Diagnostic Strategies

Stress Testing
Various diagnostic tests are available for the evaluation of suspected coronary disease. Previous Clinical Practice articles in the Journal have focused on noninvasive testing for coronary artery disease. Adults with typical or atypical features of Chest pain , especially those with major risk factors for coronary artery disease, should undergo stress testing. False positive and false negative exercise tests occur in up to 20 to 30 percent of persons (more commonly in women); coronary angiography is often necessary to resolve equivocal test results. Noninvasive testing may provide useful additional prognostic information, such as total exercise time, the inducibility of left ventricular dysfunction, blood-pressure and heart-rate responses, and, most important, the degree of myocardial ischemia. In general, poor aerobic performance and disordered heart-rate or blood-pressure responses increase the likelihood of subsequent clinical events.

Coronary Angiography
Coronary angiography remains the diagnostic gold standard for obstructive coronary artery disease, but it may miss extraluminal plaque related to coronary remodeling . Indications for angiography include poorly controlled symptoms; abnormal results on stress testing, particularly with a substantial burden of ischemia (e.g., 1 mm or more of ST-segment depression); ischemia at a low workload (below 5 to 6 metabolic equivalents); large, inducible single or multiple wall-motion abnormalities; and substantial nuclear-perfusion defects. Atypical Chest pain or inconclusive or discordant test results occasionally warrant the use of angiography. Intermediate-grade coronary obstructions (e.g., 50 to 70 percent stenosis) may require additional evaluation, such as assessment of coronary flow reserve. Suspected vasospastic or microvascular angina requires additional specialized testing.

Cardiac Biomarkers
Elevated levels of high-sensitivity C-reactive protein and other markers, including brain natriuretic peptide, have prognostic value with respect to cardiovascular events in patients with stable angina or asymptomatic coronary artery disease. However, the clinical utility of such testing remains uncertain.