modality advantages limitations and disadvantages ESC guidelines class definitions of high event risk in patients with established chronic CAD
Exercise ECG widely available, does not require intravenous access or radiation exposure, relatively inexpensive, widely validated some patients are unable to exercise, some may have certain baseline ECG abnormalities that make the ECG uninterpretable during stress, certain medications can cause false positive ST changes IIbB cardiovascular mortality >3% per year according to Duke Treadmill Score
CT coronary angiography rich evidence, high accuracy, identification and quantification of calcification and plaque volume usage of iodinated contrast material, exposure to radiation, lacks the ability to predict the functional significance of stenoses IB three-vessel disease with proximal stenoses, LM disease, or proximal anterior descending disease
SPECT or PET perfusion imaging high image quality susceptible to technical and acquisition issues, use of ionizing radiation, dependent on operator expertise, limited availability and a relatively high cost IB area of ischaemia >=10% of the left ventricle myocardium
Stress echocardiography
versatile/patient-friendly, lack of ionizing radiation Inexpensive
dependent on image quality due to body habitus or pulmonary disease, technical challenges, operator dependent
IB
>=3 of 16 segments with stress-induced hypokinesia or akinesia
Stress CMR
high resolution and reproducibility, identification of plaque ulceration and intraplaque hemorrhage
expensive and low availability, complex training required
IB
>=2 of 16 segments with stress perfusion defects or >=3 dobutamine-induced dysfunctional segments