Table 18

Suspected/stable coronary artery disease

Class^a

Level^b

Guideline

Whenever history suggests myocardial ischaemia, a stress ECG test is recommended, and, if positive or ambiguous, an imaging stress test (stress echocardiography, stress CMR or nuclear scintigraphy) is recommended.

I

C

[22]

In subjects with intermediate pretest probability for suspected coronary artery disease and stable symptoms, stress CMR, stress-echo, SPECT or PET are recommended

I

A

[16]

In patients with suspected stable coronary artery disease and intermediate pretest probability of 15 % - 65 % and LVEF =50 %, stress imaging is preferred as the initial test option if local expertise and availability permit.

I

B

[20]

An imaging stress test is recommended as the initial test for diagnosing stable coronary artery disease if the pretest probability is between 66-85 % or if LVEF is <50 % in patients without typical angina.

I

B

[20]

An imaging stress test is recommended in patients with resting ECG abnormalities, which prevent accurate interpretation of ECG changes during stress.

I

B

[20]

Stress imaging for risk stratification is recommended in patients with a non-conclusive exercise ECG

I

B

[20]

Risk stratification is recommended based on clinical assessment and the results of the stress test initially employed for making a diagnosis of stable coronary artery disease

I

B

[20]

In asymptomatic adults with diabetes or asymptomatic adults with a strong family history of coronary artery disease or when previous risk assessment testing suggests high risk of coronary artery disease, such as a coronary artery calcium score of 400 or greater stress imaging tests (MPI, stress echocardiography, perfusion CMR) may be considered for advanced cardiovascular risk assessment.

IIb

C

[20]

In patients with stable coronary disease after a significant change in symptom level, risk stratification using stress ECG (unless they cannot exercise or display ECG changes which make the ECG non evaluable) or preferably stress imaging if local expertise and availability permit is recommended

I

B

[20]

In patients with known stable coronary artery disease and a deterioration in symptoms, stress imaging is recommended for risk stratification if the site and extent of ischemia would influence clinical decision making

I

B

[20]

An exercise ECG or stress imaging if appropriate is recommended in the presence of recurrent or new symptoms once instability has been ruled out.

I

C

[20]

Reassessment of the prognosis using stress testing may be considered in asymptomatic patients after the expiration of the period for which the previous test was felt to be valid (“warranty period”)

IIb

C

[20]

Risk stratification before non-cardiac surgery

Class^a

Level^b

Guideline

Imaging stress testing is recommended before high-risk surgery in patients with more than two clinical risk factors and poor functional capacity (<4 METs).

I

C

[18]

Imaging stress testing may be considered before high- or intermediate-risk surgery in patients with one or two clinical risk factors and poor functional capacity (<4 METs).c

IIb

C

[18]

Imaging stress testing is not recommended before low-risk surgery, regardless of the patient’s clinical risk.

III

C

[18]

Acute coronary syndrome

Class^a

Level^b

Guideline

In patients with no recurrence of chest pain, normal ECG findings and normal levels of cardiac troponin (preferably high-sensitivity), but suspected acute coronary syndrome, a non-invasive stress test (preferably with imaging) for inducible ischaemia is recommended before deciding on an invasive strategy.

I

A

[9]

If echocardiography is not feasible, CMR may be used as an alternative for assessment of infarct size and resting LV function after STEMI.

IIb

C

[26]

For patients with multivessel disease, or in whom revascularization of other vessels is considered, stress testing or imaging (e.g. using stress myocardial perfusion scintigraphy, stress echocardiography, positron emission tomography or CMR) for ischaemia and viability is indicated after STEMI before or after discharge.

I

A

[26]

Before coronary revascularization

Class^a

Level^b

Guideline

An imaging stress test should be considered to assess the functional severity of intermediate lesions on coronary arteriography.

IIa

B

[20]

To achieve a prognostic benefit by revascularization in patients with coronary artery disease, ischemia has to be documented by non-invasive imaging

I

A-C

[16]

After coronary revascularization

Class^a

Level^b

Guideline

In asymptomatic patients after revascularisation, early imaging testing should be considered in specific patient subsets.

IIa

C

[16]

Late (6 months) stress imaging test after revascularization may be considered to detect patients with restenosis after stenting or graft occlusion irrespective of symptoms.

IIb

C

[20]

In asymptomatic patients, routine stress testing may be considered >2 years after PCI and >5 years after CABG.

IIa

B

[16]

In symptomatic patients with revascularized stable coronary artery disease, stress imaging (stress echocardiography, CMR or MPS) is indicated rather than stress ECG.

I

C

[20]

In symptomatic patients with prior revascularization (PCI or CABG), an imaging stress test should be considered

IIa

B

[20]

In symptomatic patients after revascularization with low-risk findings at stress testing, it is recommended to reinforce medical therapy and lifestyle changes.

I

C

[16]

In symptomatic patients after revascularization with intermediate- to high-risk findings at stress testing, coronary angiography is recommended.

I

C

[16]

Heart failure

Class^a

Level^b

Guideline

CMR imaging is recommended to evaluate cardiac structure and function, to measure LVEF, and to characterize cardiac tissue, especially in subjects with inadequate echocardiographic images or where the echocardiographic findings are inconclusive or incomplete (but taking account of cautions/contraindications to CMR).

I

C

[27]

Myocardial perfusion/ischaemia imaging (echocardiography, CMR, SPECT, or PET) should be considered in patients thought to have coronary artery disease, and who are considered suitable for coronary revascularization, to determine whether there is reversible myocardial ischaemia and viable myocardium.

IIa

C

[27]

Ventricular arrhythmia

Class^a

Level^b

Guideline

Pharmacological stress testing plus imaging modality is recommended to detect silent ischaemia in patients with ventricular arrhythmias who have an intermediate probability of having coronary artery disease by age or symptoms and are physically unable to perform a symptom-limited exercise test.

I

B

[6]

CMR should be considered in patients with ventricular arrhythmias when echocardiography does not provide accurate assessment of LV and RV function and/or evaluation of structural changes.

IIa

B

[6]

Inflammatory heart disease

Class^a

Level^b

Guideline

Demonstration of persistent myocardial inflammatory infiltrates by immunohistological evidence and/or abnormal localized fibrosis by CMR after acute myocarditis may be considered as an additional indicator of increased risk of SCD in inflammatory heart disease.

IIb

C

[6]

CMR is recommended for the confirmation of myocardial involvement in pericarditis

I

C

[11]

Hypertrophic cardiomyopathy

Class^a

Level^b

Guideline

It is recommended that CMR studies in suspected HCM be performed and interpreted by teams experienced in cardiac imaging and in the evaluation of heart muscle disease

I

B

[14]

In the absence of contraindications, CMR with LGE is recommended in patients with suspected HCM who have inadequate echocardiographic windows, in order to confirm the diagnosis.

I

C

[14]

In the absence of contraindications, CMR with LGE should be considered in patients fulfilling diagnostic criteria for HCM, to assess cardiac anatomy, ventricular function, and the presence and extent of myocardial fibrosis.

IIa

B

[14]

CMR with LGE imaging should be considered in patients with suspected apical hypertrophy or aneurysm.

IIa

C

[14]

CMR with LGE may be considered before septal alcohol ablation or myectomy, to assess the extent and distribution of hypertrophy and myocardial fibrosis.

IIb

C

[14]

CMR may be considered every 5 years in clinically stable patients, or every 2–3 years in patients with progressive disease.

IIb

C

[14]

Athlete’s heart

Class^a

Level^b

Guideline

For prevention of sudden cardiac death in athletes, upon identification of ECG abnormalities suggestive of structural heart disease, echocardiography and/or CMR imaging is recommended.

I

C

[6]

Storage disease

Class^a

Level^b

Guideline

CMR with LGE imaging should be considered in patients with suspected cardiac amyloidosis.

IIa

C

[14]

Pericardial diseases

Class^a

Level^b

Guideline

CMR is second-level testing for diagnostic workup in pericarditis

I

C

[11]

CMR should be considered in suspected cases of loculated pericardial effusion, pericardial thickening and masses, as well as associated chest abnormalities

IIa

C

[11]

CMR is indicated as second-level imaging technique to assess pericardial thickness, degree and extension of pericardial involvement for the diagnosis of constrictive pericarditis

I

C

[11]

Empiric anti-inflammatory therapy may be considered in cases with transient or new diagnosis of constrictive pericarditis with concomitant evidence of pericardial inflammation (i.e. pericardial enhancement on CMR)

IIb

C

[11]

Pregnancy

Class^a

Level^b

Guideline

CMR (without gadolinium) should be considered if echocardiography is insufficient for diagnosis.

IIa

C

[30]

Imaging of the entire aorta (CT/CMR) should be performed before pregnancy in patients with Marfan syndrome or other known aortic disease.

I

C

[30]

For imaging of pregnant women with dilatation of the distal ascending aorta, aortic arch or descending aorta, CMR (without gadolinium) is recommended.

I

C

[30]

Vessel disease

Class^a

Level^b

Guideline

In stable patients with a suspicion of acute aortic syndrome, CMR is recommended (or should be considered) according to local availability and expertise

I

C

[15]

In case of initially negative imaging with persistence of suspicion of acute aortic syndrome, repetitive imaging (CT or CMR) is recommended.

I

C

[15]

In case of uncomplicated Type B aortic dissection treated medically, repeated imaging (CT or CMR) during the first days is recommended.

I

C

[15]

In uncomplicated Type B intramural hematoma, repetitive imaging (CMR or CT) is indicated.

I

C

[15]

In uncomplicated Type B penetrating aortic ulcer, repetitive imaging (CMR or CT) is indicated.

I

C

[15]

CMR or CT is indicated in patients with bicuspid aortic valve when the morphology of the aortic root and the ascending aorta cannot be accurately assessed by TTE.

I

C

[15]

In the case of aortic diameter >50 mm or an increase >3 mm/year measured by echocardiography, confirmation of the measurement is indicated, using another imaging modality (CT or CMR).

I

C

[15]

Contrast CT or CMR is recommended to confirm the diagnosis of chronic aortic dissection.

I

C

[15]

For follow-up after (T)EVAR in young patients, CMR should be preferred to CT for magnetic resonance-compatible stent grafts, to reduce radiation exposure.

IIa

C

[15]

CMR, CT, or digital subtraction angiography may be considered if carotid artery stenosis by ultrasound is >70 % and myocardial revascularization is contemplated.

IIb

C

[16]

MR angiography should not be used to rule out pulmonary embolism.

III

C

[17]

Duplex ultrasound, CT-angiography, and/or MRA are indicated to evaluate carotid artery stenosis.

I

A

[31]

When Duplex ultrasound is inconclusive, CT-angiography or gadolinium-enhanced MRA are indicated to evaluate chronic mesenteric ischaemia.

I

B

[31]

MRA (in patients with creatinine clearance >30 mL/min) is recommended to establish the diagnosis of renal artery stenosis.

I

B

[31]

Duplex ultrasound and/or CT-angiography and/or MRA are indicated to localize lower extremity artery disease lesions and consider revascularization options.

I

A

[31]