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Guideline-Based Prioritization for Cardiovascular Stress Testing (ACC/AHA Recommendations)

Class I Indications

Stress testing should be performed in patients with symptoms suggestive of CAD, including those who are being evaluated for ischemia prior to major non-cardiac surgery. These patients will be prioritized due to the high risk of undiagnosed ischemia or infarction.

Class IIa Indications

Reasonable to consider stress testing in patients with intermediate risk for CAD, especially those with equivocal symptoms. Decisions on the timing of these tests should be made based on clinical urgency.

Class IIb Indications

Stress testing may be considered for asymptomatic patients with high coronary calcium scores or other cardiovascular risk factors, but these cases should be deprioritized unless clinically necessary.

Class III (Contraindications)

Stress testing should not be performed in low-risk patients where results are unlikely to change management, or where acute non-cardiac illness is present.

Alternative Modalities to Nuclear Imaging

Given the current shortage, providers should consider other diagnostic approaches

Treadmill Stress Test

This test assesses functional capacity and symptom provocation, useful in patients without a clear need for imaging.

Stress Echocardiogram

Offers a non-nuclear option for assessing myocardial function and ischemia, making it a preferred alternative during this shortage.

CT Coronary Angiography (CTCA)

Can provide detailed anatomical views of coronary arteries in select patients.

Cardiac Catheterization

Remains an option for high-risk patients or those requiring direct visualization of coronary artery function.

Supplemental Diagnostic Measures

In addition to the above alternatives, the following tests can guide decision-making and patient care:

  • Electrocardiogram (EKG): Remains a frontline tool for evaluating patients with suspected CAD or arrhythmias.
  • Laboratory Testing: High-sensitivity troponins (hs-TnT, hs-TnI) can be crucial in identifying ongoing myocardial injury, while C-reactive protein (CRP) helps assess systemic inflammation.

Patient Care and Redirection of Resources

During this period, some patients may be redirected to outpatient facilities with available resources to ensure timely diagnosis. Providers should maintain open, transparent communication with patients about these adjustments and the rationale behind rescheduling or alternative testing.

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