Stressing Wisely
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About Stressing Wisely

Purpose

Stressing Wisely is an educational tool that lays the published appropriate use criteria for testing in chronic coronary disease side by side, so that trainees and clinicians can see how each modality is rated for a given clinical scenario, read the exact criterion behind the rating, and understand how contraindications change what is feasible.

Scope

Adults aged 18 and over in stable outpatient settings: stable symptoms possibly due to ischemia, established coronary disease, asymptomatic indications (risk assessment, surveillance, arrhythmia, heart failure, syncope, exercise programs), and evaluation before nonemergent noncardiac surgery. Acute chest pain and acute coronary syndromes, pregnancy, congenital heart disease and pediatrics are outside the scope, as are decisions about revascularization.

What the ratings mean

Appropriate, May Be Appropriate and Rarely Appropriate are the categories used by the ACC/AHA and SNMMI appropriate use criteria, as published. They are explicitly not competitive rankings. Where a document deliberately did not rate a combination the cell says “Not applicable”; where no document and no defensible inference exists it says “No data”. Inferred cells carry a confidence grade and the rule that produced them.

Not medical advice

This tool is for education and reference. It does not provide medical advice, does not establish a standard of care, and must not replace the judgment of a licensed clinician who knows the patient. Appropriate use criteria state that they should not be the sole determinant of payment decisions; the same applies here.

Privacy

The app is static. Scenario answers and contraindication selections are processed in your browser and are not transmitted or stored on a server. Your last scenario is kept in your browser’s session storage so that you can edit it.

Source documents

  • 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. Winchester DE, Maron DJ, Blankstein R, et al. J Am Coll Cardiol. 2023;81(25):2445-2467. doi:10.1016/j.jacc.2023.03.410
  • 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. Doherty JU, Daugherty SL, Kort S, et al. J Am Coll Cardiol. 2024;84(15):1455-1491. doi:10.1016/j.jacc.2024.07.022
  • Appropriate Use Criteria for PET Myocardial Perfusion Imaging 2.0. Schindler TH, Bateman TM, Berman DS, et al. Appropriate Use Criteria for PET Myocardial Perfusion Imaging 2.0. Society of Nuclear Medicine and Molecular Imaging; 2025 (pre-publication manuscript).
  • 2026 ASNC guideline for stress testing in single-photon emission computed tomography (SPECT) and positron emission tomography (PET) myocardial perfusion imaging. Duvall WL, Skali H, Aggarwal NR, et al. J Nucl Cardiol. 2026 (journal pre-proof).
  • Clinical indications for positron emission tomography myocardial perfusion imaging and myocardial blood flow quantification: An American Society of Nuclear Cardiology position statement. Bateman TM, Al-Mallah MH, Alnabelsi TS, et al. J Nucl Cardiol. 2026;57:102619. doi:10.1016/j.nuclcard.2025.102619
  • Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. Pellikka PA, Arruda-Olson A, Chaudhry FA, et al. J Am Soc Echocardiogr. 2020;33(1):1-41.e8. doi:10.1016/j.echo.2019.07.001
  • Standardized cardiovascular magnetic resonance imaging (CMR) protocols: 2020 update. Kramer CM, Barkhausen J, Bucciarelli-Ducci C, et al. J Cardiovasc Magn Reson. 2020;22:17. doi:10.1186/s12968-020-00607-1
  • SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. Narula J, Chandrashekhar Y, Ahmadi A, et al. J Cardiovasc Comput Tomogr. 2021;15(3):192-217. doi:10.1016/j.jcct.2020.11.001
  • Fractional flow reserve in coronary computed tomography angiography: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT) and the Society for Cardiovascular Angiography and Interventions (SCAI). Weir-McCall JR, et al. J Cardiovasc Comput Tomogr. 2026;20:316-332.
  • 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Gulati M, Levy PD, Mukherjee D, et al. Circulation. 2021;144:e368-e454. doi:10.1161/CIR.0000000000001029
  • 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease. Virani SS, Newby LK, Arnold SV, et al. J Am Coll Cardiol. 2023;82(9):833-955. doi:10.1016/j.jacc.2023.04.003
  • 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Rao SV, O'Donoghue ML, Ruel M, et al. J Am Coll Cardiol. 2025;85(22). (context only)

Quotations from these documents are reproduced for educational commentary with citation. The documents remain the property of their publishers.

Version

Version 3 (2026) replaces the 2023 R/Shiny application. The clinical logic is regenerated from the source tables and the rule registry; see the repository’s DECISIONS.md for the judgment calls made.