Definitions for the weight of the evidence (A-C) and classes of recommendations (I-III) can be found at the end of the "Major Recommendations" field.
Abbreviations: ACS, acute coronary syndrome; CABG, coronary artery bypass graft surgery; CAD, coronary artery disease; CCS, coronary calcium score; CT, computed tomography; ECG, electrocardiogram; FDG, flurodeoxyglucose; FPRNA, first pass radionuclide angiography; LBBB, left bundle-branch block; LV, left ventricular or left ventricle; LVH, left ventricular hypertrophy; MPHR, maximal-predicted heart rate; MPI, myocardial perfusion imaging; PCI, percutaneous coronary intervention; PET, positron emission tomography; RNA, radionuclide angiogram; RV, right ventricular or right ventricle; SPECT, single-photon emission computed tomography; STEMI, ST-segment elevation myocardial infarction; Tc-99m, technetium-99m; Tl-201, thallium-201
Recommendations for Emergency Department Imaging for Suspected Acute Coronary Syndromes (ACS)
Indication |
Test |
Class |
Level of Evidence |
1. Assessment of myocardial risk in possible ACS patients with nondiagnostic ECG and initial serum markers and enzymes, if available. |
Rest MPI |
I |
A |
2. Diagnosis of CAD in possible ACS patients with chest pain with nondiagnostic ECG and negative serum markers and enzymes or normal resting scan. |
Same day rest/stress perfusion imaging |
I |
B |
3. Routine imaging of patients with myocardial ischemia/necrosis already documented clinically, by ECG and/or serum markers or enzymes |
Rest MPI |
III |
C |
Abbreviations: ACS, acute coronary syndromes; CAD, coronary artery disease; ECG, electrocardiogram; MPI, myocardial perfusion imaging
Recommendations for Use of Radionuclide Testing in Diagnosis, Risk Assessment, Prognosis, and Assessment of Therapy After Acute ST-Segment Elevation Myocardial Infarction (STEMI)
Patient Subgroup(s) |
Indication |
Test |
Class |
Level of Evidence |
All |
1. Rest LV function |
Rest RNA or EGC-gated SPECT |
I |
B |
Thrombolytic therapy without catheterization |
2. Detection of inducible ischemia and myocardium at risk |
Stress MPI with ECG-gated SPECT whenever possible |
I |
B |
Acute STEMI |
3. Assessment of infarct size and residual viable myocardium |
MPI at rest or with stress using gated SPECT |
I |
B |
4. Assessment of RV function with suspected RV infarction |
Equilibrium or FPRNA |
IIa |
B |
Abbreviations: ECG, electrocardiography; FPRNA, first-pass radionuclide angiography; LV, left ventricular; MPI, myocardial perfusion imaging; RNA, radionuclide angiography; RV, right ventricular; SPECT, single-photon emission computed tomography; STEMI, ST-segment elevation myocardial infarction
Recommendations for Use of Radionuclide Testing for Risk Assessment/Prognosis in Patients With Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA)
Indication |
Test |
Class |
Level of Evidence |
1. Identification of inducible ischemia in the distribution of the "culprit lesion" or in remote areas in patients at intermediate or low risk for major adverse cardiac events. |
Stress MPI with ECG gating whenever possible |
I |
B |
2. Identification of the severity/extent of inducible ischemia in patients whose angina is satisfactorily stabilized with medical therapy or in whom diagnosis is uncertain. |
Stress MPI with ECG gating whenever possible |
I |
A |
3. Identification of hemodynamic significance of coronary stenosis after coronary arteriography. |
Stress MPI |
I |
B |
4. Measurement of baseline LV function. |
RNA or gated SPECT |
I |
B |
5. Identification of the severity/extent of disease in patients with ongoing suspected ischemia symptoms when ECG changes are nondiagnostic. |
Rest MPI |
IIa |
B |
Abbreviations: ECG, electrocardiography; LV, left ventricular; MPI, myocardial perfusion imaging; RNA, radionuclide angiography; SPECT, single-photon emission computed tomography
Cardiac Stress Myocardial Perfusion Single-Photon Emission Computed Tomography (SPECT) in Patients Able to Exercise
Recommendations for Diagnosis of Patients With an Intermediate Likelihood of Coronary Artery Disease (CAD) and/or Risk Stratification of Patients With an Intermediate or High Likelihood of CAD Who Are Able to Exercise (to at least 85% of Maximal Predicted Heart Rate)
Class I
- Exercise myocardial perfusion SPECT to identify the extent, severity, and location of ischemia in patients who do not have left bundle-branch block (LBBB) or an electronically-paced ventricular rhythm but do have a baseline electrocardiogram (ECG) abnormality that interferes with the interpretation of exercise-induced ST-segment changes (ventricular pre-excitation, left ventricular hypertrophy [LVH], digoxin therapy, or more than 1-mm ST depression) (Level of Evidence: B)
- Adenosine or dipyridamole myocardial perfusion SPECT in patients with LBBB or electronically-paced ventricular rhythm (Level of Evidence: B)
- Exercise myocardial perfusion SPECT to assess the functional significance of intermediate (25 to 75%) coronary lesions (Level of Evidence: B)
- Exercise myocardial perfusion SPECT in patients with intermediate Duke treadmill score (Level of Evidence: B)
- Repeat exercise myocardial perfusion imaging after initial perfusion imaging in patients whose symptoms have changed to redefine the risk for cardiac event (Level of Evidence: C)
Class IIa
- Exercise myocardial perfusion SPECT at 3 to 5 years after revascularization (either percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]) in selected high-risk asymptomatic patients (Level of Evidence: B)
- Exercise myocardial perfusion SPECT as the initial test in patients who are considered to be at high risk (patients with diabetes or patients otherwise defined as having a more than 20% 10-year risk of a coronary heart disease event) (Level of Evidence: B)
Class IIb
- Repeat exercise myocardial perfusion SPECT 1 to 3 years after initial perfusion imaging in patients with known or a high likelihood of CAD and stable symptoms and a predicted annual mortality of more than 1% to redefine the risk of a cardiac event (Level of Evidence: C)
- Repeat exercise myocardial perfusion SPECT on cardiac active medications after initial abnormal perfusion imaging to assess the efficacy of medical therapy (Level of Evidence: C)
- Exercise myocardial perfusion SPECT in symptomatic or asymptomatic patients who have severe coronary calcification (computed tomography [CT] coronary calcium score more than the 75th percentile for age and sex) in the presence on the resting ECG of pre-excitation [Wolff-Parkinson-White syndrome] or more than 1 mm ST-segment depression (Level of Evidence: B)
- Exercise myocardial perfusion SPECT in asymptomatic patients who have a high-risk occupation. (Level of Evidence: B)
Cardiac Stress Myocardial Perfusion SPECT in Patients Unable to Exercise
Recommendations for Diagnosis of Patients With an Intermediate Likelihood of CAD and/or Risk Stratification of Patients With an Intermediate or High Likelihood of CAD Who Are Unable to Exercise.
Class I
- Adenosine or dipyridamole myocardial perfusion SPECT to identify the extent, severity, and location of ischemia. (Level of Evidence: B)
- Adenosine or dipyridamole myocardial perfusion SPECT to assess the functional significance of intermediate (25 to 75%) coronary lesions (Level of Evidence: B)
- Adenosine or dipyridamole myocardial perfusion SPECT after initial perfusion imaging in patients whose symptoms have changed to redefine the risk for cardiac event (Level of Evidence: C)
Class IIa
- Adenosine or dipyridamole myocardial perfusion SPECT at 3 to 5 years after revascularization (either PCI or CABG) in selected high-risk asymptomatic patients (Level of Evidence: B)
- Adenosine or dipyridamole myocardial perfusion SPECT as the initial test in patients who are considered to be at high risk (patients with diabetes or patients otherwise defined as having a more than 20% 10-year risk of a coronary heart disease event). (Level of Evidence: B)
- Dobutamine myocardial perfusion SPECT in patients who have a contraindication to adenosine or dipyridamole (Level of Evidence: C)
Class IIb
- Repeat adenosine or dipyridamole myocardial perfusion imaging 1 to 3 years after initial perfusion imaging in patients with known or a high likelihood of CAD and stable symptoms, and a predicted annual mortality of more than 1%, to redefine the risk of a cardiac event (Level of Evidence: C)
- Repeat adenosine or dipyridamole myocardial perfusion SPECT on cardiac active medications after initial abnormal perfusion imaging to assess the efficacy of medical therapy (Level of Evidence: C)
- Adenosine or dipyridamole myocardial perfusion SPECT in symptomatic or asymptomatic patients who have severe coronary calcification (CT Coronary Calcium Score more than the 75th percentile for age and sex) in the presence on the resting ECG of LBBB or an electronically-paced ventricular rhythm (Level of Evidence: B)
- Adenosine or dipyridamole myocardial perfusion SPECT in asymptomatic patients who have a high-risk occupation (Level of Evidence: C)
Cardiac Stress Myocardial Perfusion Positron Emission Tomography (PET)
Recommendations for Diagnosis of Patients With an Intermediate Likelihood of CAD and/or Risk Stratification of Patients With an Intermediate or High Likelihood of CAD
Class I
- Adenosine or dipyridamole myocardial perfusion PET in patients in whom an appropriately indicated myocardial perfusion SPECT study has been found to be equivocal for diagnostic or risk stratification purposes (Level of Evidence: B)
Class IIa
- Adenosine or dipyridamole myocardial perfusion PET to identify the extent, severity, and location of ischemia as the initial diagnostic test in patients who are unable to exercise (Level of Evidence: B)
- Adenosine or dipyridamole myocardial perfusion PET to identify the extent, severity, and location of ischemia as the initial diagnostic test in patients who are able to exercise but have LBBB or an electronically-paced rhythm (Level of Evidence: B)
Cardiac Stress Perfusion Imaging Before Noncardiac Surgery
Recommendations
Class I
- Initial diagnosis of CAD in patients with intermediate pretest probability of disease and abnormal baseline ECG* or inability to exercise (Level of Evidence: B)
- Prognostic assessment of patients undergoing initial evaluation for suspected or proven CAD with abnormal baseline ECG* or inability to exercise (Level of Evidence: B)
- Evaluation of patients following a change in clinical status (e.g., acute coronary syndrome [ACS]) with abnormal baseline ECG* or inability to exercise (Level of Evidence: B)
- Initial diagnosis of CAD in patients with LBBB and intermediate pretest probability of disease, when used in conjunction with vasodilator stress (Level of Evidence: B)
- Prognostic assessment of patients with LBBB undergoing initial evaluation for suspected or proven CAD, when used in conjunction with vasodilator stress (Level of Evidence: B)
- Assessment of patients with intermediate or minor clinical risk predictors** and poor functional capacity (less than 4 metabolic equivalent [METS]) who require high-risk noncardiac surgery***, when used in conjunction with pharmacologic stress (Level of Evidence: C)
- Assessment of patients with intermediate clinical risk predictors**, abnormal baseline ECGs*, and moderate or excellent functional capacity (more than 4 METS) who require high-risk noncardiac surgery (Level of Evidence: C)
*Baseline ECG abnormalities that interfere with interpretation of exercise-induced ST-segment changes include LBBB, ventricular pre-excitation, ventricular pacing, LVH with repolarization changes, more than 1-mm ST depression, and digoxin therapy.
**As defined in the ACC/AHA Guideline Update for Perioperatiave Cardiovascular Evaluation for Noncardiac Surgery, intermediate clinical risk predictors include mild angina, prior myocardial infarction (MI), compensated or prior heart failure, diabetes, and renal insufficiency. Minor clinical risk predictors include advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of cerebrovascular accident, and uncontrolled hypertension.
***High-risk surgery is defined by emergent operations (particularly in the elderly), aortic and other major vascular surgery, peripheral vascular surgery, and other prolonged operations in which major fluid shifts are anticipated (i.e., reported cardiac risk often more than 5%).
Class IIb
- Routine assessment of active, asymptomatic patients who have remained stable for up to 5 years after CABG surgery (Level of Evidence: C)
- Routine evaluation of active asymptomatic patients who have remained stable for up to 2 years after previous abnormal coronary angiography or noninvasive assessment of myocardial perfusion (Level of Evidence: C)
- Diagnosis of restenosis and regional ischemia in active asymptomatic patients within weeks to months after PCI (Level of Evidence: C)
- Initial diagnosis or prognostic assessment of CAD in patients with right bundle-branch block or less than 1-mm ST depression on resting ECG (Level of Evidence: C)
Class III
- Routine screening of asymptomatic men or women with low pretest likelihood of CAD (Level of Evidence: C)
- Evaluation of patients with severe comorbidities that limit life expectancy or candidacy for myocardial revascularization (Level of Evidence: C)
- Initial diagnosis or prognostic assessment of CAD in patients who require emergency noncardiac surgery (Level of Evidence: C)
Recommendations for Use of Radionuclide Imaging in Patients With Heart Failure: Fundamental Assessment
Indication |
Test |
Class |
Level of Evidence |
1. Initial assessment of LV and RV function at rest* |
Rest RNA |
I |
A |
2. Assessment of myocardial viability for consideration of revascularization in patients with CAD and LV systolic dysfunction who do not have angina |
MPI (see Table 5), PET |
I |
B |
3. Assessment of the copresence of CAD in patients without angina |
MPI |
IIa |
B |
4. Routine serial assessment of LV and RV function at rest |
Rest RNA |
IIb |
B |
5. Initial or serial assessment of ventricular function with exercise |
Exercise RNA |
IIb |
B |
*National consensus treatment guidelines are directed by quantitative assessment of LVEF and identification of LVEF less than or equal to 40%.
Abbreviations: CAD, coronary artery disease; LV, left ventricular; MPI, myocardial perfusion imaging; PET, positron emission tomography; RNA, radionuclide angiography
Recommendations for the Use of Radionuclide Techniques to Assess Myocardial Viability
Indication |
Test |
Class |
Level of Evidence |
1. Predicting improvement in regional and global LV function after revascularization |
Stress/redistribution/reinjection 201TI |
I |
B |
Rest-redistribution imaging |
I |
B |
Perfusion plus PET FDG imaging |
I |
B |
Resting sestamibi imaging |
I |
B |
Gated SPECT sestamibi imaging |
IIa |
B |
Late 201Tl redistribution imaging (after stress) |
IIb |
B |
Dobutamine RNA |
IIb |
C |
Postexercise RNA |
IIb |
C |
Postnitroglycerin RNA |
IIb |
C |
2. Predicting improvement in heart failure symptoms after revascularization. |
Perfusion plus PET FDG imaging |
IIa |
B |
3. Predicting improvement in natural history after revascularization |
201TI imaging (rest-redistribution and stress/redistribution/reinjection) |
I |
B |
Perfusion plus PET FDG imaging |
Ia |
B |
Abbreviations: FDG, flurodeoxyglucose; PET, positron emission tomography; RNA, radionuclide angiography; SPECT, single-photon emission computed tomography; 201Tl, thallium-201
Recommendations for the Use of Radionuclide Imaging to Diagnose Specific Causes of Dilated Cardiomyopathy
Indication |
Test |
Class |
Level of Evidence |
1. Baseline and serial monitoring of LV function during therapy with cardiotoxic drugs (e.g., doxorubicin) |
Rest RNA |
I |
A |
2. RV dysplasia |
Rest RNA |
IIa |
B |
3. Assessment of posttransplant obstructive CAD |
Exercise perfusion imaging |
IIb |
B |
4. Diagnosis and serial monitoring of Chagas disease |
Exercise perfusion imaging |
IIb |
B |
5. Diagnosis of amyloid heart disease |
99mTc-pyrophosphate imaging |
IIb |
B |
6. Diagnosis and serial monitoring of sarcoid heart disease |
Rest perfusion imaging |
IIb |
B |
Rest 67Ga imaging |
IIb |
B |
7. Detection of myocarditis |
Rest 67Ga imaging |
IIb |
B |
111In antimyosin antibody imaging |
IIb |
C |
Abbreviations: 67Ga, gallium-67; 99mTc-pyrophosphate, Tc-99m-pyrophosphate; 111In, indium-111; CAD, coronary artery disease; LV, left ventricular; RNA, radionuclide angiography; RV, right ventricular
Recommendations for the Use of Radionuclide Imaging to Evaluate Hypertrophic Heart Disease
Indication |
Test |
Class |
Level of Evidence |
1. Diagnosis of CAD in hypertrophic cardiomyopathy |
Rest and exercise perfusion imaging |
IIb |
B |
2. Diagnosis and serial monitoring of hypertensive hypertrophic heart disease |
Rest RNA |
IIb |
B |
3. Diagnosis and serial monitoring of hypertrophic cardiomyopathy, with and without outflow obstruction |
Rest RNA |
III |
B |
Abbreviations: CAD, coronary artery disease; RNA, radionuclide angiography
Recommendations for the Use of Radionuclide Imaging in Valvular Heart Disease
Indication |
Test |
Class |
Level of Evidence |
1. Initial and serial assessment of LV and RV function |
Rest RNA |
I |
B |
2. Initial and serial assessment of LV function |
Exercise RNA |
IIb |
B |
3. Assessment of the copresence of coronary disease |
MPI |
IIb |
B |
Abbreviations: LV, left ventricular; RNA, radionuclide imaging angiography; RV, right ventricular; MPI, myocardial perfusion imaging
Recommendations for the Use of Radionuclide Imaging in Adults with Congenital Heart Disease
Indication |
Test |
Class |
Level of Evidence |
1. Initial and serial assessment of LV and RV function |
Rest RNA |
I |
B |
2. Shunt detection and quantification |
FPRNA |
IIa |
B |
Abbreviations: FPRNA, first-pass radionuclide angiography; LV, left ventricular; RV, right ventricular; RNA, radionuclide angiography
Definitions:
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective
Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment
Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy
Class IIb: Usefulness/efficacy is less well established by evidence/opinion
Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful
Strength of Evidence
- Data derived from multiple randomized clinical trials
- Data derived from a single randomized trial, or from nonrandomized trials
- Consensus opinion of experts