Section I: Diagnostic Testing

HPI: Episode of sudden cardiac arrest, palpitations, dyspnea, syncope, fatigue, lightheadedness.

PMH: Cardiac arrest, atrioventricular block, atrial fibrillation, atrial flutter, ventricular tachycardia.

EP = Refer patient for ElectroPhysiological study.

RS = Patient with Recurrent Syncope that remains unexplained after an appropriate evaluation.

SND = Patient with Sinus Node Dysfunction.

S-AVB = Symptomatic (palpitations, dyspnea, syncope, lightheadedness) patients in whom AtrioVentricular Block is suspected.

IVCD = IntraVentricular Conduction Delay in symptomatic (palpitations, dyspnea, syncope, lightheadedness) patients.

NCT = Narrow Complex Tachycardia.

WCT = Wide Complex Tachycardia.

SRCA = SuRvivor of Cardiac Arrest without obvious reversible cause.

C-ABL = Patients with symptomatic supraventricular tachycardia due to AVNRT, symptomatic atrial tachyarrhythmias, or ventricular tachycardia amenable to Catheter ABLation.

RS = EP

SND = EP

S-AVB = EP

IVCD = EP

NCT = EP

WCT = EP

SRCA = EP

C-ABL = EP

• – The most common arrhythmia found by EPS studies is ventricular tachycardia, and the most powerful predictor is an ejection fraction of < 40%.

1. Tracy CM, et al. American College of Cardiology/American Heart Association Clinical Competence Statement on Invasive Electrophysiology Studies, Catheter Ablation, and Cardioversion. Circulation. 2000;102:2309.

CAD = Coronary Artery Disease. Patients with intermediate pretest probability of CAD based on age, sex, and symptoms.

RA = Risk Assessment and prognosis of symptomatic patients of those with CAD. Initial evaluation for CAD, changes in clinical status, unstable angina free of symptoms.

POST-MI = Testing after Myocardial Infarction. Prognostic assessment before discharge/evaluation of medical therapy, activity prescription, and rehabilitation.

CARDIO = CARDIOpulmonary exercise testing. Evaluation of exercise capacity and response to therapy and to differentiate in cardiac vs. pulmonary limitations of capacity.

REVASC = Before and after REVASCularization. Demonstrate proof of ischemia before revascularization and evaluation of recurrent symptoms to suggest ischemia after revascularization.

ST = Refer patient for Stress Test.

CAD = ST

RA = ST

POST-MI = ST

CARDIO = ST

REVASC = ST

Stress testing is used to assess the probability and extent of coronary disease by evoking inducible ischemia and ultimately aids in therapy strategies.

Sensitivity is 60–70%, and specificity is 60–80%.

Patients with possible CAD and symptoms of ischemia should have stress testing to assess the probability of a cardiac event. There are no indications for routine testing in asymptomatic patients without CAD or risk factors, valvular heart disease. Patients at extremely low risk for coronary artery disease should not be referred for stress testing. Due to the very low pre-test probability, a false-positive is more likely than a true-positive, which will then prompt further (often invasive) testing and subject the patient to potential unessessary harm.

Contraindications:

Absolute—Active myocardial infarction, unstable angina, uncontrolled arrhythmias, severe symptomatic aortic stenosis, aortic dissection, decompensated heart failure, pulmonary embolism, myopericarditis.

Relative—Left main disease, stenotic valvular diseases, electrolyte imbalances, HTN > 200 mm Hg, HOCM, AV blocks,

1. Fraker TD Jr, et al. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007;116:2762.

2. Lee TH, et al. Noninvasive tests in patients with stable coronary artery disease. N Engl J Med. 2001;344:1840.

Patient presents with chest pain, arrhythmias, and acute coronary syndrome, or for evaluation and risk stratification.

PM Hx/PSx Hx: Hypertension, aortic dissection, kidney failure, cirrhosis, congenital heart diseases, HOCM, previous MI, history of CAD.

MPI = Refer patient for Myocardial Perfusion Imaging.

EVAL = EVALuation of chest pain/acute chest pain/new heart failure: Intermediate/high pretest for CAD in patients unable to exercise or uninterpretable ECG for patients with no ST elevation and negative cardiac enzymes.

DETECT = DETECTion of CAD: moderate CHD risk (Framingham), patients with no prior CAD evaluation and no planned cardiac catheterization.

RISK-ASS = RISK ASSessment: for airline pilots, high CHD risk (Framingham), known CAD on cardiac catheterization or prior SPECT in patients who have not been revascularized or patients with worsening symptoms, or >2 years from last study to evaluate for worsening disease, Agatston score >400, stenosis of unclear significance, intermediate Duke treadmill score, intermediate perioperative risk predictor or poor exercise tolerance (<4 METS) for high and intermediate risk surgery, thrombolytic therapy administered but not planning to undergo catheterization in patients with hemodynamically stable STEMI or patients with NSTEMI not planning to undergo early catheterization, evaluation of chest pain post-revascularzation, >5 years post-revascularization.

ISCH-VIAB = Assessment of VIABility/ISCHemia: known CAD on catheterization, patient eligibly for catheterization.

LVFUNC = Assessment of Ventricular FUNCtion: nondiagnostic echo, baseline and serial measurements when using cardiotoxic therapies (doxorubicin).

EVAL = MPI

DETECT = MPI

RISK-ASS = MPI

ISCH-VIAB = MPI

LVFUNC = MPI

Sensitivity is 85%, and specificity is 72% for detecting ischemia.

If an area of myocardium shows an unchanged diminished tracer even after injection at rest, the defect most likely represents scar or viable, underperfused myocardium.

Medications such as calcium channel–blocking drugs and beta-blocking drugs that may alter the heart rate and blood pressure response to exercise should be withheld if possible prior to the MPI test.

Negative consequences include risk of procedure from radiation or contrast exposure and poor test performance.

Contraindications to testing are unstable angina, acute myocardial infarction (MI) within 2–4 days of testing, uncontrolled systemic hypertension, untreated life-threatening arrhythmias, uncompensated congestive heart failure, advanced atrioventricular block acute myocarditis, acute pericarditis, severe mitral or aortic stenosis, severe obstructive cardiomyopathy, and acute systemic illness.

1. ACCF/ASNC Appropriateness Criteria for Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging. J Am Coll Cardiol. 2005;46:1587–1605.

2. Ritchie J, Bateman TM, Bonow RO, et al. Guidelines for clinical use of cardiac radionuclide imaging. A report of the AHA/ACC Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures. Committee on Radionuclide Imaging, developed in collaboration with the American Society of Nuclear Cardiology. Circulation. 1995;91:1278–1303.

3. Schlant RC, Friesinger GC, Leonard JJ. Clinical competence in exercise testing. A statement for physicians from the ACP/ACC/AHA Task Force on Clinical Privileges in Cardiology. J Am Coll Cardiol. 1990;16:1061–1065.

4. Updated imaging guidelines for nuclear cardiology procedures, part 1. J Nucl Cardiol. 2001;8(1):G5–G58.

HPI: Patient with chest pain or evidence of myocardial ischemia.

PMH: Coronary artery disease (CAD), congestive heart failure (CHF), myocardial infarction (MI), congenital heart disease (CHD), angina.

PSH: Percutaneous coronary intervention (PCI), valve repair.

CA = Refer for Coronary Angiography with possible intervention.

SAML = Stable Angina but with Marked Limitation of physical activity, ie, cannot walk 2 blocks or 1 flight of stairs without chest discomfort.

UA = Unstable Angina refractory to medical therapy or with recurrent symptoms after initial stabilization, chest pain > 20 minutes, ST changes (> =1 mm), pathological q waves, pulmonary edema, or age > 65.

RVS = Acute stent closure within 24 hours of PCR and/or recurrent angina or HR within 9 months of PCR.

AMI1 = Patient within 12 hours of onset of symptoms of ST elevation MI or beyond 12 hours if ischemic symptoms persist, where CA can be performed in a timely fashion (door to catheterization time < 90 minutes).

AMI2 = Patients < 75 years within 36 hours of a STEMI, who develops cardiogenic shock and can be revascularized within 18 hours of the onset of shock.

AMI3 = Persistent episodes of symptomatic ischemia with or without ECG changes; myocardial ischemia provoked by minimal exertion during recovery from MI; or ischemia at low levels of exercise with ECG changes (STD > = 1 mm) or imaging abnormalities.

AMI = AMI1, AMI2, or AMI3.

CHFI = CHF due to systolic dysfunction with angina, regional wall motion abnormalities, or evidence of myocardial ischemia when revascularization is being considered.

VLV = Prior to valve repair in patients with chest discomfort, ischemia by noninvasive imaging, multiple risk factors for CAD, or infective endocarditis with coronary embolism.

CHDI = Prior to correction of CHD in patients with chest discomfort or evidence of CAD; unexplained cardiac arrest in young patients; or prior to correction of coronary anomaly (congenital coronary stenosis, arteriovenous fistula).

SAML = CA

UA = CA

RVS = CA

AMI = CA

VLV = CA

CHFI = CA

CHDI = CA

• – Patients at risk for renal failure from contrast should be hydrated with IV .45 saline at 75 cc/hour prior to undergoing coronary angiography.

• – The risk of death, myocardial infarction, or other major embolization during coronary angiography is < 2%.

1. Scanlon P, et al. ACC/AHA guidelines for coronary angiography. J Am Coll Cardiol. 1999;33:1756–1824.

HPI: Patient with chest pain, arrhythmia, murmur, dyspnea, or baseline cardiac function evaluation.

PMH: Hypertension (HTN), coronary artery disease (CAD), myocardial infarction (MI), congestive heart failure (CHF), valvular disease, congenital heart disease (CHD), cardiomyopathy.

SH: Alcohol, smoking.

FH: Marfans disease, hypertrophic cardiomyopathy (HCM).

TTE = TransThoracic Echocardiogram.

TEE = TransEsophageal Echocardiogram.

STE = STress Echocardiogram.

GSAF = General Structure And Function = symptoms due to cardiac etiology, suspected coronary artery disease, suspected congenital heart disease, sustained or nonsustained supraventricular or ventricular tachycardia, LV function following MI, pulmonary HTN.

ACUTE = ACUTE setting = hemodynamic instability, evaluation of chest pain with nondiagnostic ECG or labs, respiratory failure with suspected cardiac etiology, complications from MI, known/suspected pulmonary embolus to guide therapy.

VALV = VALVular function = evaluation of a murmur with suspicion of valvular disease, yearly follow-up of valvular disease, valvular disease with change in clinical status, prosthetic valves, infective endocarditis.

AORT = AORTic disease = Marfans disease, evaluation of proximal aortic root.

HD = Heart Disease = evaluation of hypertensive heart disease, initial and routine evaluation of CHF and HCM, evaluation of suspected cardiomyopathy, screening for inherited cardiomyopathy, baseline and serial evaluation for therapy with cardiotoxic agents.

IE = Suspected Infective Endocarditis or its complication, persistent fever with intracardiac device with suspicion of infective endocarditis,

GUIDE = To GUIDE during cardiac intervention.

CVERS = Prior to CardioVERSion in atrial fibrillation/flutter and/or follow-up after anticoagulation.

REPAIR = Suitability of valve REPAIR.

AC-AORT = Further investigation of ACute AORTic pathology.

PHTN = Pulmonary HyperTensioN.

DYSP = DYSPnea suspected due to cardiac etiology.

RISK = RISK stratification in coronary artery disease.

GSAF/ACUTE/VALV/AORT/HD = TTE

IE/GUIDE/CVERS/REPAIR/AC-AORT = TEE

PHTN/DYSP/RISK = STE

TEE provides enhanced views of atria, mitral valve, great vessels, and prosthetic valves.

TEE has shown to have higher sensitivity for detection of endocarditis compared to TTE.

1. Douglas PS, et al. ACCF/ASE/ASNC/SCAI/SCCT/SCMR 2007 Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography. J Am Coll Cardiol. 2007;50:187.

HPI: Patient with syncope, palpitations, fatigue, dyspnea, decreased exercise tolerance.

PMH: Coronary artery disease, myocardial infarction (MI), sinus node disease, arrhythmias.

FH: Congenital heart disease, congenital long QT.

SH: Alcohol, smoking.

SYMP = SYMPtomatic patient – syncope, fatigue, lightheadedness, decreased exercise intolerance, palpitations.

ASYM = ASYMptomatic = no symptoms.

BC = BradyCardia (heart rate < 60 bpm).

PACE = Refer patient for permanent PACEmaker placement.

NOT-PACE = Do NOT refer for PACEmaker.

SND = Sinus Node Dysfunction.

ABBB = Alternating Bundle Branch Block.

CSH = Carotid Sinus Hypersensitivity.

NCS = NeuroCardiogenic Syncope.

PAVB = Persistent second or third degree AV Block.

RSVT = Recurrent SupraVentricular Tachycardia that fails with drugs or ablation.

RBBB = Right Bundle Branch Block.

PRR = Prolonged RR intervals.

2DMB = 2nd Degree Mobitz type 1 Block.

LAD = Left Axis Deviation.

RAVB = Reversible AV Blocks (sleep apnea, Lyme disease, vagal tone, drugs).

SND + SYMP + BC = PACE

SYMP + PAVB = PACE

ABBB = PACE

CSH + BC = PACE

NCS + BC = PACE

RSVT = PACE

ASYM + SND = NOT-PACE

ASYM + BC = NOT-PACE

ASYM + 2DMB = NOT-PACE

ASYM + PRR = NOT-PACE

ASYM + RBBB + LAD = NOT-PACE

RAVB = NOT-PACE

1. Epstein AE, et al. ACC/AHA/HRS Guidelines for Device-Based Therapy. Circulation. 2008;117:e350–e408.

HPI: Syncope, palpitations, fatigue, dyspnea, decreased exercise tolerance.

PMH: Cardiac arrest, ventricular tachycardia, congestive heart failure, coronary artery disease.

ICD = Refer patient for placement of Implantable-Cardioverter-Defibrillator.

SCA = Survivors of Cardiac Arrest due to ventricular fibrillation or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes.

SHD = Patients with Structural Heart Disease and spontaneous sustained VT, whether hemodynamically stable or unstable.

SYNC = Patients with SYNCope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or ventricular fibrillation induced at electrophysiological study.

PRMI-EF35 = Patients with LVEF < 35% due to PRior Myocardial Infarction who are at least 40 days post-myocardial infarction and are in NYHA functional Class II or III.

NIDC = Patients with NonIschemic Dilated Cardiomyopathy who have an LVEF ≤ 35% and who are in NYHA functional Class II or III.

LVDF = Patients with LV DysFunction due to prior myocardial infarction who are at least 40 days post-myocardial infarction, have an LVEF < 30%, and are in NYHA functional Class I.

NSVT-PRMI = Patients with NonSustained VT due to PRior Myocardial Infarction, LVEF < 40%, and inducible ventricular fibrillation or sustained VT at electrophysiological study.

SCA = ICD

SHD = ICD

SYNC = ICD

PRMI-EF35 = ICD

NIDC = ICD

LVDF = ICD

NSVT-PRMI = ICD

1. Epstein, et al. ACC/AHA/HRS 2008 Guidelines for Device Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. 2008;51:2085–2105.

2. 2) Dimarco JP. Implantable cardioverter-defibrillators. N Engl J Med. 2003; 349:1836–1847.

HPI: Patient undergoing CCT for cardiac evaluation.

PMH: Coronary artery disease, heart failure, adult congenital heart disease.

PSH: Coronary artery bypass graft (CABG), prosthetic valve placement.

CCT = Refer patient for Cardiac Computed Tomography.

SYMP-CP = SYMPtoms of Chest Pain, chest tightness, dyspnea, diminished exercise capacity + concern clinically.

ASYMP = ASYMPtomatic.

N-EXER = Normal EXERcise ECG stress test.

P-STR = Positive STRess imaging test.

N-STR = Normal STRess imaging test.

NOHF = New Onset Heart Failure with LV systolic dysfunction.

CCS = Coronary Calcium Agatston Score >100.

G-PAT = Evaluation of Graft PATency after CABG.

ANOM = Assessment of ANOMalies of coronary arterial and other thoracic arteriovenous vessels.

CHD = Assessment of complex adult Congenital Heart Disease.

VALVE = Evaluation of native and prosthetic cardiac VALVEs if clinically suspect significant valvular dysfunction.

MASS = Evaluation of suspected cardiac MASS (tumor or thrombus).

ABL = Prior to radiofrequency ABLation for atrial fibrillation.

REOP = Patient undergoing REOPerative chest or cardiac surgery.

SYMP = CCT

N-EXER + SYMP-CP = CCT

N-STR + SYMP-CP = CCT

P-STR = CCT

NOHF = CCT

CCS = CCT

G-PAT = CCT

REOP = CCT

ANOM = CCT

CHD = CCT

VALVE = CCT

MASS = CCT

ABL = CCT

1. Hendel RC, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging. Circulation. 2009;119:e561–e587.