Learn · Part 3. Choosing · 5 min read
How to think about choosing a test
The patient-level questions that shape a choice, and why the same test is rated differently in different scenarios.
60-second take
- The published criteria rate tests for scenarios. They do not rank tests, and they assume no contraindications.
- Questions that shape a choice: symptoms and how typical, prior test results, known coronary disease, ability to exercise, interpretable resting ECG, body habitus, kidney function, local expertise, and what decision the result will change.
- Some of these set the scenario in the tool, others appear as patient factors beside the rating, and local availability is yours to add.
- The same test can carry different ratings in neighbouring scenarios because the balance of benefit and risk changes.
Start with the patient, not the test
The published appropriate use criteria (AUC) rate each test for a clinical scenario. They do not rank the tests against each other, and they say so: ratings are specific to scenarios, and more than one test, or even all of them, can fall in the same category . The raters were also asked to assume that each test is locally available, performed on appropriate equipment and read by trained people , and that the patient has no contraindications to any of the tests . Several of the questions below are therefore yours to add on top of the ratings.
The questions that shape a choice
| Question | Why it matters | In the tool |
|---|---|---|
| Symptoms, and how typical? | Symptoms are the main thing that routes a patient to a table . The 2023 AUC separates likely anginal symptoms, less-likely anginal symptoms, and symptoms with a clear noncardiac explanation . | Scenario question: character of the symptoms. |
| Pretest likelihood and prior test results? | For symptomatic patients with no prior testing, the 2023 AUC dropped the step of calculating a pretest likelihood and groups patients by age and risk factors instead . Prior results have their own table. The diagnostic and prognostic value of a previous test generally decreases over time , and after an equivocal or inconclusive test, a different modality is the assumption if more testing is warranted . | Scenario questions: age, risk factors, and testing already done. |
| Known coronary disease? | Prior MI or revascularization is rated in a separate table . The 2023 chronic coronary disease guideline advises that, when there is an opportunity, clinicians should first intensify guideline-directed medical therapy and defer testing . | Scenario question: established coronary disease. |
| Can the patient exercise? | When rating exercise tests, the AUC assumes the patient can exercise to a symptomatic endpoint and reach at least 80% of predicted workload or 85% of predicted maximal heart rate . The 2021 guideline points to being able to reach 5 METs or more for exercise ECG . Exercise is the preferred stressor when the patient can do it adequately . | Patient factor, not a rating input. |
| Is the resting ECG interpretable? | Unless stated otherwise, the AUC assumes it is . Abnormal resting ST changes, digoxin, left bundle branch block, pre-excitation and paced rhythm are listed constraints for exercise ECG . | Patient factor. |
| Body habitus and acoustic windows? | Echo can be limited by acoustic windows (COPD, obesity, breast implants), SPECT by attenuation and soft-tissue artifacts, and CCTA by morbid obesity, high or irregular heart rates or heavy calcification . The 2021 guideline asks readers to consider image quality for all modalities, particularly in obese patients . | Patient factor. |
| Kidney function? | Reduced GFR (below 30 mL/min/1.73 m²) is a listed contraindication to stress CMR, and renal impairment, as defined by local protocols, is a listed constraint for CCTA . | Patient factor. |
| Local availability and expertise? | Testing choice is influenced by site expertise and availability . When several tests sit in the same rating category, clinician judgment, each test’s advantages and disadvantages and local expertise are assumed to be weighed . | Not asked. This is yours to add. |
| What decision will the result change? | The AUC treats routine or surveillance testing as testing done only because time has passed, with no change in circumstances or need to change therapy . It also includes a “defer testing” option , and advises that testing should typically not be performed “just to be sure” when a clear noncardiac cause is present . | The “No test” result and the routine-testing scenarios. |
Why the same test is rated differently in different scenarios
A rating describes how benefits and risks balance for a population of patients like the one in the scenario. “Appropriate” means benefits generally outweigh risks, “Rarely Appropriate” means there is no clear benefit-to-risk advantage, and “May Be Appropriate” covers variable evidence or disagreement . That balance moves as the symptoms, the patient’s history and the prior results change, so one test can carry different ratings in neighbouring scenarios. The three examples below come straight from the tool’s own data. Pick any one test, such as the exercise ECG or CCTA, and follow it across the cards.
Example from the tool
Less-likely anginal symptoms with a noncardiac explanation
Stable symptoms with a clear noncardiac explanation, no prior testing.
- Exercise ECGRarely Appropriate
- Exercise SPECTRarely Appropriate
- Pharmacologic SPECTRarely Appropriate
- Pharmacologic PETRarely Appropriate
- Exercise echoRarely Appropriate
- Dobutamine echoRarely Appropriate
- Stress CMRRarely Appropriate
- CAC scoreRarely Appropriate
- CCTARarely Appropriate
- Invasive angiographyRarely Appropriate
- No testAppropriate
Example from the tool
Less-likely anginal symptoms, age 50 y or above and/or ≥2 CV risk factors
Less-likely anginal symptoms, older or with several risk factors, no prior testing.
- Exercise ECGMay Be Appropriate
- Exercise SPECTMay Be Appropriate
- Pharmacologic SPECTMay Be Appropriate
- Pharmacologic PETMay Be Appropriate
- Exercise echoMay Be Appropriate
- Dobutamine echoMay Be Appropriate
- Stress CMRMay Be Appropriate
- CAC scoreMay Be Appropriate
- CCTAMay Be Appropriate
- Invasive angiographyRarely Appropriate
- No testMay Be Appropriate
Example from the tool
Likely anginal symptoms, age 50 y or above and/or ≥2 CV risk factors
Likely anginal symptoms, older or with several risk factors, no prior testing.
- Exercise ECGAppropriate
- Exercise SPECTAppropriate
- Pharmacologic SPECTAppropriate
- Pharmacologic PETAppropriate
- Exercise echoAppropriate
- Dobutamine echoAppropriate
- Stress CMRAppropriate
- CAC scoreMay Be Appropriate
- CCTAAppropriate
- Invasive angiographyAppropriate
- No testRarely Appropriate
Open any card to read the reasons behind each rating: the justification, the rule applied and the source passage.
Putting it together
A practical order is: decide what you need to learn, work out which scenario the patient belongs to, check which patient factors apply, then bring in local availability and what the result will change. The scenario builder follows roughly the same sequence, so it is a convenient way to practise.
Try the scenario builder → with a patient you know. Answer the scenario questions first, then open the patient factors strip to see how contraindications and cautions line up against the ratings.
Try it in the tool
Sources cited on this page
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