## INTRODUCTION

KEY POINTS

• The initial clinical evaluation of patients with suspected coronary artery disease (CAD) should include assessment of risk factors, age, gender, and symptom presentation.

• Critical decision points for optimal assessment include exercise testing alone or in conjunction with cardiac imaging.

• Pharmacologic testing with imaging should be considered in patients unable to exercise.

• With the growing availability of cardiac positron emission tomography (PET) myocardial perfusion imaging (MPI), the decision between single-photon emission computerized tomography (SPECT) and PET as the imaging choice is important.

• Alternatives to cardiac nuclear MPI should be entertained, considering the recent clinical trials and technological advances.

## BACKGROUND

The worldwide burden of coronary artery disease (CAD) remains substantial. Annually, an estimated 3.8 million of the US population visits the primary care services with symptoms of chest pain.1 Each year, over 660,000 patients in the United States present to hospital with either a first myocardial infarction (MI) or sudden cardiac death (SCD) due to CAD.2 Of these, 305,000 will have had a recurrent MI. An estimated 160,000 will also suffer a silent first MI.2 CAD is the leading cause of deaths across the world and is predicted to remain so for the next 20 years. The number of deaths from CAD is estimated to rise to 22.2 million deaths globally by 2030.3 An estimated $108.9 billion is spent annually on treatment of CAD and is expected to exceed$320 billion by the year 2030.2

The means and methods to detect CAD to reduce the morbidity and mortality associated with CAD remains of great importance to healthcare providers. This requires a systematic approach for early diagnosis and risk stratification of CAD to achieve optimal benefits from the current preventive and therapeutic strategies. The recent reduction in cardiac-related deaths for both male and female patients suggests that current therapies are successful and so identifying “at-risk” patients is critical.

This chapter will discuss the role of nuclear cardiac imaging for both diagnosis and risk stratification of patients with no known but suspected CAD, based upon the most recent guidelines and literature. It will also elucidate the role of nuclear imaging and asymptomatic patients and finally offer guidance as to when alternate imaging or testing may be useful. The focus will be on the following aspects:

• Evaluation of whom to test

• Approach to testing in a symptomatic patient

• Stress options: exercise or pharmacologic

• Imaging options: exercise testing alone, single-photon emission computerized tomographic (SPECT) or positron emission tomographic (PET) imaging

• Alternatives to nuclear imaging

## ASSESSMENT OF THE RISK FOR CAD

To optimize the use of testing for suspected CAD patients, the initial step involves stratifying the likelihood of such a patient having underlying disease. Although a variety of tools are available for this purpose, the evaluation of risk factors and the nature of presenting chest ...

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