Diagnostic Flowcharts

Abstract

In patients with known or suspected coronary artery disease, diagnosis and risk stratification can be aided by noninvasive tests for myocardial ischemia. Guidelines for choosing among the different stress testing approaches have been published [1–5], but the use of these tests by physicians varies widely — according to diagnostic yields, costs, and convenience. Some general principles should be considered. First, no single test or strategy has been proven to be overall superior [5]. Second, all published research consistently demonstrates that stress testing with radionuclide scintigraphy and echocardiography provides more information than exercise electrocardiography alone [1–4]. However, the fact that a test provides more information does not mean that it is the most appropriate test. Other important issues are whether the additional information is sufficient to change patient care in ways that would be expected to improve outcomes [5]. Third, regardless of which test is used, a normal test result should never be considered a guarantee that the patient does not have coronary artery disease or has no risk of cardiovascular events [3]. The rational diagnostic approach can be divided into four successive steps, progressing from the clinical picture to exercise electrocardiography, then to the imaging stress test. In highly selected cases, testing for coronary vasospasm can be considered.