Imaging in Coronary Artery Disease Risk Stratification

This Clinical Decisions article presents a 58-year-old woman with epigastric pain, shoulder and jaw discomfort, and exertional dyspnea, evaluated in the emergency department for possible coronary artery disease. Her initial ECG reveals nonspecific T-wave changes, and serial high-sensitivity troponin tests are negative. With a CHA₂DS₂-VASc score suggesting moderate cardiovascular risk and symptoms potentially ischemic in nature, two diagnostic strategies are reviewed:

• Radionuclide myocardial perfusion imaging is advocated for its ability to assess myocardial blood flow under stress and predict outcomes like infarction or death. Its clinical utility lies in correlating exercise-induced symptoms with perfusion defects and its widespread availability, although it may be less actionable several hours after symptom onset.
• Coronary CT angiography is proposed for its high diagnostic accuracy and negative predictive value, with added capability for fractional flow reserve (FFR-CT) assessment. Studies such as SCOT-HEART and ISCHEMIA support CT-based anatomical imaging for risk stratification and preventive therapy decisions.

This Clinical Decisions article presents a 58-year-old woman with epigastric pain, shoulder and jaw discomfort, and exertional dyspnea, evaluated in the emergency department for possible coronary artery disease. Her initial ECG reveals nonspecific T-wave changes, and serial high-sensitivity troponin tests are negative. With a CHA₂DS₂-VASc score suggesting moderate cardiovascular risk and symptoms potentially ischemic in nature, two diagnostic strategies are reviewed:

• Radionuclide myocardial perfusion imaging is advocated for its ability to assess myocardial blood flow under stress and predict outcomes like infarction or death. Its clinical utility lies in correlating exercise-induced symptoms with perfusion defects and its widespread availability, although it may be less actionable several hours after symptom onset.
• Coronary CT angiography is proposed for its high diagnostic accuracy and negative predictive value, with added capability for fractional flow reserve (FFR-CT) assessment. Studies such as SCOT-HEART and ISCHEMIA support CT-based anatomical imaging for risk stratification and preventive therapy decisions.