Suspected ischemic heart disease (or change in clinical status in a patient with known IHD)

See ACCF/AHA UA/NSTEMI guideline

Intermediate or high-risk UA?

Yes

No

End

Yes

No

Contraindications to stress testing?

Yes

No

Initiate guideline-directed medical therapy (see text)

Initiate guideline-directed medical therapy; consider coronary revascularization to improve survival

Technically adequate?

Yes

No

Patient able to exercise?

Yes

No

MPI or echo w/ exercise

Previous coronary revascularization?

Yes

No

Resting ECG interpretable?

Yes

No

Standard exercise ECG

Standard exercise ECG

MPI or echo w/ exercise or pharm CMR

Low likelihood IHD

Intermediate likelihood IHD

Intermediate to high likelihood IHD

Pharm stress echo

Consider coronary revascularization to improve symptoms

Regular monitoring

Successful treatment?

Yes

No

Yes

No

^* CCTA is reasonable only for patients with intermediate probability of IHD.

Recent exercise or cardiac imaging study

Low likelihood IHD

Intermediate to high likelihood IHD

CCTA, Computed coronary tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; Echo, echocardiography; IHD, ischemic heart disease; MI, myocardial infarction; MPI, myocardial perfusion imaging; Pharm, pharmacologic; UA, unstable angina; UA/NSTEMI, unstable angina/non-ST-elevation myocardial infarction.

Test results suggest high-risk coronary lesion(s)?

Yes

No

Comprehensive clinical assessment of risk, including personal characteristics, coexisting cardiac and medical conditions, and health status

Symptoms or findings suggest high-risk lesion(s)^*
or
Prior sudden death or serious ventricular arrhythmia
or
Prior stent in unprotected left main coronary artery

Recent exercise or cardiac imaging study

Or

CCTA

Initiate guideline-directed medical therapy (see text)

Or

Pharm stress MPI or echo

Pharm CMR or CCTA