American College of Cardiology

View all recommendations from this society

Released February 23, 2023

Avoid routine imaging stress tests or coronary CT angiography for the workup of palpitations or presyncope.

Palpitations, dizziness, lightheadedness, and presyncope are common symptoms. Not infrequently, these are worked-up with a variety of testing modalities including advanced cardiac imaging (PET or SPECT myocardial perfusion imaging, cardiac magnetic resonance imaging, or cardiac computed tomography). In the absence of other symptoms or signs of cardiovascular disease, cardiac imaging beyond a transthoracic echocardiogram is rarely warranted.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American College of Cardiology (ACC) formed a Choosing Wisely workgroup of member leaders from the Board of Governors, subspecialty experts, and health policy specialists. The workgroup was tasked with identifying five clinical scenarios where specific tests, treatments, or procedures should be avoided for lack of benefit. These five recommendations were pulled from ACC’s existing appropriate use criteria (AUC) and clinical practice guidelines, selecting items that were either Rarely Appropriate AUC indications or Class III guideline recommendations. The ACC’s Clinical Policy Approval Committee and Science & Quality Committee then reviewed and approved the final five items.

ACC’s disclosure and conflict of interest policy can be found at


Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease. J Am Coll Cardiol. 2019;73:488-516.

Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2017;70:e39-e110.