This document addresses the use of myocardial perfusion imaging (MPI), myocardial viability studies, and radionuclide angiography (RNA) for the evaluation of cardiac disease. Myocardial perfusion imaging can be used in the diagnosis of patients suspected of having coronary artery disease (CAD). MPI can also be used in patients with known CAD in determining the extent of myocardial ischemia, infarction or viability.

Note: Please see the following related documents for additional information:

• CG-RAD-22 Stress Echocardiography in the Outpatient Setting
• RAD.00002 Positron Emission Tomography and PET/CT Fusion
• RAD.00023 SPECT (Single Photon Emission Computed Tomography) Scans and Scintimammography

Medically Necessary 

I.    Myocardial Viability Studies

Myocardial perfusion imaging to assess myocardial viability is considered medically necessary for any of the following:

• After myocardial infarction, to detect infarct size or assess myocardium at risk; or
• After myocardial infarction, to assess myocardial viability in patients with left ventricular dysfunction who are candidates for revascularization. 

II.  Myocardial Perfusion Imaging (MPI) in Individuals with Known Coronary Artery Disease

MPI is considered medically necessary for the evaluation of individuals with documented coronary artery disease (CAD) for re-evaluation of coronary artery disease for any of the following:

• Signs or symptoms suggest worsened clinical status due to progressive coronary artery disease, or
• When asymptomatic after a revascularization procedure (coronary artery bypass grafting, coronary stenting or percutaneous angioplasty): yearly for type I diabetics and every 2-5 years for all others including those individuals with type II diabetes (appropriate interval dependent on the individual's risk factors).

III. MPI in Symptomatic Individuals with Suspected Coronary Artery Disease

Note: see Appendix A to calculate pre-test probability

MPI is considered medically necessary for the evaluation of symptomatic individuals with suspected CAD for any of the following:

• Chest pain syndrome (typical, atypical or non-anginal – see definitions) with intermediate or high pre-test probability of disease, or
• Chest pain syndrome with low or very low pre-test probability when criteria for asymptomatic patients are met (see below); or
• Angina equivalent symptoms (e.g., exertional dyspnea) when criteria for asymptomatic patients are met (see below); or
• To assess the functional significance of intermediate (25-75%) coronary lesions detected on invasive coronary angiography; or
• To further evaluate an individual after an equivocal or indeterminate exercise stress test (e.g., beta blocker interferes with attaining target heart rate); or
• To further evaluate an individual with an intermediate-risk Duke treadmill score (see Appendix B); or
• To further evaluate an individual with an abnormal exercise test in whom MPI is being considered as an alternative to cardiac catheterization (e.g., due to risk of complications of invasive angiography); or
• Presence of baseline electrocardiogram (ECG) changes that could render exercise test ECG uninterpretable (e.g., complete left bundle branch block, pre-excitation [e.g., Wolff-Parkinson-White syndrome], ventricular paced rhythm, left ventricular hypertrophy, ST depression greater than or equal to 1 mm on resting ECG, or patient on digoxin); or
• Physical limitations which would preclude ability to exercise to a level high enough to give meaningful results on a routine stress electrocardiogram test, (i.e., orthopedic problem, severe peripheral vascular disease, chronic obstructive pulmonary disease, amputation).

IV. MPI in Asymptomatic Individuals with Suspected Coronary Artery Disease

MPI is considered medically necessary for the evaluation of asymptomatic individuals with suspected CAD for any of the following:

• To assess the functional significance of intermediate (25-75%) coronary lesions detected on invasive coronary angiography; or
• Equivocal or indeterminate exercise stress test or intermediate-risk Duke treadmill score (see Appendix B); or abnormal ECG on exercise testing in a patient at low or intermediate pre-test probability of CAD; or
• High risk (greater than 20% 10 year risk of a coronary heart disease event) based on a generally accepted risk stratification method such as the Framingham Risk Score (FRS) or Systematic Coronary Risk Evaluation (SCORE), every three to five years; or
• Intermediate or high risk (greater than 10% 10 year risk of a coronary heart disease event) based on a generally accepted risk stratification method when engaged in a high-risk occupation (e.g., airline pilots, train engineers, etc.) that may adversely affect others if a coronary event were to occur.

V.   MPI in Individuals with other Cardiac Disorders

MPI is considered medically necessary for the evaluation of potential CAD for any of the following:

• Cardiomyopathy or heart failure
  1. For differentiation between ischemic and non-ischemic cardiomyopathy; or
  2. For assessment of myocardial ischemia in hypertrophic cardiomyopathy; or
  3. For assessment of co-presence of CAD in patients with heart failure without angina; or
• Congenital heart disease to detect anomalies of coronary circulation; or
• Sustained (lasting more than 30 seconds) ventricular arrhythmias suspected to be due to silent ischemia; or
• Other arrhythmia when criteria for asymptomatic patients (above) are met.

 VI.  MPI in Pre-Operative Individuals when criteria above are not met

MPI is considered medically necessary for the pre-operative evaluation of suspected CAD for any of the following:

• Individual undergoing non-coronary cardiac surgery with moderate or greater 10 year risk for coronary heart disease event (FRS or SCORE) when testing is performed to exclude concomitant coronary artery disease and preoperative left heart catheterization is not planned, or
• Individual undergoing vascular surgery and has all of the following:
  • Poor functional capacity (less than 4 METS) or cannot be assessed for functional capacity (e.g., orthopedic or neurological limitations); and
  • Three (3) or more clinical risk factors (ischemic heart disease, compensated or prior heart failure, diabetes, renal insufficiency, or cerebrovascular disease); and
  • One of the following:
    • Equivocal or indeterminate exercise stress test; or
    • Intermediate-risk Duke treadmill score (see Appendix B); or
    • Abnormal ECG on exercise testing in a patient at low or intermediate pre-test probability of CAD; or
    • Baseline ECG changes that could render exercise test ECG uninterpretable (e.g., complete left bundle branch block, pre-excitation [e.g., Wolff-Parkinson-White syndrome], ventricular paced rhythm, left ventricular hypertrophy, ST depression greater than or equal to 1mm on resting ECG, or patient on digoxin)

Not Medically Necessary 

Myocardial perfusion imaging or myocardial viability studies are considered not medically necessary for the initial evaluation of cardiac disease when none of the criteria above have been met, and for all other indications including the following classes of patients:

• Those with a low to intermediate risk of CAD and have a normal resting ECG, the ability to exercise and are not taking digoxin; or
• Those who have undergone exercise ECG testing and are at low risk on the basis of clinical and exercise testing information; or
• Routine screening of asymptomatic individuals without known CAD and who are not at high risk for CAD.

Repeat assessment for diagnosis of coronary artery disease or risk stratification using myocardial perfusion imaging, myocardial viability studies, or other modes of assessment are considered not medically necessary when clinical situations have not changed since prior study except where specifically indicated above.

Medically Necessary

I.    Radionuclide Angiography (RNA) 

Radionuclide angiography (RNA) is considered medically necessary for the evaluation of right or left ventricular function for any of the following:

• Acute myocardial infarction
• Myocarditis, cardiomyopathy, heart failure, or right ventricular dysplasia
• Patients receiving cardiotoxic drugs (e.g., doxorubicin [adriamycin]) for baseline and serial monitoring
• Congenital heart disease (also performed for detection and localization of shunts)
• After cardiac transplantation
• Valvular heart disease
• Ventricular arrhythmias, when an echocardiogram is insufficient for technical reasons to accurately assess left ventricular or right ventricular function

Not Medically Necessary

Radionuclide angiography (RNA) is considered not medically necessary for the evaluation of right or left ventricular function when the criteria above are not met.

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Cardiac nuclear imaging studies allow inspection of the heart's function under induced stress. The testing involves injecting a radioactive isotope into the circulatory system and tracking it as it passes through the heart. When exercise is not possible, pharmacologic agents may be used to induce stress.

Most current nuclear cardiac imaging applications utilize a gamma camera with either single or multiple crystals. SPECT (single photon emission computed tomography) images are tomographic reconstructions, derived from either a single- or multiple-headed gamma camera that rotates around the patient. Tomographic imaging, by displaying data in the format of slices with discrete thickness, allows better separation of myocardial and other nonmyocardial structures. While PET (positron emission tomography) scanning can also be categorized as a type of radionuclide imaging, this technology is not addressed in this document.

At this point in time, cardiac catheterization is definitive and should be used to diagnose those patients for whom there is a high clinical index of suspicion of a lesion that will require bypass surgery or angioplasty.

The American College of Cardiology (ACC) and American Heart Association (AHA) have published 2003 practice guidelines with evidenced-based recommendations regarding the clinical use of cardiac radionuclide imaging to include both myocardial perfusion imaging and radionuclide angiography studies. In addition, an ACC task force published 2005 appropriateness criteria for SPECT myocardial perfusion imaging. The ACC/AHA guidelines point out that most patients presenting with risk factors or cardiac symptoms will have a normal resting ECG and most likely normal left ventricular function. Additionally, they will, in most cases, be able to exercise and will not be taking digoxin. In an analysis of the incremental benefit of myocardial perfusion SPECT over exercise ECG in this group of patients, there was a modest benefit only which did not prove to be cost effective. Under these circumstances the guidelines recommend a stepwise approach in which an exercise ECG and not a stress imaging procedure is the initial testing strategy. However, in certain patient populations and clinical situations, myocardial perfusion imaging is recommended as the stress test of choice; these include patients who are unable to exercise, who are at high risk of having CAD (such as patients with certain risk factors including the presence of diabetes mellitus), and those with baseline ECG abnormalities that will interfere with exercise ECG interpretation. Patients with intermediate-risk Duke treadmill scores (used to calculate cardiac mortality risk from information obtained at stress testing) i.e., with a 1.25%/year risk of cardiac death have been shown in several studies to benefit from further risk assessment in the form of myocardial perfusion scintigraphy. It is also recognized that females have an increased incidence of false positive ST segment responses during exercise ECG testing suggesting the added benefit of stress perfusion imaging in women. In a 2006 practice guideline addressing the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death, ACC, AHA, and the European Society of Cardiology recommend the use of cardiac radionuclide imaging for the evaluation of ventricular arrhythmias when an echocardiogram is insufficient for technical reasons to accurately assess left ventricular or right ventricular function.

For patients classified as low risk on the basis of clinical and exercise ECG testing information, there is no compelling evidence that myocardial perfusion testing adds significant additional prognostic information. It is also unclear that detecting (screening for) preclinical CAD in asymptomatic individuals who are not at high risk will lead to therapeutic interventions providing benefits over and above interventions and recommendations based on risk factor profiling.

The Framingham Heart Study was a project that began to identify the common characteristics or factors that contribute to cardiovascular disease. The plan was to follow the development of cardiovascular disease over a long period of time in a large group of participants who had not yet developed symptoms of cardiovascular disease or had a stroke or heart attack. Over the years, monitoring of the Framingham Study population has led to the identification of the major cardiovascular disease risk factors (hypertension, high blood cholesterol, obesity, smoking, physical inactivity and diabetes). These risk factors can be compiled in a risk assessment tool that estimates the 10-year risk for developing "hard" coronary heart disease outcomes (e.g., myocardial infarction, coronary death). Subsequent to the widespread use of the Framingham risk assessment methodology, other methods have been described, including Systematic Coronary Risk Evaluation (SCORE). This alternative risk prediction method may have advantages over Framingham in select populations and the use of validated risk assessment methods such as SCORE are an acceptable alternative to the Framingham methodology.

For patients presenting with acute chest pain, randomized clinical trials indicate a high negative predictive value of a rest myocardial perfusion imaging study for excluding acute coronary syndromes in the emergency room in the presence of nondiagnostic conventional testing, and helping to guide decisions regarding hospital admission or discharge.

Pre-Operative Risk Assessment

Fleisher (2007), in the ACC/AHA updated guidelines for perioperative cardiovascular evaluation and care for non-cardiac surgery, emphasizes that symptomatic patients with or without known CAD should be evaluated based on their presenting symptoms and risk factors. They also recommend a 5 step approach to the evaluation of a preoperative patient. First, determine the urgency of the non-cardiac surgery. Second, determine if an active cardiac condition (unstable coronary syndromes, decompensated heart failure, significant arrhythmia, or severe valvular disease) or clinical risk factor (history of heart disease, heart failure, cerebrovascular disease, diabetes mellitus, or renal insufficiency) is present. Third evaluate the risk of the surgery: low (endoscopy, superficial, cataract, breast, or ambulatory), intermediate (intraperitoneal, intrathoracic, carotid endarterectomy, head and neck, orthopedic, or prostate), or vascular (aortic and major vascular surgery or peripheral vascular surgery). Fourth, evaluate the functional status. Does the patient have good functional capacity without symptoms? Functional status can be estimated from activity of daily living using the Duke Activity Index and 4 METS of activity is estimated by the ability to do light work around the house like dusting or washing dishes. Fifth, for patients with poor functional capacity (less than 4 METS), symptoms, or unknown functional capacity (e.g. unable to assess due to orthopedic or neurological disease) the authors recommend using active clinical risk factors to determine the need for further evaluation. Based on the above, the ACC/AHA guideline makes the following Class I and IIA recommendations: Patients with active cardiac conditions in whom noncardiac surgery is planned should be evaluated and treated per ACC/AHA guidelines before non-cardiac surgery (Class I, Level of Evidence B) and noninvasive stress testing of patients with 3 or more clinical risk factors and poor functional capacity (less than 4 METS) who require vascular surgery is reasonable if it will change management (Class IIa, Level of Evidence B).

Description of Cardiac Radionuclide Technique:

Myocardial Perfusion
A unique feature of nuclear cardiology is the ability to image regional myocardial blood flow distribution. Thallium is the radionuclide most commonly used, typically in conjunction with stress (i.e., exercise or dobutamine stress) or after the myocardial hyperemia induced by intravenous administration of dipyridamole or adenosine. For an exercise stress test, the radionuclide is administered in order to acquire images in both the resting state and at peak myocardial stress thus enabling an evaluation and comparison of the degree of myocardial perfusion at rest and with exercise. Fixed (present at rest and unchanged by exercise) or reversible (seen only on the exercise images with normal perfusion at rest) areas of myocardial ischemia may be demonstrated by this study. In patients with unstable angina or acute myocardial infarction, a perfusion study can be performed at rest. Technetium based radionuclides (i.e., sestamibi or teboroxime) have also been used for myocardial perfusion imaging. The shorter half life of technetium, compared with thallium, allows for administration of a large dose, with resulting improved count statistics.

Radionuclide Angiography
Radionuclide angiography collectively describes two related techniques, the first pass technique and gated blood pool imaging. As both techniques are used for similar indications, the ACC/AHA guidelines do not make a distinction between the two. Additionally, as RNA may be used to assess ischemia by imaging regional wall motion, some of the indications may overlap with those of myocardial perfusion studies. Multigated acquisition (MUGA), also referred to as equilibrium gated radionuclide angiography (ERNA), or radionuclide ventriculography (RVG), is the most accurate approach for determining ejection fraction when information about myocardial perfusion is not needed.

Cardiac Blood Pool Imaging, First Pass Technique
First pass cardiac blood pool imaging utilizes rapidly acquired image frames to observe a bolus of technetium or another suitable radionuclide, as it moves through the venous system and through the heart. By determining the change in radioactivity over time, it is possible to derive ejection fraction measurements from both the right and left ventricles and assess regional wall motion. The first pass approach is well suited for shunt detection and evaluation of right ventricular function. This approach can be applied to patients both at rest and during exercise.

Gated Blood Pool Imaging
Gated equilibrium blood pool radionuclide angiography, performed either at rest or during stress, most commonly utilizes technetium pertechnetate bound to red blood cells. Unlike the first pass technique described above, gated blood pool imaging studies are assessed over multiple cardiac cycles, synchronized with the electrocardiogram QRS complex. Similar to the first pass technique, gated blood pool imaging provides reliable left and right ventricular ejection fraction values and a means of assessing regional wall motion.

Angina, atypical or probable: chest pain or discomfort that lacks one of the characteristics of definite or typical angina

Angina, typical or definite: substernal chest pain or discomfort that is provoked by exertion or emotional stress and relieved by rest or nitroglycerin

Anginal equivalent: a group of symptoms heralding angina pectoris that does not include chest pain (e.g., dyspnea, diaphoresis, profuse vomiting in a diabetic patient, or arm or jaw pain)

Coronary heart disease (CHD) risk low: defined by the age-specific risk level that is below average; in general, low risk will correlate with a 10-year absolute CHD risk of less than 10%

Coronary heart disease (CHD) risk moderate: defined by the age-specific risk level that is average or above average; in general, moderate risk will correlate with a 10-year absolute CHD risk of between 10% and 20%

Coronary heart disease (CHD) risk high: defined as the presence of diabetes mellitus or the 10-year absolute CHD risk of greater than 20% using a validated risk prediction methodology such as FRS (Framingham Risk Score) or SCORE

 Non-anginal chest pain: chest pain or discomfort that meets one or none of the typical angina characteristics

Peer Reviewed Publications:

1. Burrell S, Dorbala S, Di Carli MF. Single photon emission computed tomography perfusion imaging for assessment of myocardial viability and management of heart failure. Curr Cardiol Rep. 2003; 5(1):32-39.
2. Christian TF, Miller TD, Bailey KR, Gibbons RJ. Exercise tomographic thallium-201 imaging in patients with coronary artery disease and normal electrocardiograms. Ann Intern Med. 1994; 121(11):825-832
3. Ding HJ, Lin CC, Wang JJ, et al. Correlation of abnormal response of left ventricular ejection fraction after exercise and left ventricular cavity-to-myocardium count ratio of Technetium-99m-Tetrofosmin Single Photon Emission Computed Tomography in patients with coronary artery disease. Jpn Heart J. 2002; 43(5):505-514.
4. Hachamovitch R. Risk assessment of patients with known or suspected CAD using stress myocardial perfusion SPECT. Part I: The ongoing evolution of clinical evidence. Rev Cardiovasc Med. 2000; 1(2):91-102.
5. Hachamovitch R, Hayes SW, Friedman, et al. Stress myocardial perfusion single-photon emission computed tomography is clinically effective and cost effective in risk stratification of patients with a high likelihood of coronary artery disease (CAD) but no known CAD. J Am Coll Cardiol. 2004; 43(2):200-208.
6. Mattera JA, Arain SA, Sinusas AJ, et al. Exercise testing with myocardial perfusion imaging in patients with normal baseline electrocardiograms: cost savings with a stepwise diagnostic strategy. J Nucl Cardiol. 1998; 5(5):498-506.
7. Okwuosa T, Williams KA. Coronary artery disease and nuclear imaging in renal failure. J Nucl Cardiol. 2006; 13(2):150-155.
8. Poornima IG, Miller TD, Christian TF, et al. Utility of myocardial perfusion imaging in patients with low-risk treadmill scores. J Am Coll Cardiol. 2004; 43(2):194-199.
9. Schinkel AF, Elhendy A, van Domburg RT, et al. Incremental value of exercise technetium-99m tetrofosmin myocardial perfusion single-photon emission computed tomography for the prediction of cardiac events. Am J Cardiol. 2003; 91(4):408-411.
10. Schouten O, van Kuijk JP, Flu WJ, et al. Long-term outcome of prophylactic coronary revascularization in cardiac high-risk patients undergoing major vascular surgery (from the randomized DECREASE-V Pilot Study). Am J Cardiol. 2009; 103(7):897-901.
11. Shaw LJ, Hendel R, Borges-Neto S, et al. Prognostic value of normal exercise and Adenosine (99m)Tc-tetrofosmin SPECT Imaging: Results from the multicenter registry of 4,728 patients. J Nucl Med. 2003; 44(4):134-139.
12. Stempfle HU, Schmid R, Tausig A, et al. Early detection of myocardial microcirculatory disturbances after primary PTCA in patients with acute myocardial infarction: Coronary blood flow velocity versus sestamibi perfusion imaging. Z Kardiol. 2002; 91(suppl 3):126-131.
13. Tsou SS, Sun SS, Kao A, et al. Exercise and rest technetium-99m-tetrofosmin lung uptake: correlation with left ventricular ejection fraction in patients with coronary artery disease. Jpn Heart J. 2002; 43(5):515-522.
14. Wackers FJ, Young LH, Inzucchi SE, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care. 2004; 27(8):1954-1961.
15. Wagner A, Mahrholdt H, Holly TA, et al. Contrast-enhanced MRI and routine Single Photon Emission Computed Tomography (SPECT) perfusion imaging for detection of sub-endocardial myocardial infarcts: An imaging study. Lancet. 2003; 361(9355):374-379.
16. Young L, Wackers F, Chyun D, 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.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Radiology. ACR Appropriateness Criteria^®, Acute Chest Pain—Low Probability of Coronary Artery Disease. 2008. Available at: http://acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascular
   Imaging/AcuteChestPainNoECGorEnzymeEvidenceofMyocardialIschemiaInfarctionDoc1.aspx. Accessed on January 29, 2009.
2. American College of Radiology. ACR Appropriateness Criteria^®, Chronic Chest Pain—High Probability of Coronary Artery Disease. 2006. Available at: http://acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascular
   Imaging/ChronicChestPainNoEvidenceofMyocardialIschemiaInfarctionUpdateinProgressDoc7.aspx. Accessed on January 29, 2009.
3. American College of Radiology. ACR Appropriateness Criteria^®, Chronic Chest Pain—Low to Intermediate Probability of Coronary Artery Disease. 2008. Available at: http://acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascular
   Imaging/ChronicChestPainSuspectedCardiacOriginUpdateinProgressDoc8.aspx. Accessed on January 29, 2009.
4. American College of Radiology. ACR Appropriateness Criteria^® Suspected Congenital Heart Disease in the Adult. 2007. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascular
   Imaging/SuspectedCongenitalHeartDiseaseintheAdultUpdateinProgressDoc18.aspx. Accessed on January 29, 2009.
5. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50(7):e1–157.
6. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology. J Am Coll Cardiol 2005; 46(8):1587-1605.
7. Fleisher L, Beckman J, Brown K, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol, 2007; 50(17):159-242.
8. Fraker TD, Fihn SD. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the 2002 Guidelines for the Management of Patients with Chronic Stable Angina. J Am Coll Cardiol, 2007; 50(23):2264-2274. Available at: http://content.onlinejacc.org/cgi/content/full/j.jacc.2007.08.002. Accessed on January 29, 2009.
9. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002; 106(14):1883-1892.
10. Klocke FJ, Baird MG, Bateman TM, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Radionuclide Imaging). J Am Coll Cardiol. 2003; 42(7):1318-1333.
11. Mieres J, Shaw L, Arai A, et al. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation. 2005; 111(5):682-696.
12. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/ American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol. 2006; 48(5):247–346. Available at: http://content.onlinejacc.org/cgi/content/full/48/5/e247. Accessed on January 29, 2009.

1. National Heart Lung and Blood Institute. Framingham Heart Study. Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CHD (Myocardial Infarction and Coronary Death). Available at: http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof. Accessed on April 14, 2008.

Angina
Congenital Heart Disease
Coronary Artery Bypass Grafting/Angioplasty
Coronary Artery Disease (CAD)
Dilated Cardiomyopathy
Heart Transplantation
Hypertrophic Cardiomyopathy
Ischemic Chest Pain
Left Ventricular Dysfunction
Myocardial Infarction
Myocardial Perfusion
Myocardial Viability
Myocarditis
Radionuclide Angiography (RNA) Indications
Valvular Heart Disease
Ventricular Arrhythmias 

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Appendix A

Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms*

*No data exist for patients <30 or >69 years, but it can be assumed that prevalence of CAD increases with age. In a few cases, patients with ages at the extremes of the decades listed may have probabilities slightly outside the high or low range. High indicates >90%; intermediate, 10%–90%; low, <10%; and very low, <5%.

From: American College of Cardiology. ACC/AHA 2002 Guideline Update for Exercise Testing: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation. 2002; 106(14):1883-1892.

Appendix B

Duke Treadmill Score (DTS)

DTS = [exercise time (in minutes)] – [5 × ST-segment deviation in millimeters*] – [4 x exercise angina index]

*Note that ST-segment deviation can be measured at 60 to 80 ms after the J point. If the amount of exercise-induced ST-segment deviation is less than 1 mm, the value entered into the score for ST deviation is 0. Exercise time is based on a standard Bruce protocol.

DTS Results:

From: American College of Cardiology. ACC/AHA 2002 Guideline Update for Exercise Testing: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation. 2002; 106(14):1883-1892.