Unstable Chest Pain Evidence Table
Year Author Title
2013 D'Ascenzo "Coronary computed tomographic
angiography for detection of coronary
artery disease in patients presenting to
the emergency department with chest
pain: a meta-analysis of randomized
clinical trials"
2017 Chen "Coronary computed tomographic
angiography for patients with low-to-
intermediate risk chest pain: a systematic
review and meta-analysis"
2019 Iannaccone "Diagnostic accuracy of functional,
imaging and biochemical tests for patients
presenting with chest pain to the
emergency department: a systematic
review and meta-analysis"
2016 Nabi "Optimizing evaluation of patients with
low-to-intermediate risk acute chest pain: Medicine
a randomized study comparing stress
myocardial perfusion tomography
incorporating stress-only imaging versus
cardiac CT"
2016 Dedic "Coronary CT angiography for suspected
ACS in the era of high-sensitivity
troponins"
2015 Levsky "Coronary computed tomography
angiography versus radionuclide
myocardial perfusion imaging in patients
with chest pain admitted to telemetry"
2015 Linde "Long-term clinical impact of coronary CT JACC: Cardiovascular
angiography in patients with recent acute- Imaging
onset chest pain"
2014 Hamilton-Craig "Diagnostic performance and cost of CT International Journal of
angiography versus stress ECG—a Cardiology
randomized prospective study of
suspected acute coronary syndrome chest
pain in the emergency department (CT-
COMPARE)"
2013 Miller "Stress CMR reduces revascularization,
hospital readmission, and recurrent
cardiac testing in intermediate-risk
patients with acute chest pain"
2013 Linde "Cardiac computed tomography guided
treatment strategy in patients with recent Cardiology
acute-onset chest pain: results from the
randomised, controlled trial: CArdiac cT in
the treatment of acute CHest pain
(CATCH)"
2012 Hoffmann "Coronary CT angiography versus
standard evaluation in acute chest pain"
2012 Litt "CT angiography for safe discharge of
patients with possible acute coronary
syndromes"
2011 Miller "Is coronary computed tomography
angiography a resource sparing strategy in
the risk stratification and evaluation of
acute chest pain? Results of a randomized
controlled trial"
2011 Goldstein "The CT-STAT (coronary computed
tomographic angiography for systematic
triage of acute chest pain patients to
treatment) trial"
2010 Miller "Stress cardiac magnetic resonance
imaging with observation unit care
reduces cost for patients with emergent
chest pain: a randomized trial"
Journal Grade Notes n Rule Rule (simple)
European Heart Journal 1a Meta-analysis of RCT (4) For patients with low to intermediate risk chest CCTA increases revascularization,
— Cardiovascular n=2,567 pain, CCTA increases coronary reduces time to diagnosis and
Imaging revascularizations (OR 1.88), reduces time to decreases costs.
2,567
diagnosis (-7.68 hr) and decreases ED costs (-
$680).
Oncotarget 1a Systematic, meta-analysis of For patients wth low to intermediate risk chest CCTA does not alter clinical
randomized (8) n=14,749 pain, CCTA versus SOC increased the rate of outcomes in comparison to SOC.
14,749
coronary angiography, with similar rates of
MACE, death and readmission.
European Heart Journal. 1a Meta-analysis of prospective "Coronary computed tomography showed the CCTA is the most accurate
Acute Cardiovascular studies (observational or highest level of diagnostic accuracy (sensitivity noninvasive modality for acute
Care randomized controlled trial) 0.93 [0.81–0.98] and specificity 0.90 chest pain, followed by myocardial
comparing [0.93–0.94]), along with myocardial perfusion perfusion. Stress echo and
functional/imaging or scintigraphy (sensitivity 0.85 [0.77–0.91] and exercise testing is less efficacious.
biochemical tests for patients 49,541 specificity 0.92 [0.83–0.96]). Stress echography
presenting with chest pain to was inferior to coronary computed
the emergency department tomography but noninferior to myocardial
— 77 studies, 49,541 patients perfusion scintigraphy, while exercise testing
(mean age 59.9 years) showed the lower level of diagnostic
accuracy. "
The Journal of Nuclear 1b RCT n=598 For patients with low to intermediate risk chest SPECT optimized with stress-only
pain, SPECT optimized with stress-only imaging imaging is an alternative to CCTA
was similar to CCTA in time to diagnosis, length with potential benefits.
598 of hospital stay and cost, with improved
prognostic accuracy and less radiation.
Journal of the American 1b RCT n=500 For patients with low to intermediate risk chest CCTA reduces outpatient testing
College of Cardiology pain, hsTN plus CCTA is associated with less and lowers costs (34%).
outpatient testing and lower direct medical
500 costs (34%), but did not identify more patients
requiring ICA, shorten hospital stay or increase
discharge rates.
Annals of Internal 1b RCT n=400 For patients with low to intermediate risk chest CCTA and MPI do not significantly
Medicine pain, CCTA versus MPI resulted in similar ICA differ in outcomes or resource
(15% v 16%) at one year, lengths of stay (28.9 v utilization. CCTA reduces radiation
30.4 hr), death (0.5% v 3%), CV events (4.5% v and increases patient satisfaction
4.5%), re-hospitalization (43% v 49%), ED visits over MPI.
400 (63% v 58%) and outatient cardiology visits
(23% v 21%) at 40.4 months. CCTA resulted in
lower radiation exposure (24 v 29 mSv) and
higher patient satisfaction.
1b RCT n=600 For patients with low to intermediate risk chest CCTA improves clinical outcomes
pain, CCTA versus SOC resulted in decreased
600 rates of MACE (cardiac death, MI,
hospitalization for unstable angina, late
revascularization; HR 0.36, p=0.04)
1b RCT n=562 For patients with low to intermediate risk chest CCTA improves diagnostic
pain, CCTA had a sensitivity of 100% and a performance with decreased
specificity of 94%, with higher odds of hospital costs (20%) and length of
562 downstream testing (OR 2.0) but lower 30-day stay (35%).
costs ($2,193 v $2,704) and length of stay (13.5
hr v 19.7 hr). No post-discharge CV events at
30 d.
JACC: Cardiovascular 1b RCT n=105 For patients with low to intermediate risk chest CMR reduces revascularization,
Imaging pain, CMR versus SOC (admission) reduced readmission and recurrent testing
length of stay, revascularizations, hospital over SOC.
105 readmission and recurrent cardiac testing,
without increasing post-discharge ACS at 90 d.
International Journal of 1b RCT n=600 For patients with low to intermediate risk chest CCTA improves PPV for significant
pain, CCTA had a PPV of significant stenoses of coronary stenosis and increases
71% (versus 36% with SOC). ICA rates were revascularization freq.
similar (17% CCTA, 12% SOC), but confirmed
significant stenosis in 12% CCTA versus 4% in
600
SOC (p=.001), with higher rates of
revascularization (10% versus 4%). Clinical
events at 120 days were similar in both groups
(3% CCTA, 5% SOC).
The New England 1b RCT (age 40–74) n=1,000 If ACS is suspected, ED patients 40–75 yo, CCTA CCTA improves clinical decision
Journal of Medicine versus SOC decreased ED discharge time (7.6 making.
hr), increased direct discharge from ED (47%
1,000 versus 12%) and increased downstream
testing. There was no difference in cumulative
costs.
The New England 1b RCT (2:1, age>30) n=1,370 For patients >30 yrs with low to intermediate CCTA resulted in safe, expedited
Journal of Medicine risk chest pain, CCTA was safe (0% death or MI and increased rates of ED
1,370 at 30 days), increased ED discharge (49.6% discharge.
versus 22.7%) and shortened length of stay (18
hr versus 24.8 hr).
Academic Emergency 1b RCT n=60 For patients with low to intermediate risk chest CCTA reduces re-hospitalization
Medicine pain, CCTA versus SOC resulted in reduced re- (90 d) without increasing cost.
60 hospitalization at 90 d without increasing
resources (cost) used.
Journal of the American 1b RCT n=699 For patients with low to intermediate risk chest CCTA reduces time to diagnosis
College of Cardiology pain, CCTA versus MPI resulted in 54% (54%) and cost (38%) over MPI.
reduction in time to diagnosis (2.9 h versus 6.3
699 h), 38% reduction in costs ($2,137 versus
$3,458) with no difference in MACE (0.8%
versus 0.4%).
Annals of Emergency 1b RCT n=110 For patients with low to intermediate risk chest CMR reduces costs over SOC.
Medicine pain, CMR versus SOC (admission) reduced
110 incident cost without any cases of missed ACS.

Year Author Title
2008 Chang "Usefulness of 64-slice multidetector
computed tomography as an initial
diagnostic approach in patients with acute
chest pain"
2014 El-Hayek "Meta-analysis of coronary computed
tomography angiography versus standard Cardiology
of care strategy for the evaluation of low
risk chest pain: are randomized controlled
trials and cohort studies showing the
same evidence?"
2011 Takakuwa "A meta-analysis of 64-section coronary
CT angiography findings for predicting 30-
day major adverse cardiac events in
patients presenting with symptoms
suggestive of acute coronary syndrome"
2012 Bunch "A systematic review of the predictive
value of a coronary computed
tomography angiography as compared
with coronary calcium scoring in
alternative noninvasive technique in
detecting coronary artery disease and
evaluating acute coronary syndrome in an
acute care setting"
2015 Stochkendahl "Clinical characteristics, myocardial International Journal of
perfusion deficits, and clinical outcomes Cardiology
of patients with non-specific chest pain
hospitalized for suspected acute coronary
syndrome: a four-year prospective cohort
study"
2015 Ferencik "Highly sensitive troponin I followed by
advanced coronary artery disease
assessment using computed tomography
angiography improves acute coronary
syndrome risk stratification accuracy and
work-up for patients with acute chest pain
— results from ROMICAT II trial"
2015 Pursnani "Use of coronary artery calcium scanning Circulation:
beyond coronary computed tomographic Cardiovascular Imaging
angiography in the emergency
department evaluation for acute chest
pain: the ROMICAT II trial"
2015 Ferencik "Computed tomography-based high-risk
coronary plaque score to predict acute
coronary syndrome among patients with
acute chest pain—results from the
ROMICAT II trial"
2014 Puchner "High-risk plaque detected on coronary CT
angiography predicts acute coronary
syndromes independent of significant
stenosis in acute chest pain: results from
the ROMICAT-II trial"
2020 Linde "Coronary CT angiography in patients with
non-ST-segment elevation acute coronary
syndrome"
ACS acute coronary syndrome
CAC coronary artery calcium
CCTA coronary computed tomographic
angiography
CMR cardiac magnetic resonance
ED emergency department
hsTN high-sensitivity troponin
ICA invasive coronary angiography
MACE major adverse cardiac event
MI myocardial infarction
MPI myocardial perfusion imaging
OR odds ratio
RCT randomized control trial
SOC standard of care
SPECT single photon emission computed
tomography
Unstable Chest Pain Evidence Table
Journal Grade Notes
American Heart Journal 1b RCT n=268
International Journal of 2a Meta-analysis of RCT (4) and
cohorts (3) n=6,058
Academic Radiology 2a Meta-analysis of (9) n=1,559
Dimensions of Critical 2a Systematic review of
Care Nursing prospective/RCT/review
studies (12) n=7,530
2b Prospective cohort, n=272
JACC: Cardiovascular 2b Prospective cohort, n=160
Imaging
2b (RCT subanalysis) CCTA
patients taken from RCT,
n=473
Journal of 2b (RCT subanalysis) CCTA
Cardiovascular patients taken from RCT,
Computed Tomography n=260
Journal of the American 2b (RCT subanalysis) CCTA
College of Cardiology patients taken from RCT,
n=472
Journal of the American 2b (RCT subanalysis) The
College of Cardiology VERDICT (Very Early Versus
Deferred Invasive Evaluation
Using Computerized
Tomography for patients
with acute coronary
syndrome) trial
(NCT02061891) of NSTEACS
randomized to very early
(within 12 h) or standard (48
to 72 h) invasive coronary
angiography (ICA).
Observational component of
the trial, a clinically blinded
coronary CTA was conducted
prior to ICA in both groups.
Coronary CTA was conducted
in 1,023 patients
n Rule Rule (simple)
For patients with low, intermediate and high CCTA is safe and reduces length of
risk chest pain, CCTA versus SOC resulted in stay.
268 similar ACS diagnosis, with decreased length of
stay and no MACE at follow-up.
For patients with low to intermediate risk chest CCTA reduces risk of ACS and
pain, CCTA versus SOC resulted in reduced risk future ED visits.
of ACS and rates of repeat ED visits, less
6,058 hospital readmission, and no difference in ICA
but increased revascularization procedures.
For patients with low to intermediate risk chest CCTA identifies patients who can
pain, CCTA had a pooled sensitivity of 93.3, be safely discharged (NPV 99.3%).
1,559 specificity of 89.9, PPV 48.1, NPV 99.3 for
excluding 30 d MACE. (Note: positive result
was ≥ 50% stenosis.)
CCTA versus CAC scoring resulted in higher CCTA improves diagnostic
pooled sensitivity (92.9% v 90%), specificity accuracy over coronary artery
(84.4% v 66.7%) and PPV (70% v 37.5%), with calcium scoring.
slightly lower NPV (96.4% v 97.9%).
7,530
For patients with acute, nonspecific chest pain SPECT MPI predicts incident CAD.
(age 18–75), SPECT MPI with +myocardial
perfusion deficit predicted primary (CAD death,
272 ACS, revascularization) and secondary (all-
cause death, stroke) outcomes that were not
differentiated by usual clinical classifications.
For patients with low to intermediate risk chest hsTN I followed by CCTA improves
pain, high sensitivity troponin I (hsTN I) risk stratification and diagnostic
followed by CCTA improves diagnostic accuracy accuracy (CCTA alone may be
for ACS compared to hsTN I alone. ACS rates better without hsTN).
160 for low risk [0%], intermediate risk [8.6%], high
risk [58.3%] improved to 0%, 7.7% and 64%.
However, CCTA alone may be better than hsTN
+ CCTA.
For patients with low to intermediate risk chest CAC scan does not add value
pain, CCTA with CAC score=0 did not exclude beyond CCTA to predict ACS.
ACS (0.8%), and high CAC score (>400) does
473 not predict ACS (49%). Optimal CAC>22 c-
statistic=0.81 was inferior to CCTA 0.92.
For patients with low to intermediate risk chest CCTA with ROMICAT score may
pain, incorporating the ROMICAT score derived improve ACS diagnostic
from high risk plaque features was an performance.
260 independent predictor of ACS and incremental
to gender and presence of >50% stenosis alone
(AUC 0.91 versus 0.85, p=0.002).
For patients with low to intermediate risk chest High risk plaques on CCTA are a
pain, CCTA with high risk plaques increased predictor of ACS.
472 likelihood of ACS either independently (OR:
8.9) or with ≥50% stenosis (OR: 38.6).
NSTEACS randomized 1:1 to very early (within Coronary CTA has a high
12 h) or standard (48 to 72 h) invasive diagnostic accuracy to rule out
coronary angiography (ICA). As an clinically significant coronary
observational component of the trial, a artery disease for patients with
clinically blinded coronary CTA was conducted NSTEACS.
prior to ICA in both groups. A coronary stenosis
≥50% was found by coronary CTA in 68.9% and
by ICA in 67.4% of the patients. Per-patient
NPV of coronary CTA was 90.9%, and the
1,023 positive predictive value, sensitivity and
specificity were 87.9%, 96.5% and 72.4%,
respectively.