Coll Cardiol 2013;61:2233-41.
35. Hlatky MA, De Bruyne B, Pontone G, et al. Quality-of-Life and Economic Outcomes of Assessing Fractional Flow Reserve With Computed Tomography Angiography: PLATFORM. J Am Coll Cardiol. 66(21):2315-23, 2015 Dec 01.
36. Norgaard BL, Leipsic J, Gaur S, et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). J Am Coll Cardiol 2014;63:1145-55.
37. Danad I, Szymonifka J, Twisk JWR, et al. Diagnostic performance of cardiac imaging methods to diagnose ischaemia-causing coronary artery disease when directly compared with fractional flow reserve as a reference standard: a meta-analysis. Eur Heart J 2017;38:991-98.
38. Zhuang B, Wang S, Zhao S, Lu M. Computed tomography angiography-derived fractional flow reserve (CT-FFR) for the detection of myocardial ischemia with invasive fractional flow reserve as reference: systematic review and meta-analysis. Eur Radiol 2020;30:712-25.
39. Patel MR, Norgaard BL, Fairbairn TA, et al. 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT: The ADVANCE Registry. JACC Cardiovasc Imaging 2020;13:97-105.
40. Sakuma H, Ichikawa Y, Chino S, Hirano T, Makino K, Takeda K. Detection of coronary artery stenosis with whole-heart coronary magnetic resonance angiography. J Am Coll Cardiol 2006;48:1946-50.
41. Kato S, Kitagawa K, Ishida N, et al. Assessment of coronary artery disease using magnetic resonance coronary angiography: a national multicenter trial. J Am Coll Cardiol. 56(12):983-91, 2010 Sep 14.
42. Bettencourt N, Ferreira N, Chiribiri A, et al. Additive value of magnetic resonance coronary angiography in a comprehensive cardiac magnetic resonance stress-rest protocol for detection of functionally significant coronary artery disease: a pilot study. Circ Cardiovasc Imaging. 2013;6(5):730-738.
43. Barbier CE, Bjerner T, Johansson L, Lind L, Ahlstrom H. Myocardial scars more frequent than expected: magnetic resonance imaging detects potential risk group. J Am Coll Cardiol 2006;48:765-71.
44. Catalano O, Moro G, Perotti M, et al. Late gadolinium enhancement by cardiovascular magnetic resonance is complementary to left ventricle ejection fraction in predicting prognosis of patients with stable coronary artery disease. J Cardiovasc Magn Reson 2012;14:29.
45. Abbasi SA, Ertel A, Shah RV, et al. Impact of cardiovascular magnetic resonance on management and clinical decision-making in heart failure patients. J Cardiovasc Magn Reson 2013;15:89.
46. Bikiri E, Mereles D, Voss A, et al. Dobutamine stress cardiac magnetic resonance versus echocardiography for the assessment of outcome in patients with suspected or known coronary artery disease. Are the two imaging modalities comparable? Int J Cardiol 2014;171:153-60.
47. Wallace EL, Morgan TM, Walsh TF, et al. Dobutamine cardiac magnetic resonance results predict cardiac prognosis in women with known or suspected ischemic heart disease. JACC Cardiovasc Imaging 2009;2:299-307.
48. Shah R, Heydari B, Coelho-Filho O, et al. Stress cardiac magnetic resonance imaging provides effective cardiac risk reclassification in patients with known or suspected stable coronary artery disease. Circulation 2013;128:605-14.
49. Gargiulo P, Dellegrottaglie S, Bruzzese D, et al. The prognostic value of normal stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: a meta-analysis. Circ Cardiovasc Imaging 2013;6:574-82.
50. Nagel E, Greenwood JP, McCann GP, et al. Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease. N Engl J Med 2019;380:2418-28.
51. Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR, Carlos RC. Diagnostic performance of stress cardiac magnetic resonance imaging in the detection of coronary artery disease: a meta-analysis. J Am Coll Cardiol 2007;50:1343-53.
52. Hamon M, Fau G, Nee G, Ehtisham J, Morello R. Meta-analysis of the diagnostic performance of stress perfusion cardiovascular magnetic resonance for detection of coronary artery disease. J Cardiovasc Magn Reson 2010;12:29.
53. Nagel E, Lehmkuhl HB, Bocksch W, et al. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation 1999;99:763-70.
54. Hundley WG, Hamilton CA, Thomas MS, et al. Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography. Circulation 1999;100:1697-702.
55. Bengel FM, Higuchi T, Javadi MS, Lautamaki R. Cardiac positron emission tomography. J Am Coll Cardiol 2009;54:1-15.
56. Tsukamoto T, Morita K, Naya M, et al. Myocardial flow reserve is influenced by both coronary artery stenosis severity and coronary risk factors in patients with suspected coronary artery disease. Eur J Nucl Med Mol Imaging 2006;33:1150-6.
57. Dorbala S, Vangala D, Sampson U, Limaye A, Kwong R, Di Carli MF. Value of vasodilator left ventricular ejection fraction reserve in evaluating the magnitude of myocardium at risk and the extent of angiographic coronary artery disease: a 82Rb PET/CT study. J Nucl Med 2007;48:349-58.
58. Mc Ardle BA, Dowsley TF, deKemp RA, Wells GA, Beanlands RS. Does rubidium-82 PET have superior accuracy to SPECT perfusion imaging for the diagnosis of obstructive coronary disease?: A systematic review and meta-analysis. J Am Coll Cardiol 2012;60:1828-37.
59. Dorbala S, Hachamovitch R, Curillova Z, et al. Incremental prognostic value of gated Rb-82 positron emission tomography myocardial perfusion imaging over clinical variables and rest LVEF. JACC Cardiovasc Imaging 2009;2:846-54.
60. Dorbala S, Di Carli MF, Beanlands RS, et al. Prognostic value of stress myocardial perfusion positron emission tomography: results from a multicenter observational registry. J Am Coll Cardiol 2013;61:176-84.
61. Di Carli MF, Dorbala S, Curillova Z, et al. Relationship between CT coronary angiography and stress perfusion imaging in patients with suspected ischemic heart disease assessed by integrated PET-CT imaging. J Nucl Cardiol. 2007;14(6):799-809.
62. Giri S, Shaw LJ, Murthy DR, et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation 2002;105:32-40.
63. Soman P, Taillefer R, DePuey EG, Udelson JE, Lahiri A. Enhanced detection of reversible perfusion defects by Tc-99m sestamibi compared to Tc-99m tetrofosmin during vasodilator stress SPECT imaging in mild-to-moderate coronary artery disease. J Am Coll Cardiol 2001;37:458-62.
64. Emmett L, Iwanochko RM, Freeman MR, Barolet A, Lee DS, Husain M. Reversible regional wall motion abnormalities on exercise technetium-99m-gated cardiac single photon emission computed tomography predict high-grade angiographic stenoses. J Am Coll Cardiol 2002;39:991-8.
65. Baghdasarian SB, Noble GL, Ahlberg AW, Katten D, Heller GV. Risk stratification with attenuation corrected stress Tc-99m sestamibi SPECT myocardial perfusion imaging in the absence of ECG-gating due to arrhythmias. J Nucl Cardiol 2009;16:533-9.
66. Jaarsma C, Leiner T, Bekkers SC, et al. Diagnostic performance of noninvasive myocardial perfusion imaging using single-photon emission computed tomography, cardiac magnetic resonance, and positron emission tomography imaging for the detection of obstructive coronary artery disease: a meta-analysis. J Am Coll Cardiol. 2012;59(19):1719-1728.
67. Hachamovitch R, Rozanski A, Hayes SW, et al. Predicting therapeutic benefit from myocardial revascularization procedures: are measurements of both resting left ventricular ejection fraction and stress-induced myocardial ischemia necessary? J Nucl Cardiol 2006;13:768-78.
68. Schaap J, Kauling RM, Boekholdt SM, et al. Incremental diagnostic accuracy of hybrid SPECT/CT coronary angiography in a population with an intermediate to high pre-test likelihood of coronary artery disease. Eur Heart J Cardiovasc Imaging 2013;14:642-9.
69. Schaap J, de Groot JA, Nieman K, et al. Hybrid myocardial perfusion SPECT/CT coronary angiography and invasive coronary angiography in patients with stable angina pectoris lead to similar treatment decisions. Heart 2013;99:188-94.
70. Smart SC, Bhatia A, Hellman R, et al. Dobutamine-atropine stress echocardiography and dipyridamole sestamibi scintigraphy for the detection of coronary artery disease: limitations and concordance. J Am Coll Cardiol 2000;36:1265-73.
71. 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.
72. Schinkel AF, Bax JJ, Geleijnse ML, et al. Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? Eur Heart J. 2003;24(9):789-800.
73. Salame G, Juselius WE, Burden M, et al. Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine. 17(2):98-104, 2018 06.Crit. pathw. cardiol.. 17(2):98-104, 2018 06.
74. Plana JC, Mikati IA, Dokainish H, et al. A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease The OPTIMIZE Trial. JACC Cardiovasc Imaging 2008;1:145-52.
75. De Bruyne B, Pijls NH, Kalesan B, et al. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012;367:991-1001.
76. Fearon WF, Shilane D, Pijls NH, et al. Cost-effectiveness of percutaneous coronary intervention in patients with stable coronary artery disease and abnormal fractional flow reserve. Circulation 2013;128:1335-40.
77. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009;360:213-24.
78. Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med 2020;382:1395-407.
79. Spertus JA, Jones PG, Maron DJ, et al. Health-Status Outcomes with Invasive or Conservative Care in Coronary Disease. N Engl J Med 2020;382:1408-19.
80. Rochitte CE, George RT, Chen MY, et al. Computed tomography angiography and perfusion to assess coronary artery stenosis causing perfusion defects by single photon emission computed tomography: the CORE320 study. Eur Heart J 2014;35:1120-30.
81. Nieman K, Cury RC, Ferencik M, et al. Differentiation of recent and chronic myocardial infarction by cardiac computed tomography. Am J Cardiol 2006;98:303-8.
82. Achenbach S. Coronary CT Angiography: Moving Up on the Risk Scale. J Am Coll Cardiol 2020;75:464-66.
83. Min JK, Dunning A, Lin FY, et al. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol 2011;58:849-60.
84. Bittencourt MS, Hulten EA, Murthy VL, et al. Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care: A Meta-Analysis. Circulation. Cardiovascular imaging. 9(4):e004419, 2016 Apr.Circ Cardiovasc Imaging. 9(4):e004419, 2016 Apr.
85. Ferencik M, Mayrhofer T, Bittner DO, et al. Use of High-Risk Coronary Atherosclerotic Plaque Detection for Risk Stratification of Patients With Stable Chest Pain: A Secondary Analysis of the PROMISE Randomized Clinical Trial. JAMA Cardiology. 3(2):144-152, 2018 02 01.JAMA Cardiol. 3(2):144-152, 2018 02 01.
86. Nerlekar N, Ha FJ, Cheshire C, et al. Computed Tomographic Coronary Angiography-Derived Plaque Characteristics Predict Major Adverse Cardiovascular Events: A Systematic Review and Meta-Analysis. Circ Cardiovasc Imaging 2018;11:e006973.
87. Motoyama S, Ito H, Sarai M, et al. Plaque Characterization by Coronary Computed Tomography Angiography and the Likelihood of Acute Coronary Events in Mid-Term Follow-Up. J Am Coll Cardiol 2015;66:337-46.
88. Andreini D, Modolo R, Katagiri Y, et al. Impact of Fractional Flow Reserve Derived From Coronary Computed Tomography Angiography on Heart Team Treatment Decision-Making in Patients With Multivessel Coronary Artery Disease: Insights From the SYNTAX III REVOLUTION Trial. Circ Cardiovasc Interv 2019;12:e007607.
89. Kumbhani DJ, Ingelmo CP, Schoenhagen P, Curtin RJ, Flamm SD, Desai MY. Meta-analysis of diagnostic efficacy of 64-slice computed tomography in the evaluation of coronary in-stent restenosis. Am J Cardiol 2009;103:1675-81.
90. Bello D, Shah DJ, Farah GM, et al. Gadolinium cardiovascular magnetic resonance predicts reversible myocardial dysfunction and remodeling in patients with heart failure undergoing beta-blocker therapy. Circulation. 2003; 108(16):1945-1953.
91. Bogaert J, Kalantzi M, Rademakers FE, Dymarkowski S, Janssens S. Determinants and impact of microvascular obstruction in successfully reperfused ST-segment elevation myocardial infarction. Assessment by magnetic resonance imaging. Eur Radiol 2007;17:2572-80.
92. Ganame J, Messalli G, Masci PG, et al. Time course of infarct healing and left ventricular remodelling in patients with reperfused ST segment elevation myocardial infarction using comprehensive magnetic resonance imaging. Eur Radiol 2011;21:693-701.
93. Grover S, Bell G, Lincoff M, et al. Utility of CMR Markers of Myocardial Injury in Predicting LV Functional Recovery: Results from PROTECTION AMI CMR Sub-study. Heart Lung Circ 2015;24:891-7.
94. Ingkanisorn WP, Rhoads KL, Aletras AH, Kellman P, Arai AE. Gadolinium delayed enhancement cardiovascular magnetic resonance correlates with clinical measures of myocardial infarction. J Am Coll Cardiol 2004;43:2253-9.
95. Kim RJ, Albert TS, Wible JH, et al. Performance of delayed-enhancement magnetic resonance imaging with gadoversetamide contrast for the detection and assessment of myocardial infarction: an international, multicenter, double-blinded, randomized trial. Circulation 2008;117:629-37.
96. Kim RJ, Wu E, Rafael A, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med. 2000 Nov 16;343(20):1445-53.
97. Orn S, Manhenke C, Anand IS, et al. Effect of left ventricular scar size, location, and transmurality on left ventricular remodeling with healed myocardial infarction. Am J Cardiol 2007;99:1109-14.
98. Wellnhofer E, Olariu A, Klein C, et al. Magnetic resonance low-dose dobutamine test is superior to SCAR quantification for the prediction of functional recovery. Circulation 2004;109:2172-4.
99. 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.