2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

Abstract

HomeCirculationVol. 126, No. 252012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart DiseaseA 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 Stephan D. Fihn, MD, MPH, Julius M. Gardin, MD, Jonathan Abrams, MD, Kathleen Berra, MSN, ANP, James C. Blankenship, MD, Apostolos P. Dallas, MD, Pamela S. Douglas, MD, JoAnne M. Foody, MD, Thomas C. Gerber, MD, PhD, Alan L. Hinderliter, MD, Spencer B. KingIII, MD, Paul D. Kligfield, MD, Harlan M. Krumholz, MD, Raymond Y.K. Kwong, MD, Michael J. Lim, MD, Jane A. Linderbaum, MS, CNP-BC, Michael J. Mack, MD, Mark A. Munger, PharmD, Richard L. Prager, MD, Joseph F. Sabik, MD, Leslee J. Shaw, PhD, Joanna D. Sikkema, MSN, ANP-BC, Craig R. SmithJr, MD, Sidney C. SmithJr, MD, John A. Spertus, MD, MPH and Sankey V. Williams, MD Stephan D. FihnStephan D. Fihn †ACP Representative. Search for more papers by this author , Julius M. GardinJulius M. Gardin *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Jonathan AbramsJonathan Abrams ‡ACCF/AHA Representative. Search for more papers by this author , Kathleen BerraKathleen Berra *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , James C. BlankenshipJames C. Blankenship *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Apostolos P. DallasApostolos P. Dallas *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Pamela S. DouglasPamela S. Douglas *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , JoAnne M. FoodyJoAnne M. Foody *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Thomas C. GerberThomas C. Gerber ‡ACCF/AHA Representative. Search for more papers by this author , Alan L. HinderliterAlan L. Hinderliter ‡ACCF/AHA Representative. Search for more papers by this author , Spencer B. KingIIISpencer B. KingIII *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Paul D. KligfieldPaul D. Kligfield ‡ACCF/AHA Representative. Search for more papers by this author , Harlan M. KrumholzHarlan M. Krumholz ‡ACCF/AHA Representative. Search for more papers by this author , Raymond Y.K. KwongRaymond Y.K. Kwong ‡ACCF/AHA Representative. Search for more papers by this author , Michael J. LimMichael J. Lim *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Jane A. LinderbaumJane A. Linderbaum ¶Critical care nursing expertise. Search for more papers by this author , Michael J. MackMichael J. Mack *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Mark A. MungerMark A. Munger *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Richard L. PragerRichard L. Prager #STS Representative. Search for more papers by this author , Joseph F. SabikJoseph F. Sabik *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Leslee J. ShawLeslee J. Shaw *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Joanna D. SikkemaJoanna D. Sikkema *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , Craig R. SmithJrCraig R. SmithJr **AATS Representative. Search for more papers by this author , Sidney C. SmithJrSidney C. SmithJr *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author , John A. SpertusJohn A. Spertus *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author and Sankey V. WilliamsSankey V. Williams *Writing committee members are required to recuse themselves from voting on sections to which their specific relationship could apply; see Appendix 1 for detailed information. Search for more papers by this author Originally published19 Nov 2012https://doi.org/10.1161/CIR.0b013e318277d6a0Circulation. 2012;126:e354–e471is corrected byCorrectionsOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 Table of ContentsPreamble. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e3571. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e3591.1. Methodology and Evidence Overview. . . . . . .e3591.2. Organization of the Writing Committee. . . . . .e3601.3. Document Review and Approval. . . . . . . . . . .e3601.4. Scope of the Guideline. . . . . . . . . . . . . . . . . . .e3601.5. General Approach and Overlap With Other Guidelines or Statements. . . . . . . . . . . . . . . . .e3621.6. Magnitude of the Problem. . . . . . . . . . . . . . . .e3631.7. Organization of the Guideline. . . . . . . . . . . . . .e3641.8. Vital Importance of Involvement by an Informed Patient: Recommendation. . . . . . . . .e3642. Diagnosis of SIHD. . . . . . . . . . . . . . . . . . . . . . . . . .e3672.1. Clinical Evaluation of Patients With Chest Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . .e3672.1.1. Clinical Evaluation in the Initial Diagnosis of SIHD in Patients With Chest Pain: Recommendations. . . . . . . .e3672.1.2. History. . . . . . . . . . . . . . . . . . . . . . . . . .e3672.1.3. Physical Examination. . . . . . . . . . . . . . .e3682.1.4. Electrocardiography. . . . . . . . . . . . . . . .e3682.1.4.1. Resting Electrocardiography to Assess Risk: Recommendation. . . . . . . . . . .e3692.1.5. Differential Diagnosis. . . . . . . . . . . . . .e3702.1.6. Developing the Probability Estimate. . .e3702.2. Noninvasive Testing for Diagnosis of IHD. . . .e3712.2.1. Approach to the Selection of Diagnostic Tests to Diagnose SIHD. . . .e3712.2.1.1. Assessing Diagnostic Test Characteristics. . . . . . . . . .e3722.2.1.2. Safety and Other Considerations Potentially Affecting Test Selection. . . . . .e3732.2.1.3. Exercise Versus Pharmacological Testing. . . . . .e3742.2.1.4. Concomitant Diagnosis of SIHD and Assessment of Risk. . . . . . . . . . . . . . . . . . .e3742.2.1.5. Cost-Effectiveness. . . . . . . . . . .e3752.2.2. Stress Testing and Advanced Imaging for Initial Diagnosis in Patients With Suspected SIHD Who Require Noninvasive Testing: Recommendations. . . . . . . . . . . . . . . . .e3752.2.2.1. Able to Exercise. . . . . . . . . . . .e3752.2.2.2. Unable to Exercise. . . . . . . . . .e3762.2.2.3. Other. . . . . . . . . . . . . . . . . . . . .e3772.2.3. Diagnostic Accuracy of Nonimaging and Imaging Stress Testing for the Initial Diagnosis of Suspected SIHD. . . . . . . .e3772.2.3.1. Exercise ECG . . . . . . . . . . . . . .e3772.2.3.2. Exercise and Pharmacological Stress Echocardiography. . . . . . . . . . .e3772.2.3.3. Exercise and Pharmacological Stress Nuclear Myocardial Perfusion SPECT and Myocardial Perfusion PET. . . .e3782.2.3.4. Pharmacological Stress CMR Wall Motion/Perfusion. . . . . . .e3782.2.3.5. Hybrid Imaging. . . . . . . . . . . . .e3782.2.4. Diagnostic Accuracy of Anatomic Testing for the Initial Diagnosis of SIHD. . . . . . . . . . . . . . . . . . . . . . . . .e3792.2.4.1. Coronary CT Angiography. . . .e3792.2.4.2. CAC Scoring. . . . . . . . . . . . . .e3792.2.4.3. CMR Angiography. . . . . . . . . .e3793. Risk Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . .e3803.1. Clinical Assessment. . . . . . . . . . . . . . . . . . . . .e3803.1.1. Prognosis of IHD for Death or Nonfatal MI: General Considerations. . . . . . . . . .e3803.1.2. Risk Assessment Using Clinical Parameters. . . . . . . . . . . . . . . . . . . . . . .e3803.2. Advanced Testing: Resting and Stress Noninvasive Testing. . . . . . . . . . . . . . . . . . . . .e3813.2.1. Resting Imaging to Assess Cardiac Structure and Function: Recommendations. . . . . . . . . . . . . . . . .e3813.2.2. Stress Testing and Advanced Imaging in Patients With Known SIHD Who Require Noninvasive Testing for Risk Assessment: Recommendations. . . . . . .e3833.2.2.1. Risk Assessment in Patients Able to Exercise. . . . . . . . . . . .e3833.2.2.2. Risk Assessment in Patients Unable to Exercise. . . . . . . . . .e3833.2.2.3. Risk Assessment Regardless of Patients' Ability to Exercise. . . . . . . . . . . . . . . .e3843.2.2.4. Exercise ECG. . . . . . . . . . . . . .e3853.2.2.5. Exercise Echocardiography and Exercise Nuclear MPI. . . .e3853.2.2.6. Dobutamine Stress Echocardiography and Pharmacological Stress Nuclear MPI. . . . . . . . . . . . . . .e3863.2.2.7. Pharmacological Stress CMR Imaging. . . . . . . . . . . . . .e3863.2.2.8. Special Patient Group: Risk Assessment in Patients Who Have an Uninterpretable ECG Because of LBBB or Ventricular Pacing. . . . . . . . . . . . . . . . . . . .e3863.2.3. Prognostic Accuracy of Anatomic Testing to Assess Risk in Patients With Known CAD. . . . . . . . . . . . . . . . . . . . .e3873.2.3.1. Coronary CT Angiography. . . .e3873.3. Coronary Angiography. . . . . . . . . . . . . . . . . . .e3873.3.1. Coronary Angiography as an Initial Testing Strategy to Assess Risk: Recommendations. . . . . . . . . . . . . . . . .e3873.3.2. Coronary Angiography to Assess Risk After Initial Workup With Noninvasive Testing: Recommendations. . . . . . . . . . .e3874. Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e3894.1. Definition of Successful Treatment. . . . . . . . . .e3894.2. General Approach to Therapy. . . . . . . . . . . . . .e3904.2.1. Factors That Should Not Influence Treatment Decisions. . . . . . . . . . . . . . . .e3924.2.2. Assessing Patients' Quality of Life. . . .e3934.3. Patient Education: Recommendations. . . . . . . .e3934.4. Guideline-Directed Medical Therapy. . . . . . . .e3954.4.1. Risk Factor Modification: Recommendations. . . . . . . . . . . . . . . . .e3954.4.1.1. Lipid Management. . . . . . . . . .e3954.4.1.2. Blood Pressure Management. . .e3974.4.1.3. Diabetes Management. . . . . . . .e3984.4.1.4. Physical Activity. . . . . . . . . . . .e3994.4.1.5. Weight Management. . . . . . . . .e4004.4.1.6. Smoking Cessation Counseling. . . . . . . . . . . . . . . .e4014.4.1.7. Management of Psychological Factors. . . . . . . .e4014.4.1.8. Alcohol Consumption. . . . . . . .e4024.4.1.9. Avoiding Exposure to Air Pollution. . . . . . . . . . . . . . .e4034.4.2. Additional Medical Therapy to Prevent MI and Death: Recommendations. . . . .e4034.4.2.1. Antiplatelet Therapy. . . . . . . . .e4034.4.2.2. Beta-Blocker Therapy. . . . . . . .e4044.4.2.3. Renin-Angiotensin-Aldosterone Blocker Therapy. . . . . . . . . . . . . . . . . . .e4054.4.2.4. Influenza Vaccination. . . . . . . .e4064.4.2.5. Additional Therapy to Reduce Risk of MI and Death. . . . . . . . . . . . . . . . . . . .e4074.4.3. Medical Therapy for Relief of Symptoms. . . . . . . . . . . . . . . . . . . . . . .e4084.4.3.1. Use of Anti-ischemic Medications: Recommendations. . . . . . . . . . .e4084.4.4. Alternative Therapies for Relief of Symptoms in Patients With Refractory Angina: Recommendations. . . . . . . . . . .e4114.4.4.1. Enhanced External Counterpulsation. . . . . . . . . . . .e4124.4.4.2. Spinal Cord Stimulation. . . . . .e4124.4.4.3. Acupuncture. . . . . . . . . . . . . . .e4135. CAD Revascularization. . . . . . . . . . . . . . . . . . . . . .e4135.1. Heart Team Approach to Revascularization Decisions: Recommendations. . . . . . . . . . . . .e4135.2. Revascularization to Improve Survival: Recommendations. . . . . . . . . . . . . . . . . . . . . .e4165.3. Revascularization to Improve Symptoms: Recommendations. . . . . . . . . . . . . . . . . . . . . .e4175.4. CABG Versus Contemporaneous Medical Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e4175.5. PCI Versus Medical Therapy. . . . . . . . . . . . .e4175.6. CABG Versus PCI. . . . . . . . . . . . . . . . . . . . .e4185.6.1. CABG Versus Balloon Angioplasty or BMS. . . . . . . . . . . . . . . . . . . . . . .e4185.6.2. CABG Versus DES. . . . . . . . . . . . . .e4185.7. Left Main CAD. . . . . . . . . . . . . . . . . . . . . . .e4195.7.1. CABG or PCI Versus Medical Therapy for Left Main CAD. . . . . . . . . . . . . .e4195.7.2. Studies Comparing PCI Versus CABG for Left Main CAD. . . . . . . . . . . . . .e4195.7.3. Revascularization Considerations for Left Main CAD. . . . . . . . . . . . . .e4195.8. Proximal LAD Artery Disease. . . . . . . . . . . .e4205.9. Clinical Factors That May Influence the Choice of Revascularization. . . . . . . . . . .e4205.9.1. Completeness of Revascularization. . .e4205.9.2. LV Systolic Dysfunction. . . . . . . . . .e4205.9.3. Previous CABG. . . . . . . . . . . . . . . . .e4215.9.4. Unstable Angina/Non–ST-Elevation Myocardial Infarction. . . . . . . . . . . . .e4215.9.5. DAPT Compliance and Stent Thrombosis: Recommendation. . . . . .e4215.10. Transmyocardial Revascularization. . . . . . . . .e4215.11. Hybrid Coronary Revascularization: Recommendations. . . . . . . . . . . . . . . . . . . . . .e4215.12. Special Considerations. . . . . . . . . . . . . . . . . .e4225.12.1. Women. . . . . . . . . . . . . . . . . . . . . . . .e4225.12.2. Older Adults. . . . . . . . . . . . . . . . . . . .e4235.12.3. Diabetes Mellitus. . . . . . . . . . . . . . . .e4245.12.4. Obesity. . . . . . . . . . . . . . . . . . . . . . . .e4255.12.5. Chronic Kidney Disease. . . . . . . . . . .e4255.12.6. HIV Infection and SIHD. . . . . . . . . .e4265.12.7. Autoimmune Disorders. . . . . . . . . . . .e4265.12.8. Socioeconomic Factors. . . . . . . . . . . .e4265.12.9. Special Occupations. . . . . . . . . . . . . .e4266. Patient Follow-Up: Monitoring of Symptoms and Antianginal Therapy. . . . . . . . . . . . . . . . . . . . . . . . .e4266.1. Clinical Evaluation, Echocardiography During Routine, Periodic Follow-Up: Recommendations. . . . . . . . . . . . . . . . . . . . . . .e4276.2. Follow-Up of Patients With SIHD. . . . . . . . . .e4276.2.1. Focused Follow-Up Visit: Frequency. . .e4286.2.2. Focused Follow-Up Visit: Interval History and Coexisting Conditions. . . . .e4286.2.3. Focused Follow-Up Visit: Physical Examination. . . . . . . . . . . . . . .e4296.2.4. Focused Follow-Up Visit: Resting 12-Lead ECG. . . . . . . . . . . . . . . . . . . . .e4296.2.5. Focused Follow-Up Visit: Laboratory Examination. . . . . . . . . . . . . . . . . . . . . .e4296.3. Noninvasive Testing in Known SIHD. . . . . . . .e4296.3.1. Follow-Up Noninvasive Testing in Patients With Known SIHD: New, Recurrent, or Worsening Symptoms Not Consistent With Unstable Angina: Recommendations. . . . . . . . . . . . . . . . .e4296.3.1.1. Patients Able to Exercise. . . . .e4296.3.1.2. Patients Unable to Exercise. . .e4306.3.1.3. Irrespective of Ability to Exercise. . . . . . . . . . . . . . . . . .e4306.3.2. Noninvasive Testing in Known SIHD—Asymptomatic (or Stable Symptoms): Recommendations. . . . . . . .e4316.3.3. Factors Influencing the Use of Follow-Up Testing. . . . . . . . . . . . . . . . .e4326.3.4. Patient Risk and Testing. . . . . . . . . . . .e4326.3.5. Stability of Results After Normal Stress Testing in Patients With Known SIHD. . . . . . . . . . . . . . . .e4336.3.6. Utility of Repeat Stress Testing in Patients With Known CAD. . . . . . . . . .e4336.3.7. Future Developments. . . . . . . . . . . . . . .e434Appendix 1. Author Relationships With Industry and Other Entities (Relevant). . . . . . . . . . . . .e464Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant). . . . . . . . . .e467Appendix 3. Abbreviations List. . . . . . . . . . . . . . . . . .e470Appendix 4. Nomogram for Estimating–Year CAD Event-Free Survival. . . . . . . . . . . . . . . . .e471Anderson Jeffrey L., MD, FACC, FAHAPreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist physicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits as well as evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceA recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline (primarily Class I)–recommended therapies. This new term, GDMT, will be used herein and throughout all future guidelines.Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines might be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of this guideline were required to disclose all such current health care-related relationships, including those existing 24 months (from 2005) before initiation of the writing effort. The writing committee chair may not have any relevant relationships with industry or other entities (RWI); however, RWI are permitted for the vice chair position. In December 2009, the ACCF and AHA implemented a new policy that requires a minimum of 50% of the writing committee to have no relevant RWI; in addition, the disclosure term was changed to 12 months before writing committee initiation. The present guideline was developed during the transition in RWI policy and occurred over an extended period of time. In the interest of transparency, we provide full information on RWI existing over the entire period of guideline development, including delineation of relationships that expired more than 24 months before the guideline was finalized. This information is included in Appendix 1. These statements are reviewed by the Task Force and all members during each conference call and meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1. Authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the writing committee is supported exclusively by the ACCF, AHA, American College of Physicians (ACP), American Association for Thoracic Surgery (AATS), Preventive Cardiovascular Nurses Association (PCNA), Society for Cardiovascular Angiography and Interventions (SCAI), and Society of Thoracic Surgeons (STS), without commercial support. Writing committee members volunteered their time for this activity.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA.Jeffrey L. Anderson, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence OverviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted as the document was compiled through December 2008. Repeated literature searches were performed by the guideline development staff and writing committee members as new issues were considered. New clinical trials published in peer-reviewed journals and articles through December 2011 were also reviewed and incorporated when relevant. Furthermore, because of the extended development time period for this guideline, peer review comments indicated that the sections focused on imaging technologies required additional updating, which occurred during 2011. Therefore, the evidence review for the imaging sections includes published literature through December 2011.Searches were limited to studies, reviews, and other evidence in human subjects and that were published in English. Key search words included but were not limited to the following: accuracy, angina, asymptomatic patients, cardiac magnetic resonance (CMR), cardiac rehabilitation, chest pain, chronic angina, chronic coronary occlusions, chronic