In settings where the study may be adequately monitored, dobutamine-stress functional cardiac MRI provides high sensitivity and specificity for ischemia by the induction of wall motion abnormality [56]. However, adenosine-stress cardiac MRI perfusion imaging is easier to perform and also has been shown to have relatively high sensitivity and specificity for the presence of CAD [56-59]. Dipyridamole-stress MRI can also show ischemia-related wall motion abnormalities, perfusion defects and scar and can help direct revascularization [60]. MRA Coronary Arteries Coronary MRA is a developing modality to evaluate the coronary arteries. Coronary MRA has been shown to identify severe stenosis, but its sensitivity and specificity for moderate or mild lesions is lower [61,62]. Technological developments may make the use of coronary MRA more widespread and result in shorter acquisition times and improved spatial resolution [63]. Arteriography Coronary ICA may be used if less-invasive imaging was consistent with the presence of significant CAD. However, the use of ICA as a first-line tool to evaluate for CAD in patients who are low to intermediate probability will not have a high diagnostic yield [64], and utilizing noninvasive testing prior to ICA increases the yield of positive ICA [64]. Exercise Treadmill Testing Exercise treadmill testing can be of value in the assessment of patients with low to intermediate probability for CAD. Among patients who are low to intermediate probability, exercise treadmill testing in the acute setting showed a high specificity for detecting CAD with a greater than 50% stenosis [65]. This procedure is not included on the variant table because generally only imaging procedures are assessed for appropriateness in the ACR Appropriateness Criteria documents.
Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. In settings where the study may be adequately monitored, dobutamine-stress functional cardiac MRI provides high sensitivity and specificity for ischemia by the induction of wall motion abnormality [56]. However, adenosine-stress cardiac MRI perfusion imaging is easier to perform and also has been shown to have relatively high sensitivity and specificity for the presence of CAD [56-59]. Dipyridamole-stress MRI can also show ischemia-related wall motion abnormalities, perfusion defects and scar and can help direct revascularization [60]. MRA Coronary Arteries Coronary MRA is a developing modality to evaluate the coronary arteries. Coronary MRA has been shown to identify severe stenosis, but its sensitivity and specificity for moderate or mild lesions is lower [61,62]. Technological developments may make the use of coronary MRA more widespread and result in shorter acquisition times and improved spatial resolution [63]. Arteriography Coronary ICA may be used if less-invasive imaging was consistent with the presence of significant CAD. However, the use of ICA as a first-line tool to evaluate for CAD in patients who are low to intermediate probability will not have a high diagnostic yield [64], and utilizing noninvasive testing prior to ICA increases the yield of positive ICA [64]. Exercise Treadmill Testing Exercise treadmill testing can be of value in the assessment of patients with low to intermediate probability for CAD. Among patients who are low to intermediate probability, exercise treadmill testing in the acute setting showed a high specificity for detecting CAD with a greater than 50% stenosis [65]. This procedure is not included on the variant table because generally only imaging procedures are assessed for appropriateness in the ACR Appropriateness Criteria documents.