Stress testing for diagnosis and prognosis of coronary artery disease In most cases, the initial approach to a patient with suspected coronary artery disease has been to perform myocardial stress testing which has served as a gatekeeper for invasive coronary angiography. The introduction of catheter-based coronary angiography in 1958 greatly helped the understanding and the treatment of CAD, but its associated risks restricted its application to selected patients with high pre-test probability of CAD. These ambiguities represent a major challenge to any diagnostic tool which aims at reliably establishing a diagnosis. Conversely, CAD is diagnosed in the absence of an acute coronary syndrome if angiography shows obstructive CAD. In patients with acute chest pain, the diagnosis of CAD is made if an acute coronary syndrome is confirmed by biomarkers and electrocardiogram (ECG), even in the presence of only mild CAD on cardiac catheterization. 6, 7 The diagnosis of CAD is further complicated when patients present with acute symptoms. In the light of ample evidence that many myocardial infarctions arise from coronary atherosclerotic lesions that are only mildly stenotic, the rationale for this terminology should be questioned. CAD is commonly used to describe the condition of stenosed coronary arteries that are associated with symptoms, often termed obstructive or significant CAD. Rather, its significance is defined by its quantity and extent. 4, 5 Thus, unlike other diseases, such as cancer or infections, the diagnosis of CAD is typically not categorical, i.e. Most seemingly healthy adult Americans have evidence of coronary atherosclerosis, with approximately 10% having obstructive disease. The diagnosis of CAD begins with a dilemma: while any definition of CAD includes a description of coronary atherosclerotic disease, there is no consensus on how much atherosclerosis is required to fulfill criteria for CAD.

Finally, the implications of this review are discussed in relation to clinical practice. This article reviews the clinical utility, limitations, as well as the hazards of stress testing compared with non-invasive coronary artery imaging by computed tomography.

These data challenge the role of stress testing as the initial imaging modality in patients with suspected coronary artery disease.

Much data in support of the diagnostic accuracy and prognostic value of non-invasive coronary angiography by computed tomography have emerged within the last few years. With the emergence of non-invasive coronary angiography, the question arises if such a strategy is still sensible, particularly, in view of only a modest agreement between stress testing results and the presence of coronary artery disease established by cardiac catheterization. To avoid the risks of an invasive procedure, stress testing is often employed for an initial assessment of patients with suspected coronary artery disease, serving as a gatekeeper for cardiac catheterization. Until recently, the diagnosis of coronary artery disease was possible only through cardiac catheterization and invasive coronary angiography. Diagnosis and management of coronary artery disease represents major challenges to our health care system, affecting millions of patients each year.

Autocad 2012 assessment test