GENERAL INFORMATION

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided.  If applicable: All prior relevant imaging results, and the reason that alternative imaging cannot be performed, must be included in the documentation submitted.
• Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.

Policy
This guideline is for stress imaging, specifically myocardial perfusion imaging (MPI), with appropriate preference for suitable alternatives, such as stress echocardiography (SE), when more suitable, unless otherwise stated (refer to Overview). 

INDICATIONS for MPI^1-4

• SUSPECTED CORONARY ARTERY DISEASE (CAD)
• Symptomatic patients without known CAD (use Diamond Forrester Table)
  • Low or intermediate pretest probability and unable to exercise (SE diversion not required)
  • High pretest probability (SE diversion not required)
  • Repeat testing in a patient with new or worsening symptoms and negative result at least one year prior AND meets one of the criteria above
• Asymptomatic patients without known CAD (SE diversion not required)
  • Previously unevaluated ECG evidence of possible myocardial ischemia including ischemic ST segment or T wave abnormalities (see Overview section)
  • Previously unevaluated pathologic Q waves (see Overview section)
  • Previously unevaluated complete left bundle branch block

ABNORMAL CALCIUM SCORES (CAC)^4-8

• ASYMPTOMATIC patient with a calcium score > 400, not previously evaluated
• SYMPTOMATIC patient with prior CAC ≥ 100

INCONCLUSIVE CAD EVALUATION AND OBSTRUCTIVE CAD REMAINS A CONCERN

• Exercise stress ECG with low-risk Duke treadmill score (≥5), (see section in Overview) but patient’s current symptoms indicate an intermediate or high pretest probability (SE diversion not required for high pretest probability)
• Exercise stress ECG with an intermediate Duke treadmill score (SE diversion not required for symptoms consistent with high pretest probability)
• Intermediate coronary computed tomography angiography (CCTA) (e.g., 40 - 70% lesions)
• Non-diagnostic exercise stress test with inability to achieve target heart rate (THR) (SE diversion not required)
• An indeterminate (equivocal, borderline, or discordant) evaluation by prior stress imaging (SE or CMR) (SE diversion not required)
• Coronary stenosis of unclear significance on previous coronary angiography⁴

FOLLOW-UP OF PATIENT’S POST CORONARY REVASCULARIZATION (PCI or CABG)⁴

• Asymptomatic follow-up stress imaging at a minimum of 2 years post coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (whichever is later) is appropriate for patients with a history of silent ischemia or a history of a prior left main stent.4 (SE diversion not required for CABG) 

OR

For patients with high occupational risk, associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers and firefighters (SE diversion not required)

• New, recurrent, or worsening symptoms post coronary revascularization is an indication for stress imaging),, if it will alter management (SE diversion not required for typical anginal symptoms or symptoms documented to be similar to those prior to revascularization).

FOLLOW-UP OF KNOWN CAD

• Follow-up of asymptomatic or stable symptoms when last invasive or non-invasive assessment of coronary disease showed hemodynamically significant CAD (ischemia on stress test or FFR ≤ 0.80 or significant stenosis in a major vessel), (≥ 50% left main coronary artery or ≥ 70 % LAD, LCX, RCA)), over two years ago, without intervening coronary revascularization is an appropriate indication for stress imaging in patients if it will alter management

SPECIAL DIAGNOSTIC CONDITIONS REQUIRING CORONARY EVALUATION

• Prior acute coronary syndrome (with documentation in MD notes), without invasive or non-invasive coronary evaluation (SE diversion not required)
• Newly diagnosed systolic heart failure or diastolic heart failure, with reasonable suspicion of cardiac ischemia (prior events, risk factors), unless invasive coronary  angiography is immediately planned (SE diversion not required)^9-11
• LVEF requiring myocardial viability assessment to assist with decisions regarding coronary revascularization^{9, 12}
• Ventricular arrhythmias
  • Sustained ventricular tachycardia (VT) > 100 bpm, ventricular fibrillation (VF), or exercise-induced VT, when invasive coronary arteriography is not immediately planned¹³ (SE diversion not required)
  • Nonsustained VT, multiple episodes, each ≥ 3 beats at ≥ 100 bpm, or frequent PVCs (defined as greater than or equal to 30/hour on remote monitoring) without known cause or associated cardiac pathology, when an exercise ECG cannot be performed¹⁴
• Prior to initiation of Class IC antiarrhythmic drug initiation (Propafenone or Flecainide), as well as annually in intermediate and high global risk patients (SE diversion not required) ^1-5
• Assessment of hemodynamic significance of one of the following documented conditions:
  • Anomalous coronary arteries¹⁶
  • Myocardial bridging of coronary artery
• Coronary aneurysms in Kawasaki’s disease^1-7 or due to atherosclerosis
• Following radiation therapy to the anterior or left chest, at 5 years post initiation and every 5 years thereafter¹⁸
• Cardiac sarcoidosis: as a combination study with Heart PET for the evaluation and treatment of cardiac sarcoidosis.¹⁹
• Cardiac amyloidosis: for the diagnosis of cardiac transthyretin amyloidosis (ATTR). Not to be used for the diagnosis of cardiac light chain amyloidosis (AL)²⁰

PRIOR TO ELECTIVE NON-CARDIAC SURGERY IN ASYMPTOMATIC PATIENTS

• An intermediate or high risk surgery with of one or more risk factors (see below), AND documentation of an inability to walk (or <4 METs) AND there has not been an imaging stress test within 1 year^21-23
  • Risk factors: history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL.
  • Surgical Risk:
    • High risk surgery: Aortic and other major vascular surgery, peripheral vascular surgery, anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
    • Intermediate risk surgery: Carotid endarterectomy, head and neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, prostate surgery
    • Low risk surgery: Endoscopic procedures, superficial procedure, cataract surgery, breast surgery
• Planning for any organ or stem cell transplantation is an indication for preoperative MPI, if there has not been a conclusive stress evaluation, CTA, or heart catheterization within the past year, at the discretion of the transplant service.^{3, 24}

POST CARDIAC TRANSPLANT (SE diversion not required)

• Annually, for the first five years post cardiac transplantation, in a patient not undergoing invasive coronary arteriography
• After the first five years post cardiac transplantation, patients with documented transplant coronary vasculopathy can be screened annually unless invasive coronary arteriography is planned

Rationale
This guideline is for stress imaging, specifically myocardial perfusion imaging (MPI), with appropriate preference for alternatives, such as stress echocardiography (SE) or stress ECG alone when more suitable (see section below).

Radionuclide myocardial perfusion imaging (MPI) allows for evaluation of cardiac perfusion at rest and at exercise, as well as using pharmacologic agents for the diagnosis and management of coronary artery disease. With radionuclide MPI, pharmacologic stress may be performed with an inotropic agent or vasodilator. These agents are indicated for patients who cannot reach an adequate endpoint with physical exercise stress testing.²⁵

Stable patients without known CAD fall into 2 categories^{1, 3, 4}:

• Asymptomatic, for whom global risk of CAD events can be determined from coronary risk factors, using calculators available online (see Websites for Global Cardiovascular Risk Calculators section).
• Symptomatic, for whom we estimate the pretest probability that their chest-related symptoms are due to clinically significant CAD (below):

The 3 Types of Chest Pain or Discomfort

• Typical Angina (Definite) is defined as including all 3 characteristics:
  • Substernal chest pain or discomfort with characteristic quality and duration
  • Provoked by exertion or emotional stress
  • Relieved by rest and/or nitroglycerine
• Atypical Angina (Probable) has only 2 of the above characteristics
• Nonanginal Chest Pain/Discomfort has only 0 - 1 of the above characteristics

The medical record should provide enough detail to establish the type of chest pain. From those details, The Pretest Probability of obstructive CAD is estimated from the Diamond Forrester Table below, recognizing that in some cases multiple additional coronary risk factors could increase pretest probability^{1, 4}:

• Very low: <5% pretest probability of CAD, usually not requiring stress evaluation
• Low: 5 – 10% pretest probability of CAD
• Intermediate: 10% – 90% pretest probability of CAD
• High: >90% pretest probability of CAD

OVERVIEW:
MMPI may be performed without diversion to a SE in any of the following^{4, 26}:

• Inability to Exercise
  • Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
  • Limited functional capacity (< 4 METS) such as one of the following:
    • Unable to take care of their ADLs or ambulate
    • Unable to walk 2 blocks on level ground
    • Unable to climb 1 flight of stairs
• Other Comorbidities
  • Severe chronic obstructive pulmonary disease (COPD) with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
  • Poorly controlled hypertension, with systolic BP > 180 or diastolic BP > 120 (and clinical urgency not to delay MPI)
• ECG and Echo-Related Baseline Findings
  • Prior cardiac surgery (coronary artery bypass graft or valvular)
  • Documented poor acoustic imaging window
  • Left ventricular ejection fraction ≤ 40%
  • Pacemaker or ICD
  • Persistent atrial fibrillation
  • Resting wall motion abnormalities that would make SE interpretation difficult
  • Complete left bundle branch block (LBBB)
• Risk-Related scenarios
  • High pretest probability in suspected CAD
  • Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs (prior to initiation of therapy and annually)
  • Arrhythmia risk with exercise
• Previously unevaluated pathologic Q waves (in two contiguous leads) defined as the following:
  • >40 ms (1 mm) wide
  • >2 mm deep
  • >25% of depth of QRS complex

ECG Stress Test Alone versus Stress Testing with Imaging
Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) require that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise⁴:

• The (symptomatic) low or intermediate pretest probability patient who can exercise and has an interpretable ECG⁴
• The patient who is under evaluation for exercise-induced arrhythmia
• The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
• For the evaluation of syncope or presyncope during exertion²⁷

Duke Exercise ECG Treadmill Score²⁸

Calculates risk from ECG treadmill alone:

• The equation for calculating the Duke treadmill score (DTS) is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x exercise angina score), with angina score being 0 = none, 1 = non-limiting, and 2 = exercise-limiting
• The score typically ranges from - 25 to + 15. These values correspond to low-risk (with a score of ≥ + 5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of ≤ - 11) categories

An uninterpretable baseline ECG includes¹:

• ST segment depression 1 mm or more; (not for non-specific ST- T wave changes)
• Ischemic looking T waves; at least 2.5 mm inversions (excluding V1 and V2)
• LVH with repolarization abnormalities, pre-excitation pattern such as WPW, ventricular paced rhythm, or LBBB
• Digitalis use with associated ST segment abnormalities
• Resting HR under 50 bpm on a medication, such as beta-blockers or calcium channel blockers, that is required for patient’s treatment and cannot be stopped, with an anticipated suboptimal workload

Global Risk of Cardiovascular Disease

Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years. High global risk by itself generally lacks scientific support as an indication for stress imaging. There are rare exceptions, such as patients requiring IC antiarrhythmic drugs who might require coronary risk stratification prior to initiation of the drug.

• CAD Risk—Low 10-year absolute coronary or cardiovascular risk less than 10%.
• CAD Risk—Moderate 10-year absolute coronary or cardiovascular risk between 10% and 20%.
• CAD Risk—High 10-year absolute coronary or cardiovascular risk of greater than 20%.

Websites for Global Cardiovascular Risk Calculators*29-33
*Patients who have already manifested cardiovascular disease are already at high global risk and are not applicable to the calculators.

*Patients who have already manifested cardiovascular disease are already at high global risk and are not applicable to the calculators.

Definitions of Coronary Artery Disease^{1, 3, 6, 34}
Percentage stenosis refers to the reduction in diameter stenosis when angiography is the method and can be estimated or measured using angiography or more accurately measured with intravascular ultrasound (IVUS).

• Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. Its incorporation into global risk can be achieved by using the MESA risk calculator.
• Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate) generally implies at least one of the following:
  • Suggested by percentage diameter stenosis ≥ 70% by angiography; intermediate lesions are 50 – 69%³⁵
  • For a left main artery, suggested by a percentage stenosis ≥ 50%%^{1, 36, 37}
  • FFR (fractional flow reserve) ≤ 0.80 for a major vessel^{36, 37}
  • Demonstrable ischemic findings on stress testing (ECG or stress imaging), that are at least mild in degree
• FFR (fractional flow reserve) is the distal to proximal pressure ratio across a coronary lesion. Less than or equal to 0.80 is considered a significant reduction in coronary flow.

Anginal Equivalent^{1, 27}
Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons to suspect that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia). This may include respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope per se is not an anginal equivalent.

Abbreviations

References  

1. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. Dec 18 2012;126(25):e354-471. doi:10.1161/CIR.0b013e318277d6a0
2. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. J Am Coll Cardiol. Jun 9 2009;53(23):2201-29. doi:10.1016/j.jacc.2009.02.013
3. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. Oct 2013;34(38):2949-3003. doi:10.1093/eurheartj/eht296
4. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. Feb 4 2014;63(4):380-406. doi:10.1016/j.jacc.2013.11.009
5. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr. Dec 01 2021;doi:10.1016/j.jcct.2021.11.009
6. Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons. J Am Coll Cardiol. May 2 2017;69(17):2212-2241. doi:10.1016/j.jacc.2017.02.001
7. Budoff MJ, Raggi P, Beller GA, et al. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient: The Imaging Council of the American College of Cardiology. JACC Cardiovasc Imaging. Feb 2016;9(2):176-92. doi:10.1016/j.jcmg.2015.11.011
8. Aguilar-Salinas CA, Rojas R, Gomez-Perez FJ, et al. Analysis of the agreement between the World Health Organization criteria and the National Cholesterol Education Program-III definition of the metabolic syndrome: results from a population-based survey. Diabetes Care. May 2003;26(5):1635.
9. Patel MR, White RD, Abbara S, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR appropriate utilization of cardiovascular imaging in heart failure: a joint report of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Foundation Appropriate Use Criteria Task Force. J Am Coll Cardiol. May 28 2013;61(21):2207-31. doi:10.1016/j.jacc.2013.02.005
10. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. Oct 15 2013;62(16):e147-239. doi:10.1016/j.jacc.2013.05.019
11. Doherty John U, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease. Journal of the American College of Cardiology. 2019/02/05 2019;73(4):488-516. doi:10.1016/j.jacc.2018.10.038
12. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. May 3 2022;145(18):e876-e894. doi:10.1161/cir.0000000000001062
13. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. Oct 2 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054
14. Zimetbaum PJ, Wylie JV. Nonsustained ventricular tachycardia: Clinical manifestations, evaluation, and management. Wolters Kluwer. Updated August 26, 2022. Accessed February 2, 2023. https://www.uptodate.com/contents/nonsustained-ventricular-tachycardia-clinical-manifestations-evaluation-and-management
15. Reiffel JA, Camm AJ, Belardinelli L, et al. The HARMONY Trial: Combined Ranolazine and Dronedarone in the Management of Paroxysmal Atrial Fibrillation: Mechanistic and Therapeutic Synergism. Circ Arrhythm Electrophysiol. Oct 2015;8(5):1048-56. doi:10.1161/circep.115.002856
16. Gräni C, Buechel RR, Kaufmann PA, Kwong RY. Multimodality Imaging in Individuals With Anomalous Coronary Arteries. JACC Cardiovasc Imaging. Apr 2017;10(4):471-481. doi:10.1016/j.jcmg.2017.02.004
17. Newburger JW, Takahashi M, Burns JC. Kawasaki Disease. J Am Coll Cardiol. Apr 12 2016;67(14):1738-49. doi:10.1016/j.jacc.2015.12.073
18. Lancellotti P, Nkomo VT, Badano LP, et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging. Aug 2013;14(8):721-40. doi:10.1093/ehjci/jet123
19. Skali H, Schulman AR, Dorbala S. 18F-FDG PET/CT for the assessment of myocardial sarcoidosis. Curr Cardiol Rep. Apr 2013;15(4):352.
20. Gillmore JD, Maurer MS, Falk RH, et al. Nonbiopsy Diagnosis of Cardiac Transthyretin Amyloidosis. Circulation. Jun 14 2016;133(24):2404-12. doi:10.1161/circulationaha.116.021612
21. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. Sep 14 2014;35(35):2383-431. doi:10.1093/eurheartj/ehu282
22. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. Dec 09 2014;64(22):e77-137. doi:10.1016/j.jacc.2014.07.944
23. Velasco A, Reyes E, Hage FG. Guidelines in review: Comparison of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery and the 2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular assessment and management. J Nucl Cardiol. 02 2017;24(1):165-170. doi:10.1007/s12350-016-0643-8
24. Lentine KL, Costa SP, Weir MR, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol. Jul 31 2012;60(5):434-80. doi:10.1016/j.jacc.2012.05.008
25. Pagnanelli RA, Camposano HL. Pharmacologic Stress Testing with MyocardialPerfusion Imaging. J Nucl Med Technol. Dec 2017;45(4):249-252. doi:10.2967/jnmt.117.199208
26. Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. J Nucl Cardiol. Jun 2016;23(3):606-39. doi:10.1007/s12350-015-0387-x
27. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. Aug 1 2017;70(5):620-663. doi:10.1016/j.jacc.2017.03.002
28. Mark DB, Hlatky MA, Harrell FE, Jr., Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. Jun 1987;106(6):793-800. doi:10.7326/0003-4819-106-6-793
29. McClelland RL, Jorgensen NW, Budoff M, et al. 10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) With Validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study). J Am Coll Cardiol. Oct 13 2015;66(15):1643-53. doi:10.1016/j.jacc.2015.08.035
30. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. Sep 10 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.010
31. D'Agostino RB, Sr., Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. Feb 12 2008;117(6):743-53. doi:10.1161/circulationaha.107.699579
32. Goff DC, Jr., Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. Jun 24 2014;129(25 Suppl 2):S49-73. doi:10.1161/01.cir.0000437741.48606.98
33. Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. Jama. Feb 14 2007;297(6):611-9. doi:10.1001/jama.297.6.611
34. Mintz G. IVUS in PCI Guidance. American College of Cardiology. Updated June 13, 2016. Accessed January 27, 2023. https://www.acc.org/latest-in-cardiology/articles/2016/06/13/10/01/ivus-in-pci-guidance
35. Patel MR, Bailey SR, Bonow RO, et al. ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Society of Thoracic Surgeons. J Thorac Cardiovasc Surg. Jul 2012;144(1):39-71. doi:10.1016/j.jtcvs.2012.04.013
36. Mintz G. IVUS in PCI Guidance. American College of Cardiology. Updated June 13, 2016. Accessed October 22, 2021. https://www.acc.org/latest-in-cardiology/articles/2016/06/13/10/01/ivus-in-pci-guidance
37. Lotfi A, Davies JE, Fearon WF, Grines CL, Kern MJ, Klein LW. Focused update of expert consensus statement: Use of invasive assessments of coronary physiology and structure: A position statement of the society of cardiac angiography and interventions. Catheter Cardiovasc Interv. Aug 1 2018;92(2):336-347. doi:10.1002/ccd.27672

Coding Section 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

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