GENERAL INFORMATION

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 
• Where a specific clinical indication is not directly addressed in this guideline, medical necessity determination will be made based on widely accepted standard of care criteria. These criteria are supported by evidence-based or peer-reviewed sources such as medical literature, societal guidelines and state/national recommendations.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

This guideline is for stress imaging, specifically Stress Echocardiography (SE) with appropriate preference for suitable alternatives, such as an exercise treadmill exam without imaging, when more suitable, unless otherwise stated (refer to Background section). 

When a noncardiac explanation is provided for symptoms, no testing is required (AUC Score 8)  ⁽¹⁾

All criteria are substantiated by the latest evidence-based medical literature. To enhance transparency and reference, Appropriate Use (AUC) scores, when available, are diligently listed alongside the criteria.

This guideline first defaults to AUC scores established by published, evidence-based guidance endorsed by professional medical organizations. In the absence of those scores, we adhere to a standardized practice of assigning an AUC score of 6. This score is determined by considering variables that ensure the delivery of patient-centered care in line with current guidelines, with a focus on achieving benefits that outweigh associated risks. This approach aims to maintain a robust foundation for decision-making and underscores our commitment to upholding the highest standards of care. ^(2–6)

Indications for Stress Echocardiography  ^(1,7–10)

• Symptomatic patients without known CAD.  No imaging stress test within the last 12 months. The terms ‘typical’, ‘atypical’, and ‘non-anginal symptoms’ can still be observed in medical records (consult the Diamond Forrester table in the Definitions section). However, the American College of Cardiology (ACC) has simplified its terminology to ‘Less likely anginal symptoms’ and ‘Likely anginal symptoms’ (refer to Definitions) and utilized below.
  • Less-likely anginal symptoms
    • When baseline EKG makes standard exercise test inaccurate (see Definitions section) (AUC Score 8)  ⁽¹⁾

• • Likely Anginal Symptoms (typical angina)
    • < 50 years old with ≤ one risk factor if an electrocardiogram (ECG) treadmill test cannot be done. **AUC scores for this bullet point are identical for myocardial perfusion imaging (MPI), stress echo, and exercise tolerance test (ETT) (AUC Score 7). ⁽¹⁾ Although the ACC guideline does not specify youth and gender, decisions should be guided by best medical judgment, considering factors such as safety and radiation exposure.

• • • ≥ 50 years old (AUC Score 8) ⁽¹⁾

• • Repeat testing in patient with new or worsening symptoms and negative result at least one year ago AND meets one of the criteria above

• Asymptomatic patients without known CAD
  • Previously unevaluated ECG evidence of possible myocardial ischemia including ischemic ST segment or T wave abnormalities (see Background section)

• • Previously unevaluated pathologic Q waves (see Background section)
  • Previously unevaluated complete left bundle branch block 

• STABLE SYMPTOMS with a prior Coronary Calcium Agatston Score of >100. No prior stress imaging done within the last 12 months ^(1,11) (AUC Score 7) ⁽¹⁾
• ASYMPTOMATIC high global CAD risk patient with a prior Coronary Calcium Agatston Score of >100. No prior stress imaging done within the last 12 months ^(11,13)
• ASYMPTOMATIC patient with Coronary Calcium Agatston Score > 400 (or a qualitative assessment where 'severe' coronary artery calcification is stated in a report incidentally detected on CT imaging performed for other clinical indications)  No prior stress imaging done within the last 12 months ⁽¹⁴⁾

• Exercise stress ECG with low-risk Duke treadmill score ≥5, but patient’s current symptoms indicate an indicate increasing likelihood of disease
• Exercise stress ECG with an intermediate Duke treadmill score (AUC 8) ⁽¹⁾
• A previously unevaluated ventricular wall motion abnormality demonstrated by another imaging modality and stress echo is being performed to determine if the patient has myocardial ischemia ^(1,15) (AUC Score 5) ⁽¹⁾

• Intermediate coronary computed tomography angiography (CCTA) defined as 40%-70% lesion (AUC Score 7) ⁽¹⁾

• Coronary stenosis of unclear significance on previous coronary angiography not previously evaluated

• Asymptomatic follow-up stress imaging at a minimum of 2 years post coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) (whichever is later) is appropriate for patients with:
  • High risk: diabetes with accelerated progression of CAD, chronic kidney disease (CKD), peripheral artery disease (PAD), prior brachytherapy, In-Stent Restenosis (ISR), or saphenous vein graph (SVG) intervention (AUC Score 7) ⁽¹⁾
  • A history of silent ischemia (AUC Score 7) ⁽¹⁾
  • A history of a prior left main stent (AUC Score 5) ⁽¹⁾

• For patients with high occupational risk, associated with public safety, airline and boat pilots, bus and train drivers, bridge and tunnel workers/toll collectors, police officers and firefighters

• New, recurrent, or worsening symptoms, treated medically or by revascularization is an indication for stress imaging, if it will alter management for typical anginal symptoms or symptoms documented to be similar to those prior to revascularization if no imaging stress test within the last 12 months. (AUC Score 8)  ^(1,11)

• Routine follow-up of asymptomatic or stable symptoms when last invasive or non-invasive assessment of coronary disease showed hemodynamically significant CAD (ischemia on stress test or fractional flow reserve (FFR) ≤ 0.80 or significant stenosis in a major vessel (≥ 50% left main coronary artery or ≥ 70% left anterior descending artery (LAD), left circumflex artery (LCX), right coronary artery (RCA)), over two years ago without intervening coronary revascularization, is an appropriate indication for stress imaging

• Prior acute coronary syndrome (with documentation in MD notes), within last 12 months, without a prior stress test or coronary angiography performed since that time
• Newly diagnosed systolic or diastolic heart failure, with reasonable suspicion of cardiac ischemia (prior events, risk factors), unless invasive coronary angiography is immediately planned ⁽¹⁶⁾
• Ventricular arrhythmias ⁽¹⁷⁾
  • Sustained ventricular tachycardia (VT) > 100 bpm (AUC Score 7) ⁽¹⁾ , ventricular fibrillation (VF) (AUC Score 7) ⁽¹⁾ , or exercise-induced VT (AUC Score 8) ⁽¹⁾ , when invasive coronary arteriography has not been performed

• • Non-sustained VT, multiple episodes, each ≥ 3 beats at ≥ 100 bpm, frequent premature ventricular contractions (PVCs) (defined as greater than or equal to 30/hour on remote monitoring), when an exercise ECG cannot be performed (AUC Score 7) ⁽¹⁾

• For intermediate and high-risk global patients who require initiation of Class IC antiarrhythmic drugs. It can be performed annually thereafter until discontinuation of drug use ⁽¹⁷⁾ (AUC Score 7) ⁽¹⁾

• Hemodynamic assessment of ischemia in one of the following documented conditions:
  • Anomalous coronary arteries in an asymptomatic individual without prior stress echocardiography (AUC Score 8) ⁽¹⁸⁾
  • Myocardial bridging of a coronary artery ⁽¹⁹⁾

• Coronary aneurysms in Kawasaki’s disease ⁽²⁰⁾
• Following radiation therapy to the anterior or left chest, at 5 years post initiation and every 5 years thereafter ⁽²¹⁾  (AUC Score 6) ⁽¹⁾

Evaluation with Inclusion of Doppler

• For the evaluation of aortic stenosis and flow (contractile) reserve in symptomatic patients with severe aortic stenosis by calculated valve area, low flow / low gradient, and ejection fraction < 50% ^(2,22)
• For evaluation of asymptomatic moderate or severe aortic stenosis (AS) for measurement of changes in valve hemodynamics ^(2,22) (AUC Score 8) ⁽²²⁾
• Non-severe aortic regurgitation (AR) with symptoms: Assessment of functional capacity and to assess for other causes of symptoms ^(2,22) (AUC Score 7) ⁽²²⁾
• For evaluation of mitral stenosis (MS) if there is ^(2,22) :
  • Exertional shortness of breath which suggests the amount of MS is worse than is seen on the resting echocardiogram (AUC Score 8) ⁽²²⁾

• For evaluation for mitral regurgitation (MR) if there is one of the following ^(2,22,23) :
  • Exertional shortness of breath which suggests the amount of MR is worse than is seen on the resting echocardiogram (AUC Score 8) ⁽²²⁾
  • The echocardiogram is not able to distinguish whether the MR is moderate or severe in a patient that is asymptomatic (AUC Score 7) ⁽²²⁾

• For symptomatic patients with hypertrophic cardiomyopathy (HCM), who do not have resting or provocable outflow tract gradient ≥ 50 mmHg on transthoracic echocardiogram (TTE), for detection and quantification of dynamic left ventricular outflow tract (LVOT) obstruction ⁽²⁴⁾
• For asymptomatic patients with HCM who do not have a resting or provocable outflow tract gradient ≥ 50 mmHg on TTE ⁽²⁴⁾

• For unexplained dyspnea and suspected heart failure with preserved left ventricular ejection fraction (LVEF) heart failure with preserved ejection fraction (HFpEF) with normal or equivocal diastolic function on resting images (AUC Score 8) ⁽¹⁾

• An intermediate or high-risk surgery with of one or more risk factors (see below), AND documentation of an inability to walk (or < 4 METs) AND there has not been an imaging stress test within 1 year ^(25–27) (AUC Score 6) ⁽²⁸⁾
  • Risk factors: history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine >2.0 mg/dL.
  • Surgical Risks: 
    • High risk surgery: Aortic and other major vascular surgery, peripheral vascular surgery, anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
    • Intermediate risk surgery: Carotid endarterectomy, head and neck surgery, intraperitoneal and intrathoracic surgery, orthopedic surgery, prostate surgery
    • Low risk surgery: Endoscopic procedures, superficial procedure, cataract surgery, breast surgery

• Planning for any organ or stem cell transplantation is an indication for preoperative stress imaging, if there has not been a conclusive stress evaluation, CTA, or heart catheterization within the past year, at the discretion of the transplant service (AUC Score 6) ⁽²⁸⁾

Post Cardiac Transplantation

• Annually, post cardiac transplantation, in a patient not undergoing invasive coronary arteriography

Background

Stress echocardiography is an exercise stress test which utilizes echocardiography to provide information on exercise tolerance, ischemic burden, and structural heart disease including valvular disease and provides analysis of left ventricular function.

Stress echocardiography (SE) refers to ultrasound imaging of the heart during exercise electrocardiography (ECG) testing, during which visualized wall motion abnormalities can provide evidence of potential significant coronary artery disease (CAD).

While drug-induced stress with dobutamine can be an alternative to exercise stress testing in patients who are unable to exercise, this guideline does not require use of this modality. Hence, reference in this document to SE predominantly refers to exercise stress echocardiography.

Although SE provides comparable accuracy without radiation risk, relative to myocardial perfusion imaging (MPI), scenarios which do not permit effective use of SE might be better suited for stress imaging with MPI, cardiovascular magnetic resonance imaging (CMR) or positron emission tomography (PET), or coronary computed tomography angiography (CCTA). 

Cardiac Doppler ultrasound is a form of ultrasound that can detect and measure blood flow. Doppler ultrasound depends on the Doppler Effect, a change in the frequency of a wave resulting from the motion of a reflector, the red blood cell. There are three types of Doppler ultrasound performed during a cardiac Doppler examination:

• Pulsed Doppler
• Continuous wave Doppler
• Color flow Doppler

A reasonable diagnostic or therapeutic procedure can be defined as that for which the expected clinical benefits outweigh the associated risks, enhancing patient care and health outcomes in a cost-effective manner. ⁽⁴⁾

• Appropriate Care - Median Score 7-9
• May be Appropriate Care - Median Score 4-6
• Rarely Appropriate Care - Median Score 1-3

• Stable patients without known CAD fall into 2 categories ^(1,7,8) :
  • Asymptomatic patients, for whom Global Risk of CAD events can be determined from coronary risk factors using calculators available online (see Websites for Global Cardiovascular Risk Calculators section)
  • Symptomatic patients, for whom we estimate the Pretest Probability that their chest-related symptoms are due to clinically significant CAD (see below):
• The medical record should provide enough detail to establish the type of chest pain: 
  • Likely Anginal symptoms encompass chest/epigastric/shoulder/arm/jaw pain, chest pressure/discomfort occurring with exertion or emotional stress and relieved by rest, nitroglycerine or both.
  • Less-Likely Anginal symptoms include dyspnea, or fatigue not relieved by rest/nitroglycerin, as well as generalized fatigue or chest discomfort with a time course not indicative of angina (e.g., resolving spontaneously within seconds or lasting for an extended period unrelated to exertion).
• Risk Factors for Coronary disease include (but not limited to): diabetes mellitus, smoking, family history of premature CAD (men age less than 55, females less than 65), hypertension, dyslipidemia.
• Beginning 2023, the classification terms for angina were updated within the ACC’s Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease to Less Likely Anginal Symptoms and Likely Anginal Symptoms as in #2. Previously, the document referred to ‘Typical Angina’, ‘Atypical Angina’ and ‘Non-Anginal’ symptoms, defined by the Diamond Forrester Table. We still provide this information for your reference ^(1,7,8) :

Age (Years)	Gender	Typical/Definite Angina Pectoris	Atypical/Probable Angina Pectoris	Nonanginal Chest Pain
≤ 39	Men	Intermediate	Intermediate	Low
	Women	Intermediate	Very low	Very low
40 – 49	Men	High	Intermediate	Intermediate
	Women	Intermediate	Low	Very low
50 – 59	Men	High	Intermediate	Intermediate
	Women	Intermediate	Intermediate	Low
≥ 60	Men	High	Intermediate	Intermediate
	Women	High	Intermediate	Intermediate

Very low: < 5% pretest probability of CAD, usually not requiring stress evaluation

Low: 5 - 10% pretest probability of CAD

Intermediate: 10% - 90% pretest probability of CAD

High: > 90% pretest probability of CAD

• MPI may be performed without diversion to SE in any of the following ^(1,32) :
  • Inability to exercise
    • Physical limitations precluding ability to exercise for at least 3 full minutes of Bruce protocol
    • Limited functional capacity (< 4 metabolic equivalents) such as one of the following:
      • Cannot take care of their activities of daily living (ADLs) or ambulate
      • Cannot walk 2 blocks on level ground
      • Cannot climb 1 flight of stairs
      • Cannot vacuum, dust, do dishes, sweep, or carry a small grocery bag
  • Other Comorbidities
    • Severe chronic obstructive pulmonary disease with pulmonary function test (PFT) documentation, severe shortness of breath on minimal exertion, or requirement of home oxygen during the day
    • Poorly controlled hypertension, with systolic BP > 180 or Diastolic BP > 120 (and clinical urgency not to delay MPI)
  • ECG and Echo-Related Baseline Findings
    • Prior cardiac surgery (coronary artery bypass graft or valvular)
    • Documented poor acoustic imaging window
    • Left ventricular ejection fraction ≤ 40%
    • Pacemaker or ICD
    • Persistent atrial fibrillation
    • Resting wall motion abnormalities that would make SE interpretation difficult
    • Complete left bundle branch block (LBBB)
  • Risk-related scenarios
    • High pretest probability in suspected CAD
    • Intermediate or high global risk in patients requiring type IC antiarrhythmic drugs (prior to initiation of therapy and annually)
    • Arrhythmia risk with exercise
  • Previously unevaluated pathologic Q waves (in two contiguous leads) defined as the following:
    • 40 ms (1 mm) wide
    • 2 mm deep
    • 25% of depth of QRS complex

• ECG Stress Test Alone versus Stress Testing with Imaging
  Prominent scenarios suitable for an ECG stress test WITHOUT imaging (i.e., exercise treadmill ECG test) are inferred from the guidelines presented above, often requiring that the patient can exercise for at least 3 minutes of Bruce protocol with achievement of near maximal heart rate AND has an interpretable ECG for ischemia during exercise ⁽¹⁾ :
  • The (symptomatic) low or intermediate pretest probability patient who can exercise and has an interpretable ECG 
  • The patient who is under evaluation for exercise-induced arrhythmia
  • For the evaluation of syncope or presyncope during exertion
  • The patient who requires an entrance stress test ECG for a cardiac rehab program or for an exercise prescription
  • When exercise cannot be performed, pharmacologic stress can be considered.

• Duke Exercise ECG Treadmill Score ⁽³³⁾

Calculates risk from ECG treadmill alone:

• • The equation for calculating the Duke treadmill score (DTS) is: DTS = exercise time in minutes - (5 x ST deviation in mm or 0.1 mV increments) - (4 x exercise angina score), with angina score being 0 = none, 1 = non-limiting, and 2 = exercise-limiting.
  • The score typically ranges from - 25 to + 15. These values correspond to low-risk (with a score of ≥ + 5), intermediate risk (with scores ranging from - 10 to + 4), and high-risk (with a score of ≤ -11) categories.
• An uninterpretable baseline ECG includes ⁽⁷⁾ :
  • ST segment depression is considered significant when there is 1 mm or more, not for non-specific ST- T wave changes
  • Ischemic looking T waves are considered significant when there are at least 2.5 mm inversions (excluding V1 and V2)
  • LVH with associated STT abnormalities, pre-excitation pattern such as WPW, a ventricular paced rhythm, or left bundle branch block
  • Digitalis use
  • Resting HR under 50 bpm on a medication, such as beta-blockers or calcium channel blockers, that is required for patient’s treatment and cannot be stopped, with an anticipated suboptimal workload

• Global Risk of Cardiovascular Disease
  • Global risk of CAD is defined as the probability of manifesting cardiovascular disease over the next 10 years and refers to asymptomatic patients without known cardiovascular disease. It should be determined using one of the risk calculators below. A high risk is considered greater than a 20% risk of a cardiovascular event over the ensuing 10 years. High global risk by itself generally lacks scientific support as an indication for stress imaging. There are rare exemptions, such as patients requiring IC antiarrhythmic drugs, who might require coronary risk stratification prior to initiation of the drug.
    • CAD Risk—Low
      10-year absolute coronary or cardiovascular risk less than 10%.
    • CAD Risk—Moderate
      10-year absolute coronary or cardiovascular risk between 10% and 20%.  
    • CAD Risk—High
      10-year absolute coronary or cardiovascular risk of greater than 20%.

Risk Calculator	Link to Online Calculator
Framingham Cardiovascular Risk	https://reference.medscape.com/calculator/framingham-cardiovascular-disease-risk
Reynolds Risk Score Can use if no diabetes Unique for use of family history	http://www.reynoldsriskscore.org/
Pooled Cohort Equation	http://clincalc.com/Cardiology/ASCVD/PooledCohort.aspx?example
ACC/AHA Risk Calculator	http://tools.acc.org/ASCVD-Risk-Estimator/
MESA Risk Calculator With addition of Coronary Artery Calcium Score, for CAD-only risk	https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx

*Patients who have known CAD are already at high global risk and are not applicable to the calculators.

• Definitions of Coronary Artery Disease ^{(7,8,12,39,40)}

Percentage stenosis refers to the reduction in diameter stenosis when angiography is the method and can be estimated or measured using angiography or more accurately measured with intravascular ultrasound (IVUS).

• • Coronary artery calcification is a marker of risk, as measured by Agatston score on coronary artery calcium imaging. Its incorporation into Global Risk can be achieved by using the MESA risk calculator.
  • Ischemia-producing disease (also called hemodynamically or functionally significant disease, for which revascularization might be appropriate), generally implies at least one of the following:
    • Suggested by percentage diameter stenosis > 70% by angiography; intermediate lesions are 50 – 69% ⁽¹⁾
    • For a left main artery, suggested by a percentage stenosis ≥ 50% or minimum lumen cross-sectional area on IVUS ≤ 6 square mm ^(7,40,41)
    • FFR (fractional flow reserve) ≤ 0.80 for a major vessel ^(40,41)

• • FFR (fractional flow reserve) is the distal to proximal pressure ratio across a coronary lesion during maximal hyperemia induced by either intravenous or intracoronary adenosine. Less than or equal to 0.80 is considered a significant reduction in coronary flow
• Anginal Equivalent ^(7,42,43)
  • Development of an anginal equivalent (e.g., shortness of breath, fatigue, or weakness) either with or without prior coronary revascularization should be based upon the documentation of reasons to suspect that symptoms other than chest discomfort are not due to other organ systems (e.g., dyspnea due to lung disease, fatigue due to anemia). This may include respiratory rate, oximetry, lung exam, etc. (as well as d-dimer, chest CT(A), and/or PFTs, when appropriate), and then incorporated into the evaluation of coronary artery disease as would chest discomfort. Syncope per se is not an anginal equivalent. 

Summary of Evidence

ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease ⁽¹⁾

Study Design: This document is an appropriate use criterion (AUC) for the detection and risk assessment of chronic coronary disease. It was developed by the American College of Cardiology Solution Set Oversight Committee and other specialty societies.

Target Population: Patients with known or suspected chronic coronary disease, including those with symptoms of ischemia, those without symptoms but at risk for atherosclerotic cardiovascular disease, and those with other cardiovascular conditions.

Key Factors: The AUC provides ratings for various diagnostic and prognostic tests, including stress testing, imaging, and invasive procedures. It aims to guide clinicians in selecting appropriate tests based on clinical scenarios, considering factors such as patient symptoms, prior testing, and risk factors. The document also includes a "no test" option for certain scenarios, emphasizing the importance of clinical judgment and patient preferences.

 

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease ⁽⁷⁾

Study Design: This document is a practice guideline for the diagnosis and management of patients with stable ischemic heart disease. It was developed by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, along with other associations.

Target Population: Adult patients with stable known or suspected ischemic heart disease, including those with new-onset chest pain or stable pain syndromes.

Key Factors: The guideline covers various aspects such as clinical evaluation, risk assessment, treatment recommendations, and patient follow-up. It emphasizes the importance of patient involvement in decision-making and provides detailed recommendations for diagnosis, risk assessment, and treatment, including lifestyle modifications and medical therapy. 

 

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease ⁽⁹⁾

Study Design: This guideline provides an update on the management of patients with chronic coronary disease, consolidating new evidence since the previous guidelines. It was developed by the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

Target Population: Patients with chronic coronary disease, including those with stable ischemic heart disease and those who have had a myocardial infarction or revascularization.

Key Factors: The guideline emphasizes a patient-centered approach, considering social determinants of health and incorporating shared decision-making and team-based care. It includes recommendations for lifestyle changes, medical therapy, revascularization, and management of special populations.

Analysis ^(1,7,9) :

Stress echocardiography is consistently recognized as a valuable tool for diagnosing and managing patients with CAD and SIHD. The shared conclusions across the three articles highlight its diagnostic accuracy, non-invasive nature, and role in risk stratification. However, the articles differ in their focus on methodology, clinical scenarios, and technological advancements. The 2012 guidelines provide a foundational review of evidence, while the 2023 updates incorporate new studies and advancements in imaging technologies. The appropriate use criteria in the Winchester 2023 article offer practical guidance for clinicians in selecting the right test based on patient characteristics and clinical presentation.

Shared Conclusions:

• All three articles emphasize the diagnostic value of stress echocardiography in detecting myocardial ischemia and assessing cardiac function. Stress echocardiography is highlighted as a reliable method for evaluating patients with suspected coronary artery disease (CAD) and stable ischemic heart disease (SIHD).
• Stress echocardiography is consistently recommended for risk stratification in patients with known or suspected CAD. It helps in identifying patients at higher risk for adverse cardiovascular events, guiding therapeutic decision-making.
• The non-invasive nature of stress echocardiography is praised across all articles. It is considered a safer alternative to invasive procedures like coronary angiography, especially for initial diagnostic purposes 

 

Acronyms/Abbreviations

ACC: American College of Cardiology

ADLs: Activities of daily living

CABG: Coronary artery bypass grafting surgery

CAD: Coronary artery disease

CCTA: Coronary computed tomography angiography

CKD: Chronic kidney disease

CMR: Cardiovascular magnetic resonance imaging

CT(A): Computed tomography (angiography)

DTS: Duke Treadmill Score

ECG: Electrocardiogram

ETT: Exercise tolerance test

FFR: Fractional flow reserve

HCM: Hypertrophic cardiomyopathy

ISR: : In-Stent Restenosis

IVUS: Intravascular ultrasound         

LAD: Left anterior descending artery

LBBB: Left bundle-branch block

LCX: left circumflex artery

LVEF: Left ventricular ejection fraction

LVH: Left ventricular hypertrophy

LVOT: Left ventricular outflow tract

MESA: Multi-Ethnic Study of Atherosclerosis             

MET: Estimated metabolic equivalent of exercise

MI: Myocardial infarction

MPI: Myocardial perfusion imaging

MR: Mitral regurgitation

MS: Mitral stenosis

PAD: peripheral artery disease

PCI: Percutaneous coronary intervention

PET: Positron emission tomography

PFT: Pulmonary function test

PVCs: Premature ventricular contractions

RCA: Right coronary artery

SE: Stress echocardiography

SPECT: Single-photon emission computed tomography

SVG: Saphenous vein graph

TTE: Transthoracic echocardiography

VT: Ventricular tachycardia

VF: Ventricular fibrillation

WPW: Wolff-Parkinson-White

References

1.           Winchester DE, Maron DJ, Blankstein R, et al. ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease. J Am Coll Cardiol. 2023;81(25):2445-2467. doi:10.1016/j.jacc.2023.03.410

2.           Bonow RO, O’Gara PT, Adams DH, et al. 2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020;75(17):2236-2270. doi:https://doi.org/10.1016/j.jacc.2020.02.005

3.           Fitch Kathryn, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA Appropriateness Method User’s Manual. RAND.; 2001. Accessed October 8, 2024. https://www.rand.org/pubs/monograph_reports/MR1269.html

4.           Hendel RC, Lindsay BD, Allen JM, et al. ACC Appropriate Use Criteria Methodology: 2018 Update. J Am Coll Cardiol. 2018;71(8):935-948. doi:10.1016/j.jacc.2018.01.007

5.           Hendel RC, Patel MR, Allen JM, et al. Appropriate Use of Cardiovascular Technology: 2013 ACCF appropriate use criteria methodology update. J Am Coll Cardiol. 2013;61(12):1305-1317. doi:10.1016/j.jacc.2013.01.025

6.           Patel MR, Spertus JA, Brindis RG, et al. ACCF Proposed Method for Evaluating the Appropriateness of Cardiovascular Imaging. J Am Coll Cardiol. 2005;46(8):1606-1613. doi:10.1016/j.jacc.2005.08.030

7.           Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. Circulation. 2012;126(25):e354-471. doi:10.1161/CIR.0b013e318277d6a0

8.           Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease. Eur Heart J. 2013;34(38):2949-3003. doi:10.1093/eurheartj/eht296

9.           Virani SS, Newby LK, Arnold S V., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. J Am Coll Cardiol. 2023;82(9):833-955. doi:10.1016/j.jacc.2023.04.003

10.        Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415-3537. doi:10.1093/eurheartj/ehae177

11.        Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;144(22):e368-e454. doi:10.1161/CIR.0000000000001029

12.        Patel MR, Calhoon JH, Dehmer GJ, et al. ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease. J Am Coll Cardiol. 2017;69(17):2212-2241. doi:10.1016/j.jacc.2017.02.001

13.        Budoff MJ, Raggi P, Beller GA, et al. Noninvasive Cardiovascular Risk Assessment of the Asymptomatic Diabetic Patient. JACC Cardiovasc Imaging. 2016;9(2):176-192. doi:10.1016/j.jcmg.2015.11.011

14.        Hecht HS, Blaha MJ, Kazerooni EA, et al. CAC-DRS: Coronary Artery Calcium Data and Reporting System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr. 2018;12(3):185-191. doi:10.1016/j.jcct.2018.03.008

15.        Guzmán A, Navarro E, Obando L, et al. Effectiveness of interventions to reverse the diagnosis of metabolic syndrome: update of a mixed treatment comparison meta-analysis. Biomédica. 2019;39(4):647-662. doi:10.7705/biomedica.4684

16.        Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022;79(17):e263-e421. doi:10.1016/j.jacc.2021.12.012

17.        Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054

18.        Sachdeva R, Valente AM, Armstrong AK, et al. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease. J Am Coll Cardiol. 2020;75(6):657-703. doi:10.1016/j.jacc.2019.10.002

19.        Evbayekha EO, Nwogwugwu E, Olawoye A, et al. A Comprehensive Review of Myocardial Bridging: Exploring Diagnostic and Treatment Modalities. Cureus. Published online August 8, 2023. doi:10.7759/cureus.43132

20.        McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, treatment, and long-term management of Kawasaki disease. Circulation. 2017;135(17):e927-e999. doi:10.1161/CIR.0000000000000484

21.        Lancellotti P, Nkomo VT, Badano LP, et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging. 2013;14(8):721-740. doi:10.1093/ehjci/jet123

22.        Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease. J Am Coll Cardiol. 2017;70(13):1647-1672. doi:10.1016/j.jacc.2017.07.732

23.        Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol. 2021;77(4):e25-e197. doi:10.1016/j.jacc.2020.11.018

24.        Ommen SR, Ho CY, Asif IM, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy. J Am Coll Cardiol. 2024;83(23):2324-2405. doi:10.1016/j.jacc.2024.02.014

25.        Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944

26.        Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J. 2014;35(35):2383-2431. doi:10.1093/eurheartj/ehu282

27.        Velasco A, Reyes E, Hage FG. Guidelines in review: Comparison of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery and the 2014 ESC/ESA guidelines on noncardiac surgery: Cardiovascular assessment and management. Journal of Nuclear Cardiology. 2017;24(1):165-170. doi:10.1007/s12350-016-0643-8

28.        Doherty JU, Daugherty SL, Kort S, et al. ACC/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2024 Appropriate Use Criteria for Multimodality Imaging in Cardiovascular Evaluation of Patients Undergoing Nonemergent, Noncardiac Surgery. J Am Coll Cardiol. Published online October 8, 2024. doi:10.1016/j.jacc.2024.07.022

29.        Washington State Health Care Authority. Noninvasive Cardiac Imaging. 20211105A; 2022. https://www.hca.wa.gov/about-hca/programs-and-initiatives/health-technology-assessment/noninvasive-cardiac-imaging

30.        Diamond GA, Forrester JS. Analysis of Probability as an Aid in the Clinical Diagnosis of Coronary-Artery Disease. New England Journal of Medicine. 1979;300(24):1350-1358. doi:10.1056/NEJM197906143002402

31.        Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol. 2014;63(4):380-406. doi:10.1016/j.jacc.2013.11.009

32.        Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. Journal of Nuclear Cardiology. 2016;23(3):606-639. doi:10.1007/s12350-015-0387-x

33.        Shaw LJK, Peterson ED, Shaw LJK, et al. Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups. Circulation. 1998;98(16):1622-1630. doi:10.1161/01.cir.98.16.1622

34.        Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. J Am Coll Cardiol. 2019;74(10):e177-e232. doi:10.1016/j.jacc.2019.03.010

35.        D’Agostino RB, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: The Framingham heart study. Circulation. 2008;117(6):743-753. doi:10.1161/CIRCULATIONAHA.107.699579

36.        Goff DC, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. J Am Coll Cardiol. 2014;63:2935-2959. doi:10.1016/j.jacc.2013.11.005

37.        McClelland RL, Jorgensen NW, Budoff M, et al. 10-Year Coronary Heart Disease Risk Prediction Using Coronary Artery Calcium and Traditional Risk Factors. J Am Coll Cardiol. 2015;66(15):1643-1653. doi:10.1016/j.jacc.2015.08.035

38.        Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. JAMA. 2007;297(6):611-619. doi:10.1001/jama.297.6.611

39.        Tobis J, Azarbal B, Slavin L. Assessment of Intermediate Severity Coronary Lesions in the Catheterization Laboratory. J Am Coll Cardiol. 2007;49(8):839-848. doi:10.1016/j.jacc.2006.10.055

40.        Shlofmitz E, Ali ZA, Maehara A, Mintz GS, Shlofmitz R, Jeremias A. Intravascular Imaging-Guided Percutaneous Coronary Intervention: A Universal Approach for Optimization of Stent Implantation. Circ Cardiovasc Interv. 2020;13(12):E008686. doi:10.1161/CIRCINTERVENTIONS.120.008686

41.        Lotfi A, Davies JE, Fearon WF, Grines CL, Kern MJ, Klein LW. Focused update of expert consensus statement: Use of invasive assessments of coronary physiology and structure: A position statement of the society of cardiac angiography and interventions. Catheterization and Cardiovascular Interventions. 2018;92(2):336-347. doi:10.1002/ccd.27672

42.        Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope. J Am Coll Cardiol. 2017;70(5):e39-e110. doi:10.1016/j.jacc.2017.03.003

43.        Brignole M, Moya A, de Lange FJ, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883-1948. doi:10.1093/eurheartj/ehy037

Coding Section

Codes	Number	Description
CPT	93320	Doppler echocardiography, pulsed wave and/or continuous wave with special display (list separately in addition to codes for echocardiography imaging); complete
	93321	Doppler echocardiography, pulsed wave and/or continuous wave with special display (list separately in addition to codes for echocardiography imaging); follow-up or limited study (list separately in addition to codes for echocardiography imaging)
	93325	Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography imaging)
	93350	Echocardiography, transthoracic, real-time with image documentation (2D), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress with interpretation and report
	93351	Echocardiography, transthoracic, real-time with image documentation (2D), includes m-mode recording, when performed, during the rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional.
	93352	Use of echocardiographic contrast agent during stress echocardiography   (list separately in addition to code for primary procedure)
	93356	Myocardial strain imaging using speck tracking-derived assessment of myocardial mechanics (list separately in addition to codes for echocardiography imaging)
	C89230	sweat collection by iontophoresis
	C89240	unlisted miscellaneous pathology test
	C89280	assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes
	C89290	biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos
	C89300	semen analysis; presence and/or motility of sperm including Huhner Test (coital)

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2026 Forward     

01/28/2026

NEW POLICY