Mario J Garcia

KEY POINTS

■ Functional tests such as stress electrocardiography, stress echocardiography, or stress nuclear perfusion imaging have limited accuracy for the detection of anatomical disease but provide important prognostic information.

■ Impaired chronotropic response and heart rate recovery are powerful predictors of outcomes. However, it is unknown whether these variables are modifiable by revascularization.

■ A normal exercise echocardiogram or myocardial perfusion imaging result is associated with a low risk for cardiac events. The extent of stress-induced segmental wall motion and perfusion abnormalities helps define incremental levels of risk and which populations of patients will benefit most from revascularization.

■ Positron emission tomography (PET) is one of the most sensitive methods for the identification of viable myocardium. The detection of gadolinium-delayed enhancement by cardiac magnetic resonance (CMR) is the most sensitive method for identifying scarred, nonviable myocardium.

■ A normal multidetector computed tomography (MDCT) coronary angiogram study virtually excludes the presence of coronary artery disease. However, functional testing should be considered after MDCT studies that show moderate anatomical coronary stenosis, given the relative overestimation of stenosis severity by MDCT.

Patients with known or suspected coronary artery disease (CAD) who are asymptomatic or have stable symptoms are often evaluated noninvasively. Functional tests such as stress electrocardiography, stress echocardiography, or stress nuclear perfusion imaging are intended to detect and quantify the presence of ischemia based on electrical, mechanical, or perfusion abnormalities, indirectly establishing the burden of CAD. Functional test results have limited accuracy for the detection of anatomic disease but have been shown to provide important prognostic information, including the prediction of benefit from revascular-ization. More recently, multidetector computed tomography (MDCT) has emerged as a tool to evaluate the coronary anatomy noninvasively. This test is promising and has clearly established its ability to exclude the presence of significant coronary atherosclerosis. This chapter reviews the current applications of these and other noninvasive modalities for the evaluation of patients with CAD.

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