TABLE 4.

Clinical Considerations for the Use of Noninvasive Testing for Coronary Artery Disease

Ischemia Test Modality	Strengths	Limitations	Patient Considerations Favoring Its Use
Exercise stress ECG	Low cost Wide availability Assessment of exercise symptoms, capacity No ionizing radiation	Decreased accuracy compared with anatomical and stress-imaging tests Requires interpretable ECG and ability to exercise sufficiently	Rarely recommended as a stand-alone test due to frequent known CAD, inability to exercise, or significant arrhythmias
Stress echocardiography	Wide availability High diagnostic specificity Assessment of ventricular and valvular function No ionizing radiation	Decreased sensitivity compared with anatomical and other stress-imaging tests Dependent on good image quality Requires dobutamine in patients unable to exercise	Known good image quality and ability to exercise Consider use of an ultrasound-enhancing agent to improve endocardial visualization Known moderate or severe valvular disease
Stress/rest SPECT	Wide availability Relatively high diagnostic sensitivity Assessment of ventricular function	Increased artifacts resulting in nondiagnostic results and decreased diagnostic accuracy compared with stress/rest PET Radiation exposure	Known CAD or high CAC burden on chest CT imaging Preferred over stress echocardiography in patients who cannot exercise or who do not have significant bronchospastic disease
Stress/rest PET	High diagnostic accuracy Lower radiation exposure than SPECT Measures myocardial blood flow and flow reserve Assessment of ventricular function	Limited availability Relatively higher cost Lack of exercise assessment	Known CAD or high CAC burden on chest CT imaging Preferred over SPECT due to higher diagnostic accuracy and lower rate of nondiagnostic test results
Stress CMR	High diagnostic accuracy Accurate assessment of chamber sizes, ventricular and valvular function Diagnosis of prior infarction, scar, fibrosis Measurement of myocardial blood flow and flow reserve is possible but not widely available currently No ionizing radiation	Limited availability Relatively higher cost Lack of exercise assessment Long scan acquisition times Claustrophobia Often not immediately available to patients with pacemakers or ICDs Contraindicated in patients with significant renal dysfunction	Known CAD and/or cardiomyopathy Elevated troponin not thought to be secondary to ACS Known moderate or severe valvular disease No significant renal dysfunction
CTA	High diagnostic accuracy Does not require exercise Identifies nonobstructive CAD	Radiation exposure Lack of exercise assessment Contraindicated in patients with significant renal dysfunction Blooming artifacts when significant coronary calcification present Atrial fibrillation or other arrhythmias May require beta-blockade Incidental noncardiac findings	No known CAD Absence of severe coronary calcification Prior normal, mildly abnormal, or inconclusive stress test results No known iodinated contrast medium allergy or significant renal dysfunction Low likelihood of high-quality stress testing or lack of timely access

ACS = acute coronary syndrome CAC = coronary artery calcium; CAD = coronary artery disease; CMR = cardiovascular magnetic resonance; CT = computed tomography; CTA = computed tomography angiography; ECG = electrocardiogram; ICD = implantable cardioverter defibrillator; PET = positron emission tomography; SPECT = single-photon emission computed tomography.