Acute Nonspecific Chest Pain-Low Probability of Coronary Artery Disease

Variant: 1 Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
Radiography chest	Usually Appropriate	☢
CTA coronary arteries with IV contrast	Usually Appropriate	☢☢☢
US echocardiography transthoracic resting	May Be Appropriate (Disagreement)	O
Radiography ribs and thoracic spine	May Be Appropriate	☢☢
CT chest with IV contrast	May Be Appropriate	☢☢☢
CT chest without and with IV contrast	May Be Appropriate	☢☢☢
CT chest without IV contrast	May Be Appropriate	☢☢☢
CTA chest with IV contrast	May Be Appropriate	☢☢☢
V/Q scan lung	May Be Appropriate	☢☢☢
US echocardiography transesophageal	Usually Not Appropriate	O
US echocardiography transthoracic stress	Usually Not Appropriate	O
Arteriography coronary	Usually Not Appropriate	☢☢☢
Fluoroscopy barium swallow and upper GI series	Usually Not Appropriate	☢☢☢
MRA chest without and with IV contrast	Usually Not Appropriate	O
MRA chest without IV contrast	Usually Not Appropriate	O
MRA coronary arteries without and with IV contrast	Usually Not Appropriate	O
MRA coronary arteries without IV contrast	Usually Not Appropriate	O
MRI heart function and morphology without and with IV contrast	Usually Not Appropriate	O
MRI heart function and morphology without IV contrast	Usually Not Appropriate	O
MRI heart with function and inotropic stress without and with IV contrast	Usually Not Appropriate	O
MRI heart with function and inotropic stress without IV contrast	Usually Not Appropriate	O
MRI heart with function and vasodilator stress perfusion without and with IV contrast	Usually Not Appropriate	O
Nuclear medicine scan gallbladder	Usually Not Appropriate	☢☢
CT heart function and morphology with IV contrast	Usually Not Appropriate	☢☢☢☢
SPECT or SPECT/CT MPI rest and stress	Usually Not Appropriate	☢☢☢☢

Panel Members

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Discussion of Procedures by Variant

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
A. Radiography Chest

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
B. US Echocardiography Transthoracic Stress

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
C. SPECT or SPECT/CT MPI Rest and Stress

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
D. US Echocardiography Transthoracic Resting

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
E. US Echocardiography Transesophageal

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
F. CTA Chest With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
G. V/Q Scan Lung

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
H. CTA Coronary Arteries With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
I. CT Chest Without IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
J. CT Chest With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
K. CT Chest Without and With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
L. CT Heart Function and Morphology With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
M. MRA Chest Without and With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
N. MRA Chest Without IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
O. MRI Heart Function and Morphology Without IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
P. MRI Heart Function and Morphology Without and With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
Q. MRI Heart With Function and Vasodilator Stress Perfusion Without and With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
R. MRI Heart With Function and Inotropic Stress Without IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
S. MRI Heart With Function and Inotropic Stress Without and With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
T. MRA Coronary Arteries Without and With IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
U. MRA Coronary Arteries Without IV Contrast

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
V. Arteriography Coronary

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
W. Radiography Ribs and Thoracic Spine

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
X. Nuclear Medicine Scan Gallbladder

Variant 1: Acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
Y. Fluoroscopy Upper GI Series

Summary of Recommendations

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Internal Medicine. 175(3):428-36, 2015 Mar.JAMA Intern Med. 175(3):428-36, 2015 Mar.
2.	Dai S, Huang B, Zou Y, et al. The HEART score is useful to predict cardiovascular risks and reduces unnecessary cardiac imaging in low-risk patients with acute chest pain. Medicine (Baltimore). 97(22):e10844, 2018 Jun.
3.	Kolff AQ, Bom MJ, Knol RJ, van de Zant FM, van der Zee PM, Cornel JH. Discriminative Power of the HEART Score for Obstructive Coronary Artery Disease in Acute Chest Pain Patients Referred for CCTA. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine. 15(1):6-10, 2016 Mar.Crit. pathw. cardiol.. 15(1):6-10, 2016 Mar.
4.	Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 8(2):195-203, 2015 Mar.
5.	Stopyra JP, Miller CD, Hiestand BC, et al. Chest Pain Risk Stratification: A Comparison of the 2-Hour Accelerated Diagnostic Protocol (ADAPT) and the HEART Pathway. Crit. pathw. cardiol.. 15(2):46-9, 2016 06.
6.	Dedic A, Lubbers MM, Schaap J, et al. Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study. Journal of the American College of Cardiology. 67(1):16-26, 2016 Jan 05.
7.	Ferencik M, Hoffmann U, Bamberg F, Januzzi JL. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. [Review]. European Heart Journal. 37(30):2397-405, 2016 08 07.
8.	Ferencik M, Mayrhofer T, Lu MT, et al. High-Sensitivity Cardiac Troponin I as a Gatekeeper for Coronary Computed Tomography Angiography and Stress Testing in Patients with Acute Chest Pain. Clin Chem. 63(11):1724-1733, 2017 Nov.
9.	Januzzi JL, Sharma U, Zakroysky P, et al. Sensitive troponin assays in patients with suspected acute coronary syndrome: Results from the multicenter rule out myocardial infarction using computer assisted tomography II trial. American Heart Journal. 169(4):572-8.e1, 2015 Apr.
10.	Liu T, Wang G, Li P, Dai X. Risk classification of highly sensitive troponin I predict presence of vulnerable plaque assessed by dual source coronary computed tomography angiography. The International Journal of Cardiovascular Imaging. 33(11):1831-1839, 2017 Nov.
11.	Smulders MW, Kietselaer BL, Schalla S, et al. Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging?. [Review]. American Heart Journal. 177:102-11, 2016 07.Am Heart J. 177:102-11, 2016 07.
12.	Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 367(4):299-308, 2012 Jul 26.
13.	Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012; 366(15):1393-1403.
14.	Raff GL, Hoffmann U, Udelson JE. Trials of Imaging Use in the Emergency Department for Acute Chest Pain. [Review]. Jacc: Cardiovascular Imaging. 10(3):338-349, 2017 Mar.
15.	Breuckmann F, Hochadel M, Voigtlander T, et al. The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry. Cardiology. 134(2):75-83, 2016.
16.	Hollander JE, Than M, Mueller C. State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes. [Review]. Circulation. 134(7):547-64, 2016 Aug 16.
17.	American College of Radiology. ACR Appropriateness Criteria®: Acute Chest Pain — Suspected Aortic Dissection. Available at: https://acsearch.acr.org/docs/69402/Narrative/
18.	American College of Radiology. ACR Appropriateness Criteria®: Suspected Pulmonary Embolism. Available at: https://acsearch.acr.org/docs/69404/Narrative/.
19.	Scheirey CD, Fowler KJ, Therrien JA, et al. ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. J Am Coll Radiol 2018;15:S217-S31.
20.	Yoo SM, Chun EJ, Lee HY, Min D, White CS. Computed Tomography Diagnosis of Nonspecific Acute Chest Pain in the Emergency Department: From Typical Acute Coronary Syndrome to Various Unusual Mimics. [Review]. J Thorac Imaging. 32(1):26-35, 2017 Jan.
21.	American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://gravitas.acr.org/PPTS/GetDocumentView?docId=164+&releaseId=2.
22.	Lancellotti P, Price S, Edvardsen T, et al. The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association. European heart journal cardiovascular Imaging. 16(2):119-46, 2015 Feb.
23.	Merchan Ortega G, Bonaque Gonzalez JC, Sanchez Espino AD, et al. Long-term prognostic value of peak exercise echocardiogram in patients hospitalized with acute chest pain. Echocardiography. 34(6):869-875, 2017 Jun.
24.	Levsky JM, Haramati LB, Spevack DM, et al. Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial. Jacc: Cardiovascular Imaging. 11(9):1288-1297, 2018 09.
25.	Tragardh E, Tan SS, Bucerius J, et al. Systematic review of cost-effectiveness of myocardial perfusion scintigraphy in patients with ischaemic heart disease: A report from the cardiovascular committee of the European Association of Nuclear Medicine. Endorsed by the European Association of Cardiovascular Imaging. [Review]. European heart journal cardiovascular Imaging. 18(8):825-832, 2017 May 01.
26.	Kirsch J, Brown RKJ, Henry TS, et al. ACR Appropriateness Criteria® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2017;14:S2-S12.
27.	Durand E, Bauer F, Mansencal N, et al. Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study. Int J Cardiol. 241:463-469, 2017 Aug 15.
28.	Levsky JM, Spevack DM, Travin MI, et al. Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial. Annals of Internal Medicine. 163(3):174-83, 2015 Aug 04.Ann Intern Med. 163(3):174-83, 2015 Aug 04.
29.	Nabi F, Kassi M, Muhyieddeen K, et al. Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT. J Nucl Med. 57(3):378-84, 2016 Mar.
30.	Linde JJ, Hove JD, Sorgaard M, et al. Long-Term Clinical Impact of Coronary CT Angiography in Patients With Recent Acute-Onset Chest Pain: The Randomized Controlled CATCH Trial. Jacc: Cardiovascular Imaging. 8(12):1404-1413, 2015 Dec.JACC Cardiovasc Imaging. 8(12):1404-1413, 2015 Dec.
31.	Romero J, Husain SA, Holmes AA, et al. Non-invasive assessment of low risk acute chest pain in the emergency department: A comparative meta-analysis of prospective studies. Int J Cardiol. 187:565-80, 2015.
32.	Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 61(8):880-92, 2013 Feb 26.
33.	Lardo AC, Rahsepar AA, Seo JH, et al. Estimating coronary blood flow using CT transluminal attenuation flow encoding: Formulation, preclinical validation, and clinical feasibility. Journal of cardiovascular computed tomography. 9(6):559-66.e1, 2015 Nov-Dec.
34.	Kitabata H, Leipsic J, Patel MR, et al. Incidence and predictors of lesion-specific ischemia by FFRCT: Learnings from the international ADVANCE registry. J Cardiovasc Comput Tomogr 2018;12:95-100.
35.	Pursnani A, Lee AM, Mayrhofer T, et al. Early resting myocardial computed tomography perfusion for the detection of acute coronary syndrome in patients with coronary artery disease. Circulation. Cardiovascular imaging. 8(3):e002404, 2015 Mar.
36.	Sorgaard M, Linde JJ, Hove JD, et al. Myocardial perfusion 320-row multidetector computed tomography-guided treatment strategy for the clinical management of patients with recent acute-onset chest pain: Design of the CArdiac cT in the treatment of acute CHest pain (CATCH)-2 randomized controlled trial. American Heart Journal. 179:127-35, 2016 Sep.Am Heart J. 179:127-35, 2016 Sep.
37.	Burris AC 2nd, Boura JA, Raff GL, Chinnaiyan KM. Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain: Results From the ACIC Consortium. JACC Cardiovasc Imaging. 8(7):817-25, 2015 Jul.
38.	Lehman SJ, Abbara S, Cury RC, et al. Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med. 122(6):543-9, 2009 Jun.
39.	Takx RAP, Vliegenthart R, Schoepf UJ, et al. Prognostic value of CT-derived left atrial and left ventricular measures in patients with acute chest pain. European Journal of Radiology. 86:163-168, 2017 Jan.Eur J Radiol. 86:163-168, 2017 Jan.
40.	Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. [Review]. JAMA. 316(7):754-63, 2016 Aug 16.
41.	Saremi F.. Cardiac MR Imaging in Acute Coronary Syndrome: Application and Image Interpretation. [Review]. Radiology. 282(1):17-32, 2017 Jan.
42.	Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol. 2009;53(17):1475-1487.
43.	Haaf P, Garg P, Messroghli DR, Broadbent DA, Greenwood JP, Plein S. Cardiac T1 Mapping and Extracellular Volume (ECV) in clinical practice: a comprehensive review. [Review]. Journal of Cardiovascular Magnetic Resonance. 18(1):89, 2016 Nov 30.
44.	Marwick TH, Cho I, O Hartaigh B, Min JK. Finding the Gatekeeper to the Cardiac Catheterization Laboratory: Coronary CT Angiography or Stress Testing?. [Review]. J Am Coll Cardiol. 65(25):2747-56, 2015 Jun 30.
45.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.