REVIEW ARTICLE

Guidelines in review: Comparison of ESC and

ACC/AHA guidelines for the diagnosis and
management of patients with stable coronary
artery disease
Jubin Joseph, MRCP,a Alejandro Velasco, MD,b Fadi G. Hage, MD, FASNC,b,c and
Eliana Reyes, MD, PhDa,d
a
St Thomas’ Hospital, King’s College London, London, UK
b
Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at
Birmingham, Birmingham, AL
c
Section of Cardiology, Birmingham Veteran Affairs Medical Center, Birmingham, AL
d
Nuclear Medicine Department, Royal Brompton and Harefield NHS Foundation Trust, London,
UK

Received Aug 18, 2017; accepted Aug 20, 2017

doi:10.1007/s12350-017-1055-0

In 2012, the American College of Cardiology Foundation (ACCF) and the American Heart
Association (AHA) Task Force on Practice Guidelines jointly with the American College of
Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of Tho-
racic Surgeons produced a set of recommendations intended to assist physicians in the diagnosis
and management of patients with stable ischemic heart disease. Two years later, a focused
update on the 2012 guidelines was published. A year before this update, The Task Force on the
management of stable coronary artery disease (CAD) of the European Society of Cardiology
(ESC) issued a guideline on the management of stable CAD. This document brings together
European and American recommendations that include the use of stress testing and non-
invasive imaging for the diagnosis and management of patients with known or suspected
stable CAD. (J Nucl Cardiol 2017)
Key Words: Coronary artery disease Æ ischemia Æ myocardium Æ guidelines Æ non-invasive
imaging

Abbreviations LOE Level of evidence

CABG Coronary artery bypass grafting MPI Myocardial perfusion imaging
CAC Coronary artery calcium MRI Magnetic resonance imaging
CAD Coronary artery disease NSER No specific equivalent
CCTA Coronary computed tomographic recommendation
angiography PCI Percutaneous coronary intervention
LVEF Left ventricular ejection fraction PTP Pre-test probability

In 2012, the American College of Cardiology

Reprint requests: Eliana Reyes, MD, PhD, Nuclear Medicine Depart-
Foundation (ACCF) and the American Heart Associa-
ment, Royal Brompton and Harefield NHS Foundation Trust,
Sydney Street, London, SW3 6NP, UK; e.reyes@rbht.nhs.uk tion (AHA) Task Force on Practice Guidelines jointly
1071-3581/$34.00 with the American College of Physicians, American
Copyright Ó 2017 American Society of Nuclear Cardiology.
 Joseph et al Journal of Nuclear CardiologyÒ
Guidelines in review

Table 1. Stress testing for the diagnostic assessment of patients with suspected stable angina

ESC ACC/AHA
Recommendation Class LOE Class LOE
Exercise ECG is recommended as the initial test
To diagnose CAD in patients with an intermediate PTP of CAD who can exercise I B I A
adequately and have an interpretable ECG*
To evaluate control of symptoms and ischemia in patients on therapy IIa C NSER
To diagnose CAD in patients with a low PTP of CAD who require testing NSER IIa C
Exercise ECG is not recommended in patients with an uninterpretable resting ECG or III C III C
taking digitalis
Stress imaging is recommended as the initial test
To diagnose CAD in patients with an intermediate PTP of CAD (Figure 1) I B I B
IIa§
To diagnose CAD in patients with ECG abnormalities that prevent interpretation of I B I B
ECG changes during stress
To diagnose CAD if LVEF \50% in patients without typical angina I B NSER
In symptomatic patients with prior revascularization (PCI or CABG) IIa B NSER
To assess the functional significance of intermediate stenosis on invasive coronary IIa B Ik B
angiography
In patients with a low PTP of CAD who require testing and cannot exercise NSER IIa C
(pharmacological stress with echo recommended)
To diagnose CAD in patients with a low PTP of CAD who require testing and have an NSER IIb C
interpretable ECG and can exercise adequately (exercise echo recommended)
Exercise stress with nuclear MPI is not recommended in patients with a low PTP of NSER III C
CAD who can exercise and have an interpretable ECG
Pharmacological stress imaging is not recommended in patients who can exercise NSER III C
and have an interpretable ECG

* Pre-test probability (PTP) of CAD as per ESC guidelines: Low \15%, intermediate 15-85% and high [85%. The intermediate
group is classified further into (a) 15-65%, and (b) 66-85%.3 The ESC guidelines recommend the exercise ECG in patients with an
intermediate PTP of 15-65% while imaging is preferred in those with 66-85% PTP of CAD

ESC guidelines stipulate that patients with a low PTP of CAD can be managed without further non-invasive stress testing.3

Both guidelines recommend exercise over pharmacological stress whenever possible.1,3
§
Class I Uninterpretable ECG or unable to exercise; class IIa: Interpretable ECG and able to exercise
k
In the context of risk assessment before coronary revascularization as per ACC/AHA guidelines.7

Association for Thoracic Surgery, Preventive Cardio-
vascular Nurses Association, Society for Cardiovascular
Angiography and Interventions, and Society of Thoracic
Surgeons produced a set of recommendations intended
to assist physicians in the diagnosis and management of
patients with stable ischemic heart disease.1 Two years
later, a focused update on the 2012 guidelines was
published.2 A year before this update, the task force on
the management of stable coronary artery disease (CAD)
of the European Society of Cardiology (ESC) issued a
guideline on the management of stable CAD.3 This
document brings together European and American rec-
ommendations that include the use of stress testing and
non-invasive imaging for the diagnosis and management
of patients with known or suspected stable CAD. Class
(I, II, or III) and level of evidence (A, B, or C) are
provided for each recommendation (Tables 1, 2, 3, 4, 5,
6; Figures 1, 2). This represents the fourth of a new
series of comparative guidelines review published in the
Journal.4,5,6
Journal of Nuclear CardiologyÒ Joseph et al
Guidelines in review

Table 2. Recommendations for CCTA in the diagnosis of stable CAD

ESC ACC/AHA
Recommendation Class LOE Class LOE
As an alternative to stress imaging to exclude CAD in patients with a IIa C Unable to exercise IIa B
low-intermediate PTP of CAD* Able to exercise IIb
In patients with a low-intermediate PTP of CAD who cannot undergo IIa C IIa C
stress testing or after an inconclusive exercise ECG or stress
imaging test*
In intermediate PTP of CAD patients with continued symptoms and NSER IIa C
previous normal or inconclusive test
Non-contrast CT may be considered in patients with a low to NSER IIb C
intermediate PTP of CAD to determine the CAC score
Coronary calcium by CT is not recommended to identify individuals III C IIb C
with coronary artery stenosis
CCTA is not recommended as a screening test in asymptomatic III C III C
patients without clinical suspicion of CAD.3,8,9

* In the ESC guidelines, this recommendation applies to patients in whom good quality CCTA images can be expected

CAC score by non-contrast cardiac CT may be considered in patients with a low to intermediate PTP of CAD. As per ACC/AHA
guidelines, more evidence is needed to establish the diagnostic accuracy of coronary calcium imaging for the detection of
coronary artery stenosis in symptomatic patients.1

Table 3. Use of stress testing and CCTA for risk stratification in patients with stable CAD

ESC ACC/AHA
Recommendation Class LOE Class LOE
Stress testing
Risk stratification is recommended based on clinical assessment and the result of I B I B
the stress test initially employed for diagnosing CAD* IIa
Stress imaging for risk stratification is recommended in patients with an I B NSER
inconclusive exercise ECG
Exercise ECG or stress imaging is recommended for risk stratification in patients I B NSER
with stable CAD after a significant change in symptoms
Stress imaging is recommended in patients with known CAD and a deterioration in I B NSER
symptoms if the site and extent of ischemia would influence management
Stress imaging is recommended for risk assessment in patients with known IIa B I B
coronary stenosis of unclear significance being considered for revascularization
Pharmacological stress with echo or nuclear MPI should be considered in patients IIa B I B
with LBBB
Stress echo or nuclear MPI should be considered in patients with paced rhythm IIa B NSER
Pharmacological stress imaging is not recommended for risk stratification in NSER III C
patients with stable CAD who can exercise and have an interpretable ECG
CCTA
For risk stratification in patients with stable CAD IIa C
As first-line test for risk assessment in patients with stable CAD who cannot exercise IIa C
adequately
As second-line test for risk assessment in patients with stable CAD and previous IIa C
inconclusive functional test
As first-line test for risk assessment in patients with stable CAD who can exercise IIb B
but have an uninterpretable ECG
 Joseph et al Journal of Nuclear CardiologyÒ
Guidelines in review

Table 3 continued
Recommendation ESC ACC/AHA
Class LOE Class LOE
As first-line test in patients who cannot undergo stress imaging or as an alternative IIb C
to invasive coronary angiography when functional testing indicates moderate to
high risk of cardiac events

* As per ACC/AHA guidelines: In patients who can exercise and have an interpretable ECG, the exercise ECG is a class I
indication while exercise imaging is class IIa; in patients with an uninterpretable ECG, exercise imaging is class I while phar-
macological MRI is a class IIa indication. In patients unable to exercise, pharmacological stress imaging is a class I indication
except for MRI (class IIa)

ESC guidelines do not specify the clinical scenarios as the ACC/AHA guidelines do but warn about the possible overestimation
of coronary stenosis severity in segments with severe calcification on CCTA. They also recommend additional stress imaging
before referring a patient with few or no symptoms to invasive coronary angiography

Table 4. Use of stress testing and/or CCTA for re-assessment of patients with stable CAD

ESC ACC/AHA
Recommendation Class LOE Class LOE
New, recurrent, or worsening symptoms
Exercise ECG or stress imaging is recommended once instability has been ruled out I C I B
(Figure 2)* IIa
CCTA might be reasonable in patients with previous revascularization to assess NSER IIb B
patency of grafts or of coronary stents C3 mm in diameter
CCTA might be reasonable in patients with previous PCI to assess stents \3 mm in NSER IIb B
diameter in the absence of significant coronary calcification
Asymptomatic (or stable symptoms)
Exercise or pharmacological stress imaging at C2-year intervals may be considered NSER IIa C
in patients with a history of silent ischemia or who are at high risk for cardiac events
and a) cannot exercise adequately, b) have an uninterpretable ECG, or c) have a
history of incomplete revascularization
Re-assessment of prognosis using stress testing may be considered in IIb C NSER
asymptomatic patients after the warranty period of prior testing has expired
Repeat exercise ECG may be considered after at least 2 years (ESC) or C1 year IIb C IIb C
(ACC/AHA) following the last test unless there is a change in clinical status
Stress imaging or CCTA is not recommended for follow-up assessment if performed NSER III C
more frequently than at 5-year intervals post-CABG or 2-year intervals after PCI
Late (6 months) stress imaging after revascularization may be considered to detect IIb C III C
patients with restenosis after stenting or graft occlusion irrespective of symptoms

* In the ACC/AHA guidelines, the exercise ECG and stress (nuclear or echo) imaging are class I indications when performed
appropriately according to patient’s exercise capacity and ECG interpretability. Class IIa indications are as follows: (1) Exercise
imaging (nuclear or echo) in patients who can exercise and have previously required imaging with exercise stress, or have known
or at high risk for multivessel disease; (2) Pharmacological stress MRI in patients who cannot exercise adequately

Specific patient subsets indicated for early stress testing include those with safety critical professions (e.g., pilots, drivers,
divers), competitive athletes, and those who would like to engage in activities for which high oxygen consumption is required.
The ACC/AHA guidelines recommend against stress imaging more frequently than at 5-year interval post-CABG or 2-year
intervals after PCI but do not address these specific patient subsets except to mention that routine surveillance with functional
imaging is recommended in a few occupations in which the presence of even asymptomatic cardiac disease could endanger
others, such as commercial pilots, police, firefighters, and bus drivers
Journal of Nuclear CardiologyÒ Joseph et al
Guidelines in review

Table 5. Use of resting echocardiography for the assessment of patients with suspected or known
stable CAD

ESC ACC/AHA
Recommendation Class LOE Class LOE
Patients with suspected CAD
A resting echo is recommended to assess cardiac structure and function, and to I B I* B
exclude alternative causes of angina and identify regional wall motion IIb C
abnormalities suggestive of CAD
A resting echo is recommended to measure LVEF for risk stratification and for the I B I* B
evaluation of diastolic function IIb C
Echocardiography, radionuclide imaging, MRI, and cardiac CT are not III C
recommended for routine assessment of left ventricular function in patients with a
normal ECG, no history of MI, no symptoms or signs suggestive of heart failure, and
no complex ventricular arrhythmias.
Patients with known CAD
Routine re-assessment of left ventricular function (\1 year) is not recommended in NSER III C
patients with no change in clinical status and for whom no change in therapy is
contemplated.

* The ESC guidelines recommend a resting echocardiogram in all patients with suspected CAD while in the ACC/AHA guidelines,
this recommendation is subject to the presence of pathological Q waves on ECG, history of prior MI, symptoms or signs of heart
failure, complex ventricular arrhythmias, or an undiagnosed heart murmur

A resting echocardiogram may be considered in patients with hypertension or diabetes and an abnormal ECG

Although there is no specific recommendation, the ESC guidelines stipulate that ‘‘there is no indication for repeated use of
resting echocardiography on a regular basis in patients with uncomplicated stable CAD in the absence of a change in clinical
status.’’3

Table 6. Investigation of patients with suspected microvascular or vasospastic angina

ESC ACC/AHA
Recommendation Class LOE Class LOE
If suspected microvascular angina
Exercise or dobutamine echocardiography should be considered to establish IIa C
whether regional wall motion abnormalities occur in conjunction with angina and
ST-changes
Transthoracic doppler echocardiography of the left anterior descending coronary IIb C
artery with measurement of diastolic blood flow at rest and during adenosine IV
may be considered for non-invasive assessment of coronary flow reserve
Intracoronary acetylcholine and adenosine with doppler measurements may be IIb C
considered during invasive coronary angiography if the angiogram is visually
normal, to assess (endothelium dependent and non-endothelium dependent)
coronary flow reserve, and to detect vasospasm NSER
If suspected vasospastic angina
An ECG is recommended during angina if possible I C
Coronary angiography is recommended to determine the extent of CAD in patients I C
with characteristic episodic resting chest pain and ST-segment changes that resolve
with nitrates or calcium antagonists
Ambulatory ST-segment monitoring should be considered to identify ST-changes in IIa C
the absence of increased heart rate
Intracoronary provocation tests should be considered to identify the site and type IIa C
of spasm in patients with normal or non-obstructed arteries on invasive coronary
angiography and suspected vasospasm
Joseph et al Journal of Nuclear CardiologyÒ
Guidelines in review

Figure 1. ESC and ACC/AHA recommendations for stress testing and CCTA in the assessment of
patients with suspected stable CAD according to pre-test probability of disease. CAC, coronary
artery calcium; CAD, coronary artery disease; CCTA, coronary computed tomographic angiogra-
phy; ICA, invasive coronary angiography. *In the ESC guidelines, CCTA is recommended in
patients with a low-intermediate PTP of CAD (15-50%). Pharmacological stress MRI is a class IIa
indication according to the ACC/AHA guidelines.

Figure 2. ESC and ACC/AHA guidance for follow-up assessment of patients with stable CAD
according to symptoms. CAD, coronary artery disease; CCTA, coronary computed tomographic
angiography. *As per ACC/AHA guidelines: The exercise ECG and stress (nuclear or echo)
imaging are class I indications when performed appropriately according to patient’s exercise
capacity and ECG interpretability. Class IIa indications are as follows: (1) Exercise imaging in
patients who have previously required imaging with exercise stress, or have known or at high risk
for multivessel disease; (2) Pharmacological stress MRI in patients who cannot exercise adequately.
Journal of Nuclear CardiologyÒ
Disclosure
Authors declare that they have no potential conflict of
interest relevant to this document.
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