Perform coronary angiography Yes Heart Team concludes that anatomy and clinical factors indicate revascularization may improve survival (Table 18) Determine optimal method of revascularization based upon patient preferences, anatomy, other clinical factors, and local resources and expertise (Table 18) Yes No No Noninvasive testing suggests high-risk coronary lesion(s) from Figure 2 Continued Guideline- Directed Medical Therapy with ongoing patient education Go to Figure 4 Guideline-Directed Medical Therapy continued in all patients Figure 5. Algorithm for revascularization to improve survival of patients with SIHD.* *Colors correspond to the class of recommendations in the ACCF/AHA Table 1. The algorithms do not represent a comprehensive list of recommenda- tions (see text for all recommendations). pleural disease. Evidence of vascular disease includes carotid or renal artery bruits, a diminished pedal pulse, or a palpable abdominal aneurysm. Elevated blood pressure (BP), xantho- mas, and retinal exudates point to the presence of IHD risk factors. Pain reproduced by pressure on the chest wall suggests a musculoskeletal etiology but does not eliminate the possibility of angina due to IHD. 2.1.4.1. Resting Electrocardiography to Assess Risk: Recommendation Class I 1. A resting ECG is recommended in patients without an obvious, noncardiac cause of chest pain.57 59 (Level of Evidence: B) Patients with SIHD who have the following abnormalities on a resting ECG have a worse prognosis than those with normal ECGs57 59: evidence of prior MI, especially Q waves in multiple leads or an R wave in V1 indicating a posterior infarction60; persistent ST-T-wave inversions, particularly in leads V1 to V361 64; left bundle-branch block (LBBB), bifascicular block, second- or third-degree atrioventricular Figure 6. Algorithm for revascularization to improve symptoms of patients with SIHD.* *Colors correspond to the class of recommendations in the ACCF/AHA Table 1. 