2021 Chest Pain Clinical Update FINAL 102821

Clinical Update
ADAPTED FROM:
ACC/AHA/ASE/CHEST/SAEM/S
CCT/SCMR Guideline for the
Evaluation and Diagnosis of Chest
Pain
Links provided: Hover on underlined text to link to content.

CLASS (STRENGTH) OF RECOMMENDATION LEVEL (QUALITY) OF EVIDENCE‡
CLASS 1 (STRONG) LEVEL A
Benefit >>> Risk
• High-quality evidence‡ from more than 1 RCT
Suggested phrases for writing recommendations: • Meta-analyses of high-quality RCTs
• Is recommended • One or more RCTs corroborated by high-quality registry studies
• Is indicated/useful/effective/beneficial
• Should be performed/administered/other LEVEL B-R
Table 1. • Comparative-Effectiveness Phrases†:
− Treatment/strategy A is recommended/indicated in preference to treatment
(Randomized)
• Moderate-quality evidence‡ from 1 or more RCTs
Applying ACC/AHA B
− Treatment A should be chosen over treatment B • Meta-analyses of moderate-quality RCTs
LEVEL B-NR
Class of CLASS 2a (MODERATE)
Benefit >> Risk (Nonrandomized)
Recommendation and Suggested phrases for writing recommendations:

• Is reasonable
• Moderate-quality evidence‡ from 1 or more well-designed, well-
executed nonrandomized studies, observational studies, or
registry studies
Level of Evidence to
• Can be useful/effective/beneficial
• Comparative-Effectiveness Phrases†: • Meta-analyses of such studies
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD
Clinical Strategies, treatment B
− It is reasonable to choose treatment A over treatment B
(Limited Data)
Interventions,
• Randomized or nonrandomized observational or registry studies
CLASS 2b (Weak) with limitations of design or execution
Benefit ≥ Risk • Meta-analyses of such studies
Treatments, or Suggested phrases for writing recommendations:

• May/might be reasonable
• Physiological or mechanistic studies in human subjects
LEVEL C-EO
Diagnostic Testing in • May/might be considered
• Usefulness/effectiveness is unknown/unclear/uncertain or not well-
established
(Expert Opinion)
COR and LOE are determined independently (any COR may be paired with any LOE).
• Consensus of expert opinion based on clinical experience.
Patient Care CLASS 3: No Benefit (MODERATE)
A recommendation with LOE C does not imply that the recommendation is weak. Many
important clinical questions addressed in guidelines do not lend themselves to clinical trials.
Although RCTs are unavailable, there may be a very clear clinical consensus that a particular
Benefit = Risk
(Updated May 2019)*
test or therapy is useful or effective.
Suggested phrases for writing recommendations: *The outcome or result of the intervention should be specified (an improved clinical
outcome or increased diagnostic accuracy or incremental prognostic information).
• Is not recommended
• Is not indicated/useful/effective/beneficial †For comparative-effectiveness recommendation (COR 1 and 2a; LOE A and B only),
studies that support the use of comparator verbs should involve direct comparisons of the
• Should not be performed/administered/other treatments or strategies being evaluated.
CLASS 3: Harm (STRONG) ‡The method of assessing quality is evolving, including the application of standardized,
widely-used, and preferably validated evidence grading tools; and for systematic reviews,
Risk > Benefit the incorporation of an Evidence Review Committee. COR indicates Class of
Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR,
Suggested phrases for writing recommendations: nonrandomized; R, randomized; and RCT, randomized controlled trial.
• Potentially harmful
• Causes harm
• Associated with excess morbidity/mortality
Gulati, M. et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR
• Should not be performed/administered/other Guideline for the Evaluation and Diagnosis of Chest Pain. 2
Circulation.
Defining Chest Pain
“Chest pain” suggestive of ischemia is not just discomfort in the chest; it can be
discomfort in the shoulder, jaw, epigastric area, neck or back.
An initial assessment of chest pain is recommended to triage patients

effectively on the basis of the likelihood that symptoms may be attributable to
myocardial ischemia (Class 1).
Chest pain should not be described as atypical, because it is not helpful in

determining the cause and can be misinterpreted as benign in nature (Class 1).
Chest pain should be described as cardiac, possibly cardiac, or noncardiac

because these terms are more specific to the potential underlying diagnosis
(Class 1).
Gulati, M. et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. 3
Circulation.
Early Care for Acute Symptoms
Patients presenting to the ED with nontraumatic chest pain
PRIORITIES
Evaluation of all patients to focus on early
identification or exclusion of
life-threatening causes such as:
• ACS • Nonvascular Syndromes
(e.g., esophageal rupture,
• Aortic Dissection tension pneumothorax) Cardiac Chest Pain
• Pulmonary Embolism Characteristics
Characteristics of chest pain:
FOCUSED HISTORY OF CHEST PAIN • Retrosternal chest discomfort
• Gradual in intensity
Characteristics of chest pain:
• Nature • Precipitating factors • Precipitated by stress
• Onset/Duration • Relieving factors • Radiation down arm or jaw
• Location/Radiation • Associated symptoms • Associated with dyspnea, nausea,

lightheadedness
Abbreviations: ACS indicates acute coronary syndrome; and ED, emergency department.
Circulation.
Getting the Chest Pain Diagnosis Right
Other Patient-Focused Considerations for Evaluation of Chest Pain
Women Elderly Ethnically

Diverse
Women who present with chest pain are at Cultural competency training is
risk for underdiagnosis, and potential cardiac In patients with chest pain who recommended to help achieve the best
causes should always be considered (Class are >75 years of age, ACS should outcomes in patients of diverse racial and
1).* be considered when ethnic backgrounds who present with chest
accompanying symptoms such as pain (Class 1).
shortness of breath, syncope, or
In women presenting with chest pain, it is acute delirium are present, or
recommended to obtain a history that when an unexplained fall has Among patients of diverse race and ethnicity
emphasizes accompanying symptoms that occurred (Class 1). presenting with chest pain in whom English
are more common in women with ACS may not be their primary language,
(Class 1).** addressing language barriers with the use of
formal translation services is recommended
* Traditional risk scores may underestimate risk in (Class 1).
women
** Women are more likely to report multiple associated
symptoms in addition to chest pain when presenting
with ACS
Abbreviations: ACS indicates acute coronary syndrome.
Circulation.
Physical Exam in Patients with Chest Pain
In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in
the diagnosis of ACS or other potentially serious causes of chest pain (e.g., aortic dissection, PE, or esophageal
rupture) and to identify complications (Class 1).
Emergent Clinical Syndromes and Assessment Findings
Acute Coronary Syndrome Pulmonary Embolism Aortic Dissection Esophageal Rupture
• Diaphoresis • Tachycardia • Extremity pulse differential • Emesis

• Tachypnea • Dyspnea • Abrupt onset of pain • Subcutaneous emphysema
• Tachycardia • Pain with inspiration • Severe pain • Pneumothorax
• Hypotension • Syncope • Unilateral decreased or absent
• Crackles breath sounds
• S3
• MR murmur
• Exam can be normal
Abbreviations: ACS indicates acute coronary syndrome; MR, mitral regurgitation; PE, pulmonary embolism; and S3, third heart sound.
Circulation.
Physical Exam in Patients with Chest Pain; Other
Other Clinical Syndromes Physical Exam Findings
Non-coronary cardiac: • AS: Characteristic systolic murmur, tardus or parvus carotid pulse
• aortic stenosis • AR: Diastolic murmur at right of sternum, rapid carotid upstroke
• aortic regurgitation • HCM: Increased or displaced left ventricular impulse, prominent a wave in jugular
• hypertrophic cardiomyopathy venous pressure, systolic murmur that increases with Valsalva
• Pericarditis: Fever, pleuritic chest pain, increased in supine position, friction rub
Pericarditis/ Myocarditis • Myocarditis: Fever, chest pain, heart failure, S3
Esophagitis, peptic ulcer disease, • Epigastric tenderness
gall bladder disease • Right upper quadrant tenderness, Murphy’s sign
Fever, localized chest pain, may be pleuritic, friction rub may be present, regional dullness to
Pneumonia percussion, egophony
Pneumothorax Dyspnea and pain on inspiration, unilateral absence of breath sounds
Costochondritis, Tietze syndrome Tenderness of costochondral joints
Pain in dermatomal distribution, triggered by touch; characteristic rash (unilateral and

Herpes zoster dermatomal distribution)
Abbreviations: AR indicates aortic regurgitation; AS, aortic stenosis;

HCM, hypertrophic cardiomyopathy; MR, mitral regurgitation; and S3, third heart sound.
Circulation.
What to do when patients present with chest pain …
at the office?
Patients with clinical evidence of ACS or other life-threatening causes of acute
chest pain seen in the office setting should be transported urgently to the ED,
ideally by EMS (Class 1).
Unless a noncardiac cause is evident, an ECG should be performed for patients

seen in the office setting with stable chest pain; if an ECG is unavailable the
patient should be referred to the ED so one can be obtained (Class 1).
For patients with acute chest pain and suspected ACS initially evaluated in the
office setting, delayed transfer to the ED for cTn or other diagnostic testing
should be avoided Class 3: Harm.
Abbreviations: ACS indicates acute coronary syndrome; cTn, cardiac troponin; ECG, electrocardiogram;
ED, emergency department; HCP, healthcare provider; and STEMI, ST-segment elevation myocardial infarction.
Circulation.
What to do when patients present with chest pain …
to any medical facility setting?

In all patients who present with acute chest pain regardless of the setting, an
ECG should be acquired and reviewed for STEMI within 10 minutes of arrival
(Class 1).
In all patients presenting to the ED with acute chest pain and suspected ACS,
cTn should be measured as soon as possible after presentation (Class 1).
Circulation.
Electrocardiographic-Directed Management
of Chest Pain Chest Pain
History +
Physical Examination
ECG
(Class 1)
ST-depression Nondiagnostic or normal ECG

Diffuse ST-elevation New T-wave New arrhythmia
STEMI
consistent with pericarditis inversions
Repeat ECG if Leads V7-V9 are

Follow STEMI Manage pericarditis Follow NSTE-ACS
symptoms persist or reasonable if Follow arrhythmia-
guidelines guidelines
change or if troponins posterior MI specific guidelines
(Class 1) (Class 1)
positive suspected
(Class 1) (Class 2a)
Abbreviations: ECG indicates electrocardiogram; NSTE-ACS, non–ST-segment–elevation acute coronary syndrome;

MI, myocardial infarction; and STEMI, ST-segment elevation myocardial infarction.
Circulation.
Additional Diagnostic Evaluation of Chest Pain
In patients presenting with acute chest pain, a chest radiograph is useful to evaluate for other potential
cardiac, pulmonary, and thoracic causes of symptoms (Class 1).
In patients presenting with acute chest pain, serial cTn I or T levels are useful to identify abnormal values
and a rising or falling pattern indicative of acute myocardial injury (Class 1).
In patients presenting with acute chest pain, high-sensitivity cTn is the preferred biomarker because it
enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy (Class
1).
Clinicians should be familiar with the analytical performance and the 99th percentile upper reference
limit that defines myocardial injury for the cTn assay used at their institution (Class 1).
With availability of cTn, creatine kinase myocardial (CK-MB) isoenzyme and myoglobin are not useful
for diagnosis of acute myocardial injury (Class 3:No Benefit).
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Overview of Diagnostic Cardiac Testing
Favors use of CCTA Favors use of stress imaging
• Rule out obstructive CAD
Goal • Ischemia guided management
• Detect nonobstructive CAD
Availability and High quality imaging and expert High quality imaging and expert
expertise interpretation routinely available interpretation routinely available
Likelihood of
Age less than 65 Age greater or equal to 65
obstructive CAD
Prior test results Prior functional study inconclusive Prior CCTA inconclusive
• Suspect scar
(especially if PET or stress CMR
• Anomalous coronary arteries
Other compelling available)
indications • Require evaluation of aorta or
• Suspect coronary microvascular
pulmonary arteries
dysfunction (when PET or CMR
available)
Abbreviations: CAD indicates coronary artery disease; CCTA , coronary computed tomographic angiography;
CMR, cardiovascular magnetic resonance; and PET, positron emission tomography.
Circulation.
Diagnostic Testing:
Coronary Computed Tomography Angiography
Indications for CCTA Contraindications to CCTA
1. To visualize and help to diagnose the 1. Allergy to iodinated contrast
extent and severity of nonobstructive 2. Inability to cooperate with scan acquisition and or breath-
and obstructive CAD. holding instructions
3. Clinical instability (decompensated HF, severe
2. Allows for evaluation of hypotension)
atherosclerotic plaque composition and 4. Renal impairments as defined by local protocols.
high-risk features (e.g., positive
remodeling, low attenuation plaque). 5. Contraindication to beta blockade in the presence of an
elevated HR and no alternative medications available for
achieving target heart rate
6. Heart rate variability and arrhythmia
7. Contraindication to nitroglycerin
Abbreviation: CAD indicates coronary artery disease; CCTA, coronary computed tomography angiography ; HF, heart failure; and HR, heart rate.
Circulation.
Overview of Diagnostic Cardiac Stress Testing
STRESS TESTING INFORMATION
Exercise ECG Stress echocardiog SPECT MP PET MRI Stress CMR M

raphy I PI
Patient capable
of exercise   
Pharmacologic
stress indicated    
Quantitative flow  
LV
dysfunction/scar    
Abbreviations: CMR, cardiovascular magnetic resonance; ECG, electrocardiogram; LV, left ventricle; MPI; myocardial perfusion imaging MRI;
magnetic resonance imaging; and PET, positron emission tomography; and SPECT, single-photon emission computed tomography.
Circulation.
Diagnostic Testing: Exercise Electrocardiogram
Indications for Exercise ECG Contraindications to Exercise ECG
1. Candidates include those without 1. Abnormal ST changes on resting ECG (>0.5mm ST depression),
disabling comorbidities (frailty, LVH, digoxin, LBBB, WPW pattern, ventricular paced rhythm
marked obesity (BMI>40kg/m2 ),
PAD, COPD, or orthopedic 2. Unable to achieve METS ≥ 5 or unsafe to exercise
limitations 3. High-risk unstable angina or ACS
2. Capable of performing activities of 4. Uncontrolled HF
daily living or able to achieve METS
≥5 5. Significant cardiac arrhythmias (VT, complete AV block) or high risk
for arrhythmias caused by QT prolongation
6. Severe symptomatic AS
7. Severe systemic arterial hypertension (≥ 200/110 mm Hg)
8. Acute illness (acute PE, myocarditis, pericarditis, aortic dissection)
Abbreviation: ACS indicates acute coronary syndrome, AS, aortic stenosis; AV, atrioventricular; BMI, body mass index; CCTA, coronary computed tomography
angiography; COPD, chronic obstructive pulmonary disease; ECG, electrocardiogram; HF, heart failure; LBBB, left bundle branch block; LVH, left ventricle
hypertrophy; METS, metabolic equivalent; PAD, peripheral artery disease; PE, pulmonary embolism; VT, ventricular tachycardia; and WPW, Wolff-Parkinson-White.
Circulation.
Diagnostic Testing: Stress Echocardiography
Indications for Stress Contraindications to Contraindications to Dobutamine
Echocardiography Stress Echocardiography (If Pharmacologic Stress test needed)
1. Limited acoustic windows 1. AV block, uncontrolled AF

1. To define ischemia severity and
risk stratification after ACS has 2. Inability to reach target HR 2. Critical AS
been ruled out. 3. Acute illness (acute PE, myocarditis,
3. Uncontrolled HF
2. Helpful with ultrasound-enhancing pericarditis, aortic dissection)
agents in providing for left 4. High-risk unstable angina, ACS
4. Hemodynamically significant LV outflow
ventricular opacification when ≥2 tract obstruction
contiguous segments or a coronary 5. Serious ventricular arrhythmia or high risk
territory is poorly visualized. for arrhythmias attributable to QT
prolongation 5. Contraindication to atropine use: narrow
angle glaucoma, myasthenia gravis,
3. Assess coronary flow velocity obstructive uropathy, obstructive GI
reserve in mid-distal left anterior 6. Respiratory failure
disorders
descending coronary artery to 7. Severe COPD, acute PE, severe
improve risk stratification. pulmonary HTN 6. Contraindication to contrast:
hypersensitivity to perflutren, blood, blood
8. Severe systemic arterial HTN (≥ 200/110 products or albumin (for Optison only)
mm Hg)
Abbreviation: ACS indicates acute coronary syndrome; AF, atrial fibrillation; AS, aortic stenosis; AV, atrioventricular; COPD, chronic obstructive pulmonary disease; GI,
gastrointestinal; HF, heart failure; HR, heart rate; HTN, hypertension; LV, left ventricle; mm Hg indicates millimeters of mercury; PE, pulmonary embolism; and QT,
QT interval.
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Diagnostic Testing:
Stress Nuclear Myocardial Perfusion Imaging
Indications for PET Contraindications to Contraindications to
or SPECT MPI Stress Nuclear MPI Vasodilator Administration
1. Detection of perfusion 1. High-risk unstable angina, 1. Significant arrhythmias (VT, second- or third-
abnormalities complicated ACS or AMI degree AV block) or sinus bradycardia <45 beats
(less than two days) per minute
2. Measurement of LV
function 2. Severe systemic arterial 2. Significant hypotension
HTN (≥ 200/110 mm Hg) (systolic BP<90mm Hg)
3. Detection of
high-risk findings 3. Known or suspected bronchoconstrictive or
(transient ischemic bronchospastic disease
dilation)
4. Recent use of dipyridamole or dipyridamole
4. PET allows containing medications
calculation of
myocardial blood flow 5. Use of methylxanthines (aminophylline, caffeine)
reserve within 12 hours
6. Known hypersensitivity to adenosine or
regadenoson
Abbreviation: ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; AV, atrioventricular; BP, blood pressure; HTN, hypertension;
LV, left ventricle; mm Hg, millimeters of mercury; MPI, myocardial perfusion imaging;
PET, positron emission tomography; SPECT, single-photon emission computed tomography; and VT, ventricular tachycardia.
Circulation.
Diagnostic Testing:
Cardiovascular Magnetic Resonance Imaging
Indications for Stress CMR MPI Contraindications to Stress CMR MPI

1. Accurately assess global and regional LV/ 1. Reduced GFR (<30 mL/min/1.73 m2)
RV function
2. Contraindications to vasodilator administration
2. Detect and localize myocardial ischemia and
infarction 3. Implanted devices that are not safe for CMR or
producing artifact limiting scan quality/
3. Determine myocardial viability interpretation
4. Detect myocardial edema and microvascular 4. Significant claustrophobia
obstruction
5. Other causes of chest pain- myocarditis
Abbreviation: CMR indicates cardiovascular magnetic resonance; GFR glomerular filtration rate;
LV left ventricle; m2, beam propagation ratio; mL, milliliter MPI, myocardial perfusion imaging; and RV right ventricle.
Circulation.
Diagnostic Cardiac Testing:
Women in Pregnancy, Postpartum or Child-Bearing Age
Ionizing radiation during If deemed necessary, risks/benefits of
pregnancy or when breast radiation from should be discussed with
feeding should be avoided the patient (e.g., angiography, CCTA,
SPECT and PET)
Iodinated contrast should be used with Lowest effective dose of radiation

caution in pregnancy but may be should be used
given postpartum
Gadolinium contrast with CMR is Alternative tests including ultrasound and

discouraged MRI should be considered as a safer
alternative
Abbreviations: CCTA indicates coronary computed tomographic angiography; CMR, cardiovascular magnetic resonance;
MRI, magnetic resonance imaging; MRI, PET, positron emission tomography; and SPECT, single-photon emission computed tomography.
Circulation.
Overview of Guideline-Based Pathways for
Evaluating Chest Pain
YES Is chest pain acute? NO
Refer to Refer to
Figure 8. General Approach to Risk Stra Figure 8. General Approach to Risk Stratifi
tification of Patients With Suspected AC cation of Patients With Suspected ACS
S
Use Appropriate Pathway for Stable Chest Pain

Low Intermediate (use High
appropriate
algorithm)
Figure 9. Evaluation Al Figure 10. Evaluation Figure 12. Clinical Deci Figure 13. Clinical Decision Pathway for
gorithm for Patients Wi Algorithm for Patients sion Pathway for Patient Patients With Stable Chest Pain (or Equiva
th Suspected ACS at Int With Suspected ACS at s With Stable Chest Pain lent) Symptoms With Prior MI, Prior Reva
ermediate Risk With N Intermediate Risk Wit and No Known CAD scularization, or Known CAD on Invasive
o Known CAD h Known CAD Coronary Angiography or CCTA, Includin
g Those With Nonobstructive CAD
Abbreviations: ACS indicates acute coronary syndrome; CAD, coronary artery disease;
CCTA, coronary computed tomographic angiography; and MI, myocardial infarction.
Circulation.
Figure 8. General Approach to Risk Stratification of  Return to previous
Patients With Suspected ACS slide
Patient with Acute Chest Pain
History + Physical Examination
ECG (Class 1)
Obvious nonischemic
Obvious noncardiac cause Possible ACS
cardiac cause
No cardiac testing required Other cardiac testing as Obtain troponin (Class 1)

(Section 4.3) needed
(Class 1)
Use CDP to risk stratify (Class 1)
Low Risk Intermediate Risk High Risk
No testing required Further diagnostic

Discharge Moderate- Invasive coronary
(Class 1) testing may be
severe angiography (Class 1)
indicated abnormality
Abbreviations: ACS indicates acute coronary syndrome; CDP, clinical decision pathway; and ECG, electrocardiogram.
Circulation.
Figure 9. Evaluation Algorithm for Patients With Suspected ACS at  Return to previous
Intermediate Risk With No Known CAD slide
Acute Chest Pain + Intermediate-Risk With No Known CAD
YES Prior testing NO
Recent negativ Prior inconclusive or Prior moderate-

e test mildly abnormal severely abnormal Stress testing CCTA (1)
stress test < 1 year < 1 year (no ICA) Exercise ECG
Stress CMR
Discharge Stress echocardiography
CCTA (2a) ICA (1) Nonobstructive
Stress PET Inconclusive Obstructive CAD
CAD
Stress SPECT (1) stenosis (>50% stenosis)
(<50% stenosis)
Nonobstructive CAD Inconclusive Obstructive CAD
(<50% stenosis) stenosis (>50% stenosis) High risk Discharge
CAD or fre
quent angi Negative or Moderate Inconclusiv High risk CAD o
na mildly severe r frequent angin
Discharge FFR-CT OR stress e a
abnormal ischemia FFR-CT OR stress
testing (2a) testing (2a) Decision to
Consider INOCA Decision to treat
pathway as an medically treat medically
outpatient for FFR-CT < 0.8 or
frequent persistent FFR-CT < 0.8 or
symptoms
moderate-severe GDMT (1) Discharge YES moderate-severe NO GDMT (1)
NO
ischemia ischemia
ICA (1) Discharge
YES
Abbreviations: CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging;
FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography; INOCA, ischemia
and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission computed tomography
Circulation.
Figure 10. General Approach to Risk Stratification of  Return to previous
Patients With Suspected ACS slide
Acute Chest Pain +

Intermediate-Risk with Known CAD
Obstructive CAD (> or = to

Nonobstructive CAD+ (<50 Option to defer testing and
% stenosis) 50% stenosis)
intensify GDMT (1) High-risk CAD
or frequent an
Stress testing gina
CCTA (Class 2a) Stress CMR
Stress echocardiography
Stress PET
Stress SPECT
Obstructive CAD (2a)
No change
(>50% stenosis)
Consider INOCA
pathway as an
Discharge outpatient for FFR-CT OR stress tes Abnormal Normal functional
frequent persistent ting (2a) functional test test
symptoms
FFR-CT < 0.8 or
GDMT (1) NO moderate-severe YES ICA (1) Discharge
Option to defer ICA with
ischemia mildly abnormal test
Discharge
Abbreviations: CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging;
CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary
angiography; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission
CT.
Circulation.
Recommendations for High-Risk Patients having
Chest Pain
Prior CABG without Dialysis Cocaine/

ACS Methamphetamine
Stress testing or
CCTA (Class 1)
In patients who experience
Reasonable to consider
acute unremitting chest
cocaine and
pain while undergoing
Indeterminate methamphetamine as a
dialysis, transfer by EMS
cause of acute chest pain
to an acute care setting is
symptoms
recommended
Intra-coronary (Class 2a).
(Class 1).
angiography is
useful (Class1)
Abbreviation: ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft;
CCTA, coronary computed tomographic angiography; and EMS, emergency medical service.
Circulation.
Evaluation of Acute Chest Pain Recommendations
With Nonischemic Cardiac Pathologies

COR RECOMMENDATIONS
1. In patients with acute chest pain in whom other potentially life-threatening nonischemic cardiac conditions are suspected
1 (e.g., aortic pathology, pericardial effusion, endocarditis), TTE is recommended for diagnosis.
With Suspected Acute Aortic Syndrome

COR RECOMMENDATIONS
1. In patients with acute chest pain where there is clinical concern for aortic dissection, computed tomography angiography
1 (CTA) of the chest, abdomen, and pelvis is recommended for diagnosis and treatment planning.
2. In patients with acute chest pain where there is clinical concern for aortic dissection, TEE or CMR should be performed to
1 make the diagnosis if CT is contraindicated or unavailable.
Abbreviations: CMR indicates cardiac magnetic resonance; COR, classification of recommendation; CT, computerized tomography; CTA, computed tomography
angiography; LOE, level of evidence; PE, pulmonary embolus; TEE, transesophageal echocardiology; and TTE, transthoracic echocardiography.
Circulation.
With Suspected Pulmonary Embolus
COR RECOMMENDATIONS
1 1. In stable patients with acute chest pain with high clinical suspicion for PE, CTA using a PE protocol is recommended
1 2. For patients with acute chest pain and possible PE, need for further testing should be guided by pretest probability.
With Suspected Myopericarditis

COR RECOMMENDATIONS
1. In patients with acute chest pain and myocardial injury who have nonobstructive coronary arteries on anatomic testing, CMR
1 with gadolinium contrast is effective to distinguish myopericarditis from other causes, including myocardial infarction and
nonobstructive coronary arteries (MINOCA).
2. In patients with acute chest pain with suspected acute myopericarditis, CMR is useful if there is diagnostic uncertainty, or to
1 determine the presence and extent of myocardial and pericardial inflammation and fibrosis.
3. In patients with acute chest pain and suspected myopericarditis, TTE is effective to determine the presence of ventricular wall
1 motion abnormalities, pericardial effusion, valvular abnormalities, or restrictive physiology.
4. In patients with acute chest pain with suspected acute pericarditis, noncontrast or contrast cardiac CT scanning may be
2b reasonable to determine the presence and degree of pericardial thickening.
Circulation.
With Valvular Heart Disease

COR RECOMMENDATIONS
1. In patients presenting with acute chest pain with suspected or known history of valvular heart disease (VHD), TTE is useful
1 in determining the presence, severity, and cause of VHD.
2. In patients presenting with acute chest pain with suspected or known VHD in whom TTE diagnostic quality is inadequate,
1 TEE (with 3D imaging if available) is useful in determining the severity and cause of VHD.
3. In patients presenting with acute chest pain with known or suspected VHD, CMR imaging is reasonable as an alternative to
2b TTE and/or TEE is nondiagnostic.
Circulation.
Other causes of chest pain
Abbreviations: GORD indicates gastro-oesophageal reflux disease; and mets, metastasis.
Circulation.
Noncardiac Chest Pain: Differential Diagnoses
Respiratory Gastrointestinal Chest Wall Psychological Other

• PE • Cholecystitis • Costochondritis • Panic disorder • Hyperventilation
syndrome
• Pneumothorax/ • Pancreatitis • Chest wall trauma • Anxiety
hemothorax • Carbon monoxide
• Hiatal hernia • Herpes Zoster • Clinical Depression poisoning
• Pneumomediastinum
• GI reflux disease • Cervical • Somatization • Sarcoidosis
• Pneumonia radiculopathy disorder
• Gastritis/ • Lead poisoning
• Bronchitis • Breast disease • Hypochondria
• Esophagitis • Prolapsed interverbal
• Pleural irritation • Rib fracture disc
• Peptic ulcer disease
• Malignancy • Musculoskeletal • Thoracic outlet
• Esophageal spasm injury syndrome
• Dyspepsia
• Sickle cell crisis
• Adverse medication
effects
Abbreviations: Gi indicates gastrointestinal; and PE, pulmonary embolus.
Circulation.
Figure 12. Clinical Decision Pathway for Patients With Stable Chest  Return to previous
Pain & No Known CAD slide
Stable Chest Pain + No Known CAD

Stress testing
No testing recommended (1) Low risk Clinical risk assessment (1) Stress CMR Exercise
Stress PET ECG
CAC or exercise ECG CCTA (1) Stress SPECT (2a)
testing in selected cases (2a) Intermediate/high risk
Stress echocardiography (1)
Mild Moderate-severe
No CAD Nonobstructive Obstructive Inconclusive
ischemia ischemia
Inconclusive (no stenosis CAD CAD
or plaque) (<50% stenosis) (≥50% stenosis)
Optimize Optimize
Stress testing Consider INOCA preventive preventive
(2a) pathway as an FFR-CT for 40-90% stenosis High risk CAD o therapies therapies (1)
outpatient for OR stress testing (2a) r frequent angin (1)
frequent or a
persistent CAC (2a) Persistent
symptoms FFR CT ≤0.8 or symptoms?
moderate-severe Invasive
ischemia coronary YES NO
angiography (1)
Follow-up testing and intensification of GDMT by initial test
NO YES Invasive Continue
results and persistence/worsening/frequency of symptoms
coronary preventive
angiography therapies
(1) (1)
Abbreviations: CAC indicates coronary artery calcium; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR,
cardiovascular magnetic resonance imaging; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline- CCTA (2a)
directed medical therapy; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT,
single-photon emission CT.
Circulation.
Figure 13. Stable Chest Pain (or Equivalent) Symptoms With Prior MI, Prior
 Return to previous
Revascularization, or Known CAD on Invasive Coronary Angiography or CCTA, slide
Including Those With Nonobstructive CAD
Stable Chest Pain + No Known CAD
Nonobstructive CAD Obstructive CAD

(<50% stenosis) (>50% stenosis)
Evaluate adequacy of GDMT

Intensification of preventive
strategies and option to Intensify GDMT and
defer testing (Class 1) option to defer testing
(Class 1) Stress testing
Stress CMR
Persistent symptoms
Stress PET
CCTA ± FFR-CT High-risk CAD o NO Stress SPECT
(FFR-CT for ≥40-90% YES r frequent angina Stress echocardiography
stenosis) (Class 1)
OR stress testing (Class 2a)
Exercise ECG (Class 2a)
FFR-CT ≤0.8 OR Invasive coronary
moderate-severe ischemia angiography with
NO (Class 2a) YES FFR or iFR (Class 1)
Moderate/severe Mild ischemia No ischemia
Invasive ischemia
See INOCA
coronary CCTA (for patients with
pathway
angiography prior CABG or stents
(Class 2a) GDMT according to SIHD guideline (Class 1)
(Class 1) >3.0 mm) (Class 2a)
Abbreviations: CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic
resonance imaging; CT, computed tomography; ECG, electrocardiogram; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy;
ICA, invasive coronary angiography; iFR, instant wave-free ratio; INOCA, ischemia and no obstructive coronary artery disease; mm, millimeters; MI,
myocardial infarction; MPI, myocardial perfusion imaging; PET, positron emission tomography; SIHD, stable ischemic heart disease; and SPECT, single-photon
emission CT.Guideline for the Evaluation and Diagnosis of Chest Pain.
Gulati, M. et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR 31
Circulation.
Patients with Suspected Ischemia and
Non-Obstructive CAD (INOCA)
COR RECOMMENDATIONS
1. For patients with persistent stable chest pain and nonobstructive CAD and at least mild myocardial ischemia on imaging, it
2a is reasonable to consider invasive coronary function testing to improve the diagnosis of coronary microvascular dysfunction
and to enhance risk stratification.
2. For patients with persistent stable chest pain and nonobstructive CAD, stress PET MPI with MBFR is reasonable to diagnose
2a microvascular dysfunction and enhance risk stratification.
3. For patients with persistent stable chest pain and nonobstructive CAD, stress CMR with the addition of MBFR measurement
2a is reasonable to improve diagnosis of coronary myocardial dysfunction and for estimating risk of MACE.
4. For patients with persistent stable chest pain and nonobstructive CAD, stress echocardiography with the addition of coronary
2b flow velocity reserve measurement may be reasonable to improve diagnosis of coronary myocardial dysfunction and for
estimating risk of MACE.
Abbreviations: CAD indicates coronary artery disease; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography;
ECG, electrocardiogram; INOCA, ischemia and no obstructive coronary artery disease; MACE, major adverse cardiac events;
MBFR, myocardial blood flow reserve; MPI, myocardial perfusion imaging; and PET, positron emission tomography.
Circulation.
Figure 14. Clinical Decision Pathway for Ischemia and Non-
Obstructive CAD (INOCA) Factors that increase the
likelihood of CMD:
• Diabetes
Stable Chest Pain
Suspected Ischemia and Non-Obstructive • Hypertension
CAD (INOCA) • Left ventricular
Stress PET or stress hypertrophy
Invasive coronary functi CMR-
on testing (requires nono must be with MBFR • Small coronary vessel size
bstructive CAD FFR ≥0. Noninvasive testing more prevalent (Class 2a) or lumen volume
8) (Class 2a) Invasive assessment more comprehensive Stress echocardiography • Infiltrative heart disease
with CFVR (Class 2b)
Epicardial IMR ≥25
artery spasm OR
CFR ≥2.0 CFR <2.0
(>90%) with
+ OR Normal MBFR Reduced Reduced
ACh Normal MBFR
IMR <25 angina with ST MBFR MBFR
+ + no ischemia
+ depression + ischemia + ischemia + no ischemia
reproduction of
negative during ACh
chest pain
provocative bolus or infusion,
+
study to ACh and epicardial Diagnostic Diagnostic
ischemic ECG Diagnostic
changes artery criteria for criteria for
constriction criteria for
INOCA – CMD +
CMD
no CMD ischemia
Noncardiac Vasospasm CMD Low risk for
CV events
Elevated risk for MACE
Intensification of preventive strategies + symptom guided GDMT(Class 1)
Abbreviations: ACh indicates acetylcholine; CAD, coronary artery disease; CFR, coronary flow reserve; CFVR, coronary flow velocity reserve; CMD,
coronary microvascular dysfunction; CMR, cardiovascular magnetic resonance imaging; CV, cardiovascular; FFR, fractional flow reserve; IMR,
index of microcirculatory restriction; INOCA, ischemia and no obstructive coronary artery disease; MACE, major adverse cardiovascular events; and
MBFR, myocardial blood flow reserve; and PET, positron emission tomography.
Circulation.
Cost Considerations
CCTA CAC Exercise ECG
CAC had lower cost & higher

Compared with stress tests, CCTA
MACE-free survival compared Lower cost compared with CT &
has similar long-term outcomes &
with exercise ECG (CRESCENT I nuclear tests
cost over 2-3 years
& II trials)
 Associated with reduced accuracy
In the CONSERVE trial,  Tiered testing may help offset its reduced
CAC was associated with 16% cost accuracy.
CCTA-guided referral to invasive
savings at 1 year compared with exercise
angiography was 1,183$ compared with  Initial cost 174$, >50% lower cost than
ECG
direct referral 2,755$ other imaging tests.
 At 3 years, the 95% CI 2-3,519$
Abbreviations: CAC indicates coronary arterial calcium; CCTA, cardiac computed tomography angiography; CI, confidence interval;
CONSERVE trial, Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization; CRESCENT trial, Comprehensive Cardiac
CT Versus Exercise Testing in Suspected Coronary Artery Disease; ECG, electrocardiography; and MACE, major adverse cardiac events.
Circulation.
Cost Considerations
Stress Stress Nuclear
Stress CMR
Echocardiography MPI
Increased cost-effectiveness Associated with favorable incremental cost-

2-year cost was highest in PET
compared to exercise ECG effectiveness
 Favorable cost-effectiveness ratio (<$50,000 per

 Similar cost at 3 years to CCTA  Cost effective in intermediate risk
quality-adjusted life years saved).
 (PROMISE trial): mean cost patients
 In the CE-MARC trial, CMR was more cost-
difference: –$363; 95% CI: –$1,562–  Similar cost to CCTA and exercise
effective than stress MPI, mainly due to
$818) ECG
diagnostic accuracy.
 Cost effective in intermediate risk  In higher likelihood patients, MPI
 Most cost-effective strategy was tiered testing
patients SPECT was the most cost-effective.
with CMR after exercise ECG.
Abbreviations: CCTA indicates cardiac computed tomography angiography; CE-MARC2 Clinical Evaluation of Magnetic Resonance Imaging in Coronary
Heart Disease-2; CI, confidence interval; CMR: cardiac magnetic resonance; ECG, electrocardiography; PET, positron emission tomography; MPI, myocardial
perfusion imaging; PROMISE trial, Prospective Multicenter Imaging Study for Evaluation of Chest Pain; and SPECT, single-positron emission computed
tomography.
Circulation.
Evidence Gaps and Future Research
Clinical
MINOCA/ Symptom Stratification &
ACS
INOCA Classification Decision Tools
Gaps in
Delays from symptom pathophysiology, Better diagnostic and management
Identify pretest probability options
onset to presentation diagnosis and
management
• RCT to assess utility and impact of

• Utilize technologies • Emphasis on complete stratification tools on outcomes
that permit acquisition testing to diagnose
and transmission of MINOCA/INOCA Machine-learning algorithms • RCT to assess which diagnostic
ECGs from home may help reduce sex and modality to eliminate to streamline
• Research to understand racial disparities in care care and improve cost-effectiveness
• Remote evaluations pathophysiology and
(e.g., telehealth) optimal therapy • Utility of high sensitivity troponin
Abbreviations: ACS indicates acute coronary syndrome; ECG, electrocardiography; INOCA, ischemia with non-obstructive coronary arteries;
MINOCA, myocardial infarction with non-obstructive coronary arteries; and RCT, randomized clinical trial.
Circulation.
Acknowledgments
Many thanks to our Guideline Ambassadors who were guided by Dr. Elliott Antman in developing this translational learning
product in support of the ACC/AHA/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain
Anais Hausvater, MD
Stephanie Koh, MD
Dae Hyun Lee, MD
Amrita Mukhopadhyay. MD
Jennifer Rymer, MD
Sonia Shah, MD
Lina Ya’qoub, MD
The American Heart Association requests this electronic slide deck be cited as follows:
Hausvater, A., Koh, S., Lee, D. H., Mukhopadhyay, A., Rymer, J., Shah, S., Ya’qoub, L., Bezanson, J. L., & Antman, E. M.
(2021). Clinical Update; Adapted from: ACC/AHA/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and
Diagnosis of Chest Pain [PowerPoint slides]. Retrieved from https://professional.heart.org/en/science-news
Circulation.
Appendix
Definitions  Return to previous
slide
CCTA - Coronary computed tomographic angiography is used to visualize and help to diagnose the extent
and severity of nonobstructive and obstructive coronary artery disease, as well as atherosclerotic plaque
composition and high-risk features (e.g., positive remodeling, low attenuation plaque).
PET - Positron emission tomography allows for detection of perfusion abnormalities, measures of left
ventricular function, and high-risk findings, such as transient ischemic dilation.
CMR - Cardiovascular magnetic resonance has the capability to accurately assess global and regional left
and right ventricular function, detect and localize myocardial ischemia and infarction, and determine
myocardial viability. CMR can also detect myocardial edema and microvascular obstruction, which can help
differentiate acute versus chronic myocardial infarction, as well as other causes of acute chest pain,
including myocarditis.
Circulation.
slide
CCTA - Coronary computed tomographic angiography is used to visualize and help to diagnose the extent
and severity of nonobstructive and obstructive coronary artery disease, as well as atherosclerotic plaque
composition and high-risk features (e.g., positive remodeling, low attenuation plaque).
Circulation.
slide
Exercise Electrocardiogram (ECG) – Diagnostic electrocardiogram monitoring during graded exercise

until physical fatigue, limiting chest pain (or discomfort), marked ischemia, or a drop in blood pressure
occurs.
Stress Echocardiography - After acute coronary syndrome (ACS) has been ruled out, stress
echocardiography can be used to define ischemia severity and for risk stratification purposes. For
transthoracic echocardiography (TTE) and stress echocardiography, ultrasound-enhancing agents are helpful
for left ventricular opacification when ≥2 contiguous segments or a coronary territory is poorly visualized.
Coronary flow velocity reserve in the mid-distal left anterior descending coronary artery has been shown to
improve risk stratification and may be helpful in the select patient with known coronary artery disease
(CAD), including nonobstructive CAD. Contraindications to stress type (exercise versus pharmacologic) and
stress echocardiography are reported in Slide 15.
SPECT MPI - Single-photon emission computed tomography (SPECT) myocardial perfusion imaging
(MPI) allows for detection of perfusion abnormalities, measures of left ventricular function, and high-risk
findings, such as transient ischemic dilation. This diagnostic test is utilized after acute coronary syndrome
(ACS) is ruled out.
Circulation.
slide
PET MPI – Positron emission computed tomography (PET) myocardial perfusion imaging (MPI) allows for
detection of perfusion abnormalities, measures of left ventricular function, and high-risk findings, such as
transient ischemic dilation. This diagnostic test is utilized after acute coronary syndrome (ACS) is ruled
out.
Stress CMR MPI – Pharmacologic stress test using cardiovascular magnetic resonance (CMR) myocardial
perfusion imaging (MPI) to accurately assess global and regional left and right ventricular function, detect
and localize myocardial ischemia and infarction, and determine myocardial viability.
Circulation.
Links for Figure 8  Return to previous
slide
Low Risk High Risk

Low Risk (<1% 30-d Risk for Death or MACE) • New ischemic changes on electrocardiogram
hs-cTn Based
(ECG)
T-0 hs-cTn below the assay limit of detection or
T-0 “very low” threshold if symptoms present for at least
• Troponin-confirmed acute myocardial
3h injury
T-0 hs-cTn and 1- or 2-h delta are both below the
T-0 and 1- or 2-h Delta assay “low” thresholds (>99% NPV for 30-d • New-onset left ventricular systolic
MACE)
dysfunction (left ventricular ejection
Clinical Decision Pathway Based
fraction (LVEF) < 40%)
HEART score <3, initial and serial cTn/hs-cTn <
HEART Pathway (20)
assay 99th percentile • Newly diagnosed moderate-severe ischemia
EDACS <16; initial and serial cTn/hs-cTn < assay
EDACS (14)
99th percentile
on stress testing
TIMI score 0, initial and serial cTn/hs-cTn < assay
ADAPT (21)
99th percentile
• Hemodynamic instability
TIMI score 0/1, initial and serial cTn/hs-cTn < assay
mADAPT
99th percentile • High clinical decision pathway (CDP) risk
NOTR (15) 0 factors score
Abbreviations: ADAPT indicates 2-hour Accelerated Diagnostic Protocol to Access Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarkers; cTn,
cardiac troponin; EDACS, Emergency Department Acute Coronary Syndrome; HEART Pathway, History, ECG, Age, Risk Factors, Troponin; hs-cTn, high-sensitivity cardiac troponin;
MACE, major adverse cardiac events; mADAPT, modified 2-hour Accelerated Diagnostic Protocol to Access Patients with Chest Pain Symptoms Using Contemporary Troponins as
the Only Biomarkers; NOTR, No Objective Testing Rule; NPV, negative predictive value; and TIMI, Thrombolysis in Myocardial Infarction.
Circulation.
slide
Recent Negative Test - Normal cardiac computed tomography angiography (CCTA) ≤2 years
(no plaque/no stenosis) OR negative stress test ≤1 year, given adequate stress.
High-risk coronary artery disease (CAD) means left main stenosis ≥ 50%; anatomically
significant 3-vessel disease (≥70% stenosis).
Fractional flow reserve with computed tomography (FFR-CT) the turnaround times may
impact prompt clinical care decisions. However, the use of FFR-CT does not require additional
testing, as would be the case when adding stress testing.
Circulation.
slide
Known coronary artery disease (CAD) is prior myocardial infarction (MI), revascularization,
known obstructive or nonobstructive CAD on invasive or cardiac computed tomography
angiography (CCTA).
If extensive plaque is present a high-quality cardiac computed tomography angiography (CCTA) is

unlikely to be achieved, and stress testing is preferred.
Obstructive coronary artery disease (CAD) includes prior coronary artery bypass
graft/percutaneous coronary intervention.
significant
3-vessel disease (70% stenosis).
Fractional flow reserve with computed tomography (FFR-CT) turnaround times may impact
prompt clinical care decisions.
Circulation.
slide
Test choice guided by patient’s exercise capacity, resting electrocardiographic abnormalities;

cardiac computed tomography angiography (CCTA) preferable in those <65 years of age and not
on optimal preventive therapies; stress testing favored in those ≥65 years of age (with a higher
likelihood of ischemia).
significant 3-vessel disease (≥70% stenosis).
Circulation.
slide
Known coronary artery disease (CAD) means prior myocardial infarction (MI),
revascularization, known obstructive CAD, nonobstructive CAD.
High-risk coronary artery disease (CAD) means left main stenosis ≥50%; or obstructive CAD
with fractional flow reserve with computed tomography (FFR-CT) ≤0.80.
Test choice guided by the patient’s exercise capacity, resting electrocardiographic abnormalities.
Circulation.
slide
Invasive coronary function testing refer to the following reference: Ford TJ, Corcoran D,
Sidik N, et al. Coronary microvascular dysfunction: assessment of both structure and function. J
Am Coll Cardiol 2018;72:584-6.
Cannot exclude microvascular vasospasm.
Circulation.

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Clinical Update

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Recommendation and Suggested phrases for writing recommendations:

Treatments, or Suggested phrases for writing recommendations:

An initial assessment of chest pain is recommended to triage patients

Chest pain should not be described as atypical, because it is not helpful in

Chest pain should be described as cardiac, possibly cardiac, or noncardiac

• Onset/Duration • Relieving factors • Radiation down arm or jaw

• Location/Radiation • Associated symptoms • Associated with dyspnea, nausea,

Women Elderly Ethnically

Abbreviations: ACS indicates acute coronary syndrome.

Emergent Clinical Syndromes and Assessment Findings

Acute Coronary Syndrome Pulmonary Embolism Aortic Dissection Esophageal Rupture

• Diaphoresis • Tachycardia • Extremity pulse differential • Emesis

Pneumothorax Dyspnea and pain on inspiration, unilateral absence of breath sounds

Costochondritis, Tietze syndrome Tenderness of costochondral joints

Pain in dermatomal distribution, triggered by touch; characteristic rash (unilateral and

Abbreviations: AR indicates aortic regurgitation; AS, aortic stenosis;

Unless a noncardiac cause is evident, an ECG should be performed for patients

to any medical facility setting?

ST-depression Nondiagnostic or normal ECG

Repeat ECG if Leads V7-V9 are

Abbreviations: ECG indicates electrocardiogram; NSTE-ACS, non–ST-segment–elevation acute coronary syndrome;

Exercise ECG Stress echocardiog SPECT MP PET MRI Stress CMR M

1. Limited acoustic windows 1. AV block, uncontrolled AF

Indications for Stress CMR MPI Contraindications to Stress CMR MPI

Iodinated contrast should be used with Lowest effective dose of radiation

Gadolinium contrast with CMR is Alternative tests including ultrasound and

Use Appropriate Pathway for Stable Chest Pain

Patient with Acute Chest Pain

History + Physical Examination

No cardiac testing required Other cardiac testing as Obtain troponin (Class 1)

Low Risk Intermediate Risk High Risk

No testing required Further diagnostic

Acute Chest Pain + Intermediate-Risk With No Known CAD

YES Prior testing NO

Recent negativ Prior inconclusive or Prior moderate-

Acute Chest Pain +

Obstructive CAD (> or = to

Prior CABG without Dialysis Cocaine/

With Nonischemic Cardiac Pathologies

With Suspected Acute Aortic Syndrome

With Suspected Myopericarditis

With Valvular Heart Disease

Abbreviations: GORD indicates gastro-oesophageal reflux disease; and mets, metastasis.

Respiratory Gastrointestinal Chest Wall Psychological Other

Abbreviations: Gi indicates gastrointestinal; and PE, pulmonary embolus.

Stable Chest Pain + No Known CAD

Nonobstructive CAD Obstructive CAD

Evaluate adequacy of GDMT

CCTA CAC Exercise ECG

CAC had lower cost & higher

 Associated with reduced accuracy

Increased cost-effectiveness Associated with favorable incremental cost-

 Favorable cost-effectiveness ratio (<$50,000 per

• RCT to assess utility and impact of

Exercise Electrocardiogram (ECG) – Diagnostic electrocardiogram monitoring during graded exercise

Low Risk High Risk

If extensive plaque is present a high-quality cardiac computed tomography angiography (CCTA) is

Test choice guided by patient’s exercise capacity, resting electrocardiographic abnormalities;

Cannot exclude microvascular vasospasm.

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