Diagnosis of Stable Ischemic Heart Disease: Summary of a Clinical
Practice Guideline From the American College of Physicians/American
College of Cardiology Foundation/American Heart Association/
American Association for Thoracic Surgery/Preventive Cardiovascular
Nurses Association/Society of Thoracic Surgeons
Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Sankey Williams, MD; Paul Dallas, MD; Douglas K. Owens, MD, MS; and
Paul Shekelle, MD, PhD, for the Clinical Guidelines Committee of the American College of Physicians*
Description: The American College of Physicians (ACP) developed
this guideline in collaboration with the American College of Cardi-
ology Foundation (ACCF), American Heart Association (AHA),
American Association for Thoracic Surgery, Preventive Cardiovascu-
lar Nurses Association, and Society of Thoracic Surgeons to help
clinicians diagnose known or suspected stable ischemic heart
disease.
Methods: Literature on this topic published before November 2011
was identified by using MEDLINE, Embase, Cochrane CENTRAL,
PsychINFO, AMED, and SCOPUS. Searches were limited to human
studies published in English. This guideline grades the evidence and
recommendations according to a translation of the ACCF/AHA
grading system into ACP’s clinical practice guidelines grading
system.
Recommendations: This guideline includes 28 recommendations
that address the following issues: the initial diagnosis of the patient
who might have stable ischemic heart disease, cardiac stress testing
to assess the risk for death or myocardial infarction in patients
diagnosed with stable ischemic heart disease, and coronary angiog-
raphy for risk assessment.
Ann Intern Med. 2012;157:729-734. www.annals.org
For author affiliations, see end of text.
EXECUTIVE SUMMARY
This guideline presents the available evidence on the
diagnosis of stable known or suspected ischemic heart dis-
ease (IHD). This is the first of 2 guidelines addressing
stable IHD; the second guideline addresses the manage-
ment of patients with stable IHD (1). Internists and other
primary care physicians are the target audiences for this
guideline. The target population is all adult patients with
stable known or suspected IHD. These recommendations
are based on the joint American College of Cardiology
Foundation (ACCF), American Heart Association (AHA),
American College of Physicians (ACP), American Associa-
tion for Thoracic Surgery (AATS), Preventive Cardiovas-
cular Nurses Association (PCNA), Society for Cardiovas-
cular Angiography and Interventions (SCAI), and Society
of Thoracic Surgeons (STS) guideline for the diagnosis and
management of patients with stable IHD published in
2012, which ACP recognized as a scientifically valid, high-
quality review of the evidence (2). Full details about meth-
ods and evidence are available in the Appendix at www
.annals.org.
Methods
The databases used for the literature search included
MEDLINE, Embase, Cochrane CENTRAL, PsychINFO,
AMED, and SCOPUS for studies published up until No-
vember 2011. The criteria for search included human partic-
ipants and English-language articles. For more details on the
methods, refer to the Appendix and the ACCF, AHA, ACP,
AATS, PCNA, SCAI, and STS guideline for the diagnosis
and management of patients with stable IHD (2).
* This paper, written by Amir Qaseem, MD, PhD, MHA; Stephan D. Fihn, MD, MPH; Sankey Williams, MD; Paul Dallas, MD; Douglas K. Owens, MD, MS; and Paul Shekelle, MD,
PhD, was developed for the Clinical Guidelines Committee of the American College of Physicians: Paul Shekelle, MD, PhD (Chair); Roger Chou, MD; Molly Cooke, MD; Paul Dallas,
MD; Thomas D. Denberg, MD, PhD; Nick Fitterman, MD; Mary Ann Forciea, MD; Robert H. Hopkins Jr., MD; Linda L. Humphrey, MD, MPH; Tanveer P. Mir, MD; Holger J.
Schu¨nemann, MD, PhD; Donna E. Sweet, MD; and Timothy Wilt, MD, MPH. Approved by the ACP Board of Regents on 16 April 2012.
See also:
Print
Related article. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735
Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . 749
Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-42
Web-Only
Appendix: Full Guideline Summary
CME quiz (preview on page I-34)
Clinical Guideline
© 2012 American College of Physicians 729
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Because this document is based on the joint guideline,
ACP translated the ACCF/AHA evidence and recommen-
dation grades into ACP’s guideline grading system (3)
(Tables 1 and 2). We included only class I and class III
statements from the joint guideline because the evidence
for these statements very clearly demonstrates the tradeoff
between benefits and harms (Table 2). For details on other
recommendations, refer to the ACCF, AHA, ACP, AATS,
PCNA, SCAI, and STS guideline for the diagnosis and
management of patients with stable IHD (2).
The objective of this guideline is to synthesize the ev-
idence for the following key questions:
1: How should a clinician evaluate a patient with chest
pain that is consistent with IHD?
2: What is the role of noninvasive testing in the diag-
nosis of stable IHD?
Recommendations
In interpreting these recommendations, it is important
to distinguish between the probability of having IHD and
the probability (risk) of death or myocardial infarction
once the diagnosis of IHD is established.
Initial Cardiac Testing to Establish Diagnosis of IHD
Recommendation 1: The organizations recommend that
patients with chest pain should receive a thorough history and
physical examination to assess the probability of IHD prior to
additional testing (Grade: strong recommendation; low-
quality evidence).
Recommendation 2: The organizations recommend that
choices regarding diagnostic and therapeutic options should be
made through a process of shared decision making involving
the patient and provider, explaining information about risks,
benefits, and costs to the patient (Grade: strong recommenda-
tion; low-quality evidence).
Recommendation 3: The organizations recommend that
patients who present with acute angina must be categorized as
stable or unstable; patients with unstable angina should be
further categorized as high, moderate, or low risk (Grade:
strong recommendation; low-quality evidence).
Recommendation 4: The organizations recommend a rest-
ing electrocardiography (ECG) in patients without an obvious
noncardiac cause of chest pain for risk assessment (Grade:
strong recommendation; moderate-quality evidence).
Recommendation 5: The organizations recommend stan-
dard exercise ECG for initial diagnosis in patients with an
intermediate pretest probability of IHD who have an inter-
pretable ECG and at least moderate physical functioning or no
disabling comorbidity (Grade: strong recommendation; high-
quality evidence).
Recommendation 6: The organizations recommend that
exercise stress with radionuclide myocardial perfusion imaging
or echocardiography should be used for patients with an inter-
mediate to high pretest probability of IHD that have an un-
interpretable ECG and at least moderate physical functioning
or no disabling comorbidity (Grade: strong recommendation;
moderate-quality evidence).
Recommendation 7: The organizations recommend that
pharmacologic stress with radionuclide myocardial perfusion
imaging, echocardiography, or cardiac magnetic resonance im-
aging should not be used for patients who have an interpreta-
ble ECG and at least moderate physical functioning or no
Table 1. The American College of Physicians’ Guideline
Grading System*
Quality of
Evidence
Strength of Recommendation
Benefits Clearly Outweigh
Risks and Burden or Risks
and Burden Clearly
Outweigh Benefits
Benefits Finely Balanced
With Risks and Burden
High Strong Weak
Moderate Strong Weak
Low Strong Weak
Insufficient evidence to determine net benefits or risks
* Adopted from the classification developed by the GRADE (Grading of Recom-
mendations Assessment, Development, and Evaluation) workgroup.
Table 2. Comparison of Grading Systems From the ACP and ACCF/AHA
ACP’s Grading System ACCF/AHA’s Grading System
(Size vs. Certainty)
Description Grade (For or Against Intervention) Grade Class
Recommendation Evidence For Against
Benefits clearly outweigh risks and burden or vice versa Strong High-quality A I III
Benefits clearly outweigh risks and burden or vice versa Strong Moderate-quality B I III
Benefits clearly outweigh risks and burden or vice versa Strong Low-quality C I III
Benefits closely balanced with risks and burden Weak High-quality A IIa, IIb NER
Benefits closely balanced with risks and burden Weak Moderate-quality B IIa, IIb NER
Uncertainty, benefits may be closely balanced with risks
and burden
Weak Low-quality C IIa, IIb NER
ACCF � American College of Cardiology Foundation; ACP � American College of Physicians; AHA � American Heart Association; NER � no equivalent rating.
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disabling comorbidity (Grade: strong recommendation; low-
quality evidence).
Recommendation 8: The organizations recommend that
exercise stress with nuclear myocardial perfusion imaging
should not be used as an initial test in low-risk patients who
have an interpretable ECG and at least moderate physical
functioning or no disabling comorbidity (Grade: strong recom-
mendation; low-quality evidence).
Recommendation 9: The organizations recommend phar-
macologic stress with radionuclide myocardial perfusion imag-
ing or echocardiography for patients with an intermediate to
high pretest probability of IHD who are incapable of at least
moderate physical functioning or with disabling comorbidity
(Grade: strong recommendation; moderate-quality evidence).
Recommendation 10: The organizations recommend that
standard exercise ECG testing should not be used for patients
that have an uninterpretable ECG or are incapable of at least
moderate physical functioning or with disabling comorbidity
(Grade: strong recommendation; low-quality evidence).
Recommendation 11: The organizations recommend as-
sessing resting left ventricular systolic and diastolic ventricular
function and evaluating for abnormalities of myocardium,
heart valves, or pericardium using Doppler echocardiography
in patients with known or suspected IHD and a prior myo-
cardial infarction, pathologic Q waves, symptoms or signs sug-
gestive of heart failure, complex ventricular arrhythmias, or an
undiagnosed heart murmur (Grade: strong recommendation;
moderate-quality evidence).
Recommendation 12: The organizations recommend that
echocardiography, radionuclide imaging, cardiac magnetic res-
onance imaging, or cardiac computed tomography should not
be used for routine assessment of left ventricular function in
patients with a normal ECG, no history of myocardial infarc-
tion, no symptoms or signs suggestive of heart failure, and no
complex ventricular arrhythmias (Grade: strong recommenda-
tion; low-quality evidence).
Recommendation 13: The organizations recommend that
routine reassessment (�1 year) of left ventricular function
using technologies such as echocardiography radionuclide im-
aging, cardiac magnetic resonance imaging, or cardiac com-
puted tomography should not be used in patients with no
change in clinical status and for whom no change in therapy is
contemplated (Grade: strong recommendation; low-quality
evidence).
Cardiac Stress Testing to Assess Risk in Patients With Known
Stable IHD Who Are Able to Exercise
Recommendation 14: The organizations recommend
standard exercise ECG testing for risk assessment in patients
who are able to exercise to an adequate workload and have an
ECG that can be interpreted during exercise (Grade: strong
recommendation; moderate-quality evidence).
Recommendation 15: The organizations recommend the
addition of either radionuclide myocardial perfusion imaging
or echocardiography to standard exercise ECG testing for risk
assessment, in patients with stable IHD who are able to exer-
cise to an adequate workload but have an uninterpretable
ECG not due to left bundle branch block or ventricular pacing
(Grade: strong recommendation; moderate-quality evidence).
Recommendation 16: The organizations recommend that
pharmacologic stress imaging (radionuclide myocardial perfu-
sion imaging, echocardiography, cardiac magnetic resonance
imaging) or cardiac computed tomography angiography should
not be used for risk assessment in patients with stable IHD
who are able to exercise to an adequate workload and have
an interpretable ECG (Grade: strong recommendation; low-
quality evidence).
Cardiac Stress Testing to Assess Risk in Patients With Known
Stable IHD Who Are Unable to Exercise
Recommendation 17: The organizations recommend
pharmacologic stress with either radionuclide myocardial per-
fusion imaging or echocardiography for risk assessment in pa-
tients who are unable to exercise to an adequate workload
regardless of interpretability of ECG (Grade: strong recom-
mendation; moderate-quality evidence).
Cardiac Stress Testing to Assess Risk in Patients With Stable
IHD Regardless of Ability to Exercise
Recommendation 18: The organizations recommend
pharmacologic stress with either radionuclide myocardial
perfusion imaging or echocardiography for risk assessment
in patients with stable IHD who have left bundle branch
block on ECG, regardless of ability to exercise to an ade-
quate workload (Grade: strong recommendation; moderate-
quality evidence).
Recommendation 19: The organizations recommend ei-
ther exercise or pharmacological stress with imaging (radionu-
clide myocardial perfusion imaging, echocardiography, or car-
diac magnetic resonance) for risk assessment in patients being
considered for revascularization of known coronary stenosis of
unclear physiologic significance (Grade: strong recommenda-
tion; moderate-quality evidence).
Recommendation 20: The organizations recommend that
a) more than 1 stress imaging study or b) a stress imaging
study and cardiac computed tomography angiography at the
same time should not be used for risk assessment in patients
with stable IHD (Grade: strong recommendation; low-quality
evidence).
Coronary Angiography as an Initial Testing Strategy to Assess
Risk in Patients With Stable IHD
Recommendation 21: The organizations recommend that
patients with stable IHD who have survived sudden cardiac
death or potentially life-threatening ventricular arrhythmia
undergo coronary angiography to assess cardiac risk (Grade:
strong recommendation; moderate quality-evidence).
Recommendation 22: The organizations recommend that
patients with stable IHD who develop symptoms and signs of
heart failure should be evaluated to determine whether coro-
Clinical GuidelineDiagnosis of Stable Ischemic Heart Disease
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Figure 1. Diagnosis of patients suspected of having ischemic heart disease.
Symptoms or finding
suggest high-risk lesion(s)†
OR
Prior sudden death or
serious ventricular
arrhythmia
OR
Prior stent in unprotected
left main coronary artery
Suspected ischemic heart disease
(or change in clinical status in a patient with known IHD)
Intermediate- or high-risk UA?*
Recent exercise or cardiac imaging studyTechnically adequate?
See ACCF/AHA UA/NSTEMI
guideline
Pharmacologic
stress
echo
Pharmacologic
stress MPI
or echo
Pharmacologic
CMR or
CCTA
MPI or echo
with exercise or
pharmacologic
CMR
Initiate guideline-
directed medical
therapy
See Figure 1 of
reference 1
Consider coronary
revascularization to
improve symptoms
See Figure 3 of
reference 1
Initiate guideline-
directed medical therapy
Consider coronary
revascularization to
improve survival
See Figure 1 of
reference 1
Regular
monitoring
MPI or
echo with
exercise
Resting ECG
interpretable?
Standard
exercise
ECG
Standard
exercise
ECG CCTA
Comprehensive clinical assessment of risk, including personal
characteristics, coexisting cardiac and medical conditions, and
health status
No
No
Contraindications to stress testing?
No
Patient able to exercise?
Yes
Yes
Previous coronary revascularization?
No
No
Yes
Yes
No
Yes
Yes
No
Successful
treatment?
Yes
Low-
likelihood IHD
Test results suggest
high-risk coronary
lesion(s)?
Intermediate-
likelihood IHD
Intermediate- to high-
likelihood IHD
Yes
Yes
OR
OR
No
No
No
Yes
Low-
likelihood
IHD
Intermediate-
to high-
likelihood IHD
CCTA � computed coronary tomography angiography; CMR � cardiac magnetic resonance; ECG � electrocardiogram; echo � echocardiography;
IHD � ischemic heart disease; MPI � myocardial perfusion imaging; UA � unstable angina; UA/NSTEMI � unstable angina/non–ST-segment
elevation myocardial infarction.
* See Table 2 of reference 2 for short-term risk of death or nonfatal myocardial infarction in patients with UA/NSTEMI.
† CCTA is reasonable only for patients with intermediate probability of IHD.
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nary angiography should be performed for risk assessment
(Grade: strong recommendation; moderate quality-evidence).
Recommendation 23: The organizations recommend that
patients with stable IHD and clinical characteristics that in-
dicate a high likelihood of severe IHD should undergo coro-
nary angiography to assess cardiac risk (Grade: strong recom-
mendation; low-quality evidence).
Coronary Angiography to Assess Risk After Initial Workup
With Noninvasive Testing
Recommendation 24: The organizations recommend
that coronary arteriography should be used for risk assess-
ment in patients with stable IHD whose clinical character-
istics and results of noninvasive testing indicate a high
likelihood of severe IHD and when the benefits are deemed
to exceed risk (Grade: strong recommendation; low-quality
evidence).
Recommendation 25: The organizations recommend that
coronary angiography for risk assessment should not be utilized
for stable IHD patients who elect not to undergo revascular-
ization or who are not candidates for revascularization based
on comorbidities or individual preferences (Grade: strong rec-
ommendation; moderate-quality evidence).
Recommendation 26: The organizations recommend that
coronary angiography should not be used to further assess risk
in patients with stable IHD who have preserved left ventric-
Figure 2. Risk assessment of patients with stable ischemic heart disease.
Yes
Known ischemic heart disease
Patient able to exercise?
Resting ECG
interpretable?
Pharmacologic
stress CMR
or CCTA
Pharmacologic
stress MPI
or echo
YesNo
OROR
OR
Consider coronary
revascularization to
improve survival
See Figur e 2 of
reference 1
Observe response
to guideline-
directed medical
therapy See Figure 1
of reference 1
Consider coronary
revascularization to
improve symptoms
See Figur e 3 of
reference 1
NoYes
Pharmacologic
stress
CMR
Standard
exercise
text
MPI or
echo with
exercise
Regular
monitoring
Pharmacologic
MPI, echo,
CCTA,
or CMR
MPI or
echo with
exercise
MPI or
echo with
exercise
Special circumstances
(irrespective of ability to
exercise) Test results suggest
high-risk coronary
lesion(s)?
LBBB on ECG?
Indeterminate result
from functional testing
Known stenosis of
unclear significance
being considered
for revascularization
No
No
No
Yes
Yes
Yes
Yes
No
CCTA
Successful
treatment?
CCTA � coronary computed tomography angiography; CMR � cardi