Noninvasive functional testing after ISCHEMIA: gatekeeper or phased-out model?

Excerpt

On August 31, 2019, at the annual congress of the European Society of Cardiology (ESC) in Paris, the ESC published five new guidelines, among them the “2019 ESC Guidelines for the Diagnosis and Management of Chronic Coronary Syndromes”, chaired by J. Knuuti and W. Wijns [1]. In these guidelines, the application of various diagnostic tests in different patient groups to rule in or rule out coronary artery disease (CAD) was updated based on a large meta-analysis of the performance of noninvasive tests published by Knuuti et al. in 2018 [2]. Key messages were a downgrading of exercise treadmill testing (ETT) because of its very limited diagnostic performance, and, conversely, an upgrade of anatomic and functional cardiac imaging, both now with class I recommendations. Based on pretest probability (PTP) of CAD, clinical likelihood, patient characteristics, preference, availability, as well as local expertise, anatomic imaging is primarily recommended for patients in the lower PTP range and functional imaging primarily for patients in the intermediate to higher range of PTP. Following the former observational registry of Hachamovitch et al. [3] and the “2018 ESC Guidelines for Myocardial Revascularization”, a large area of ischemia (>10% of left ventricular myocardium) is still considered to be an established indication for myocardial revascularization. …