Clinical Update: Acc/Aha/Ase/Chest/Saem/ SCCT/SCMR Guideline For The Evaluation and Diagnosis of Chest Pain

Clinical Update
ADAPTED FROM:
ACC/AHA/ASE/CHEST/SAEM/
SCCT/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) Benefit >>> Risk LEVEL A
Suggested phrases for writing recommendations: • High-quality evidence‡ from more than 1 RCT
• Is recommended • Meta-analyses of high-quality RCTs
• Is indicated/useful/effective/beneficial • One or more RCTs corroborated by high-quality registry studies
Table 1. • Should be performed/administered/other

• Comparative-Effectiveness Phrases†: LEVEL B-R (Randomized)
Applying
− Treatment/strategy A is recommended/indicated in preference to
• Moderate-quality evidence‡ from 1 or more RCTs
treatment B
• Meta-analyses of moderate-quality RCTs
− Treatment A should be chosen over treatment B
ACC/AHA Class of CLASS 2a (MODERATE) Benefit >> Risk
LEVEL B-NR (Nonrandomized)
Recommendation 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
and Level of • Can be useful/effective/beneficial
• Comparative-Effectiveness Phrases†:
• Meta-analyses of such studies
Evidence to
− Treatment/strategy A is probably recommended/indicated in preference to LEVEL C-LD (Limited Data)
treatment B
− It is reasonable to choose treatment A over treatment B • Randomized or nonrandomized observational or registry studies
Clinical Strategies, CLASS 2b (Weak) Benefit ≥ Risk

with limitations of design or execution
• Meta-analyses of such studies
Interventions,
• Physiological or mechanistic studies in human subjects
Suggested phrases for writing recommendations:
• May/might be reasonable LEVEL C-EO (Expert Opinion)
Treatments, or • May/might be considered

• Usefulness/effectiveness is unknown/unclear/uncertain or not well-established • Consensus of expert opinion based on clinical experience.
Diagnostic Testing CLASS 3: No Benefit (MODERATE) Benefit = Risk COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many
in Patient Care
Suggested phrases for writing recommendations: important clinical questions addressed in guidelines do not lend themselves to clinical trials.
• Is not recommended Although RCTs are unavailable, there may be a very clear clinical consensus that a particular
test or therapy is useful or effective.
• Is not indicated/useful/effective/beneficial
(Updated May 2019)* • Should not be performed/administered/other
CLASS 3: Harm (STRONG) Risk > Benefit

*The outcome or result of the intervention should be specified (an improved clinical outcome
or increased diagnostic accuracy or incremental prognostic information).
†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 treatments
Suggested phrases for writing recommendations: or strategies being evaluated.
• Potentially harmful ‡The method of assessing quality is evolving, including the application of standardized,
• Causes harm widely-used, and preferably validated evidence grading tools; and for systematic reviews, the
incorporation of an Evidence Review Committee. COR indicates Class of Recommendation;
• Associated with excess morbidity/mortality EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R,
• Should not be performed/administered/other randomized; and RCT, randomized controlled trial.
Gulati, M. et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Circulation. 2
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).
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
• Aortic Dissection (e.g., esophageal rupture, Cardiac Chest Pain
tension pneumothorax)
• Pulmonary Embolism Characteristics
Characteristics of chest pain:
FOCUSED HISTORY OF CHEST PAIN • Retrosternal chest discomfort
Characteristics of chest pain: • Gradual in intensity
• 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.
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 In patients with chest pain Cultural competency training is
are at risk for underdiagnosis, and who are >75 years of age, recommended to help achieve the
potential cardiac causes should ACS should be considered best outcomes in patients of diverse
always be considered (Class 1).* when accompanying racial and ethnic backgrounds who
symptoms such as present with chest pain (Class 1).
shortness of breath,
In women presenting with chest pain, syncope, or acute delirium
it is recommended to obtain a history Among patients of diverse race and
are present, or when an ethnicity presenting with chest pain
that emphasizes accompanying unexplained fall has
symptoms that are more common in in whom English may not be their
occurred (Class 1). primary language, addressing
women with ACS (Class 1).**
language barriers with the use of
formal translation services is
* Traditional risk scores may underestimate risk in women
** Women are more likely to report multiple associated recommended (Class 1).
symptoms in addition to chest pain when presenting
with ACS
Abbreviations: ACS indicates acute coronary syndrome.
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 breath sounds
• Crackles
• S3
• MR murmur
• Exam can be normal
Abbreviations: ACS indicates acute coronary syndrome; MR, mitral regurgitation; PE, pulmonary embolism; and S3, third heart sound.
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 venous
• hypertrophic cardiomyopathy 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.
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.
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).
Electrocardiographic-Directed Management
of Chest Pain Chest Pain
History +
Physical Examination
ECG
(Class 1)
Diffuse ST-elevation ST-depression Nondiagnostic or normal ECG

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

Follow STEMI Manage pericarditis Follow NSTE- Follow
symptoms persist reasonable if
guidelines ACS guidelines arrhythmia-
or change or if posterior MI
(Class 1) (Class 1) specific guidelines
troponins 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.
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).
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
• Anomalous coronary arteries
Other compelling (especially if PET or stress CMR 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.
Diagnostic Testing:
Coronary Computed Tomography Angiography
Indications for CCTA Contraindications to CCTA
1. To visualize and help to 1. Allergy to iodinated contrast
diagnose the extent and 2. Inability to cooperate with scan acquisition and
severity of nonobstructive and or breath-holding instructions
obstructive CAD.
3. Clinical instability (decompensated HF, severe
hypotension)
2. Allows for evaluation of 4. Renal impairments as defined by local protocols.
atherosclerotic plaque
composition and high-risk 5. Contraindication to beta blockade in the
features (e.g., positive presence of an elevated HR and no alternative
remodeling, low attenuation medications available for achieving target heart
plaque). 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.
Overview of Diagnostic Cardiac Stress Testing
STRESS TESTING INFORMATION
Stress
Exercise ECG SPECT MPI PET MRI Stress CMR MPI
echocardiography
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.
Diagnostic Testing: Exercise Electrocardiogram
Indications for Exercise ECG Contraindications to Exercise ECG
1. Candidates include those 1. Abnormal ST changes on resting ECG (>0.5mm ST
without disabling comorbidities depression), LVH, digoxin, LBBB, WPW pattern, ventricular
(frailty, marked obesity paced rhythm
(BMI>40kg/m2 ), PAD, COPD, or
orthopedic limitations 2. Unable to achieve METS ≥ 5 or unsafe to exercise
2. Capable of performing 3. High-risk unstable angina or ACS

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

1. Accurately assess global and 1. Reduced GFR (<30 mL/min/1.73 m2)
regional LV/ RV function
2. Contraindications to vasodilator
2. Detect and localize myocardial administration
ischemia and infarction
3. Implanted devices that are not safe for CMR
3. Determine myocardial viability or producing artifact limiting scan quality/
interpretation
4. Detect myocardial edema and
microvascular obstruction 4. Significant claustrophobia
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.
Diagnostic Cardiac Testing:
Women in Pregnancy, Postpartum or Child-Bearing Age
Ionizing radiation during If deemed necessary,
pregnancy or when breast risks/benefits of radiation from
feeding should be should be discussed with the
avoided patient (e.g., angiography,
CCTA, SPECT and PET)
Iodinated contrast should be Lowest effective dose of

used with caution in pregnancy radiation should be used
but may be given postpartum
Gadolinium contrast with Alternative tests including

CMR is discouraged ultrasound and 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.
Overview of Guideline-Based Pathways
for Evaluating Chest Pain
YES Is chest pain acute? NO
Refer to Figure 8. General Refer to Figure 8. General

Approach to Risk Stratification Approach to Risk Stratification of
of Patients With Suspected ACS Patients With Suspected ACS
Use Appropriate Pathway for Stable Chest Pain

Low Intermediate (use High
appropriate
algorithm)
Figure 9. Figure 13. Clinical Decision

Figure 10.
Evaluation Figure 12. Clinical Pathway for Patients With Stable
Evaluation
Algorithm for Chest Pain (or Equivalent)
Algorithm for Decision Pathway
Patients With Symptoms With Prior MI, Prior
Patients With for Patients With
Suspected ACS at Stable Chest Pain Revascularization, or Known CAD
Suspected ACS at
Intermediate Risk on Invasive Coronary Angiography
Intermediate Risk and No Known CAD
With No Known or CCTA, Including Those With
With Known CAD
CAD Nonobstructive CAD
Abbreviations: ACS indicates acute coronary syndrome; CAD, coronary artery disease;
CCTA, coronary computed tomographic angiography; and MI, myocardial infarction.
Figure 8. General Approach to Risk Stratification  Return to previous slide
of Patients With Suspected ACS
Patient with Acute Chest Pain
History + Physical Examination
ECG (Class 1)
Obvious noncardiac Obvious nonischemic

Possible ACS
cause cardiac cause
No cardiac testing Other cardiac testing Obtain troponin (Class 1)

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

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

Recent negative Prior inconclusive or Prior moderate-
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 CAD Inconclusive Obstructive CAD
Stress PET
Stress SPECT (1) (<50% stenosis) stenosis (>50% stenosis)
High risk
Nonobstructive CAD Inconclusive Obstructive CAD CAD or
(<50% stenosis) stenosis (>50% stenosis) Discharge
frequent High risk CAD or
angina Negative or Moderate
Inconclusive frequent angina
Discharge FFR-CT OR stress mildly severe
FFR-CT OR stress
testing (2a) abnormal ischemia
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
moderate-severe GDMT (1) Discharge YES moderate-severe NO GDMT (1)
symptoms 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
Figure 10. General Approach to Risk Stratification  Return to previous slide
of Patients With Suspected ACS
Acute Chest Pain +
Intermediate-Risk with Known CAD
Nonobstructive CAD+ Option to defer Obstructive CAD High-risk

(<50% stenosis) testing and intensify (> or = to 50% stenosis) CAD or
GDMT (1) frequent
Stress testing angina
CCTA (Class 2a) Stress CMR
Stress echocardiography
Stress PET
Stress SPECT
Obstructive CAD (2a)
No change
(>50% stenosis)
Consider INOCA
pathway as an FFR-CT OR stress Abnormal Normal
Discharge outpatient for
testing (2a)
frequent persistent functional test functional test
symptoms
FFR-CT < 0.8 or
GDMT NO Discharge
moderate-severe YES ICA (1) Option to defer ICA with
(1)
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.
Recommendations for High-Risk Patients
having Chest Pain
Prior CABG Dialysis Cocaine/

without ACS Methamphetamine
Stress testing or
CCTA (Class 1) In patients who
experience acute
Reasonable to
unremitting chest
pain while consider cocaine and
Indeterminate methamphetamine
undergoing dialysis,
as a cause of acute
transfer by EMS to an
chest pain symptoms
acute care setting is
Intra-coronary (Class 2a).
recommended
angiography is (Class 1).
useful (Class1)
Abbreviation: ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft;
CCTA, coronary computed tomographic angiography; and EMS, emergency medical service.
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 (e.g.,
1 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 (CTA)
1 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 make
1 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.
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.
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 in
1 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, TEE
1 (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 TTE
2b and/or TEE is nondiagnostic.
Other causes of chest pain
Abbreviations: GORD indicates gastro-oesophageal reflux disease; and mets, metastasis.
Noncardiac Chest Pain: Differential Diagnoses
Respiratory Gastrointestinal Chest Wall Psychological Other

• PE • Cholecystitis • Costochondritis • Panic disorder • Hyperventilation
syndrome
• Pneumothorax/ • Pancreatitis • Chest wall • Anxiety
hemothorax trauma • Carbon monoxide
• Hiatal hernia • Clinical poisoning
• Pneumomediastinum • Herpes Zoster Depression
• GI reflux disease • Sarcoidosis
• Pneumonia • Cervical • Somatization
• Gastritis/ radiculopathy disorder • Lead poisoning
• Bronchitis
• Esophagitis • Breast disease • Hypochondria • Prolapsed
• Pleural irritation interverbal disc
• Peptic ulcer disease • Rib fracture
• Malignancy • Thoracic outlet
• Esophageal spasm • Musculoskeletal syndrome
• Dyspepsia injury
• Sickle cell crisis
• Adverse
medication effects
Abbreviations: Gi indicates gastrointestinal; and PE, pulmonary embolus.
Figure 12. Clinical Decision Pathway for Patients With  Return to previous slide
Stable Chest Pain & No Known CAD
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 Inconclusive
Obstructive CAD ischemia ischemia
Inconclusive (no stenosis CAD
(≥50% stenosis)
or plaque) (<50% stenosis)
Optimize Optimize
Stress testing preventive preventive
Consider INOCA FFR-CT for 40-90% stenosis High risk CAD or
(2a) therapies therapies (1)
pathway as an OR stress testing (2a) frequent angina
outpatient for (1)
frequent or CAC (2a) Persistent
persistent symptoms FFR CT ≤0.8 or symptoms?
moderate-severe Invasive coronary
ischemia 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-directed medical therapy; CCTA (2a)
INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single -photon emission CT.
Figure 13. Stable Chest Pain (or Equivalent) Symptoms With Prior
 Return to previous slide
MI, Prior Revascularization, or Known CAD on Invasive Coronary
Angiography or CCTA, 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 option
defer testing (Class 1) to defer testing (Class 1)
Stress testing
Stress CMR
Persistent symptoms
High-risk CAD or Stress PET
CCTA ± FFR-CT frequent angina NO Stress SPECT
(FFR-CT for ≥40-90% stenosis) YES Stress echocardiography
OR stress testing (Class 2a) (Class 1)
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
See INOCA Invasive coronary ischemia
pathway angiography CCTA (for patients with
(Class 2a) (Class 1) prior CABG or stents >3.0 GDMT according to SIHD guideline (Class 1)
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.
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 is
2a 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 is
2a 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.
Figure 14. Clinical Decision Pathway for Ischemia and
Non-Obstructive CAD (INOCA) Factors that increase the
likelihood of CMD:
Stable Chest Pain • Diabetes

Suspected Ischemia and Non-Obstructive • Hypertension
Invasive coronary CAD (INOCA) • Left ventricular
function testing (requires Stress PET or stress CMR- hypertrophy
nonobstructive CAD FFR must be with MBFR • Small coronary vessel size
≥0.8) (Class 2a) Noninvasive testing more prevalent (Class 2a) or lumen volume
Invasive assessment more comprehensive Stress echocardiography • Infiltrative heart disease
with CFVR (Class 2b)
Epicardial artery IMR ≥25
CFR ≥2.0 spasm (>90%) OR
+ with ACh CFR <2.0
IMR <25 + OR Normal MBFR Normal MBFR Reduced MBFR Reduced MBFR
+ reproduction of angina with ST + no ischemia + ischemia + ischemia + no ischemia
negative chest pain depression during
provocative + ACh bolus or
study to ACh ischemic ECG infusion, and
Diagnostic
changes epicardial artery Diagnostic
criteria for Diagnostic
constriction criteria for CMD
INOCA – criteria for CMD
+ ischemia
no CMD
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 fl ow 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.
Cost Considerations
CCTA CAC Exercise ECG
CAC had lower cost & higher

Compared with stress tests,
MACE-free survival compared Lower cost compared with CT &
CCTA has similar long-term with exercise ECG (CRESCENT I nuclear tests
outcomes & cost over 2-3 years & II trials)
✓ Associated with reduced accuracy
In the CONSERVE trial, ✓ Tiered testing may help offset its

CAC was associated with 16% cost reduced accuracy.
CCTA-guided referral to invasive
savings at 1 year compared with
angiography was 1,183$ compared ✓ Initial cost 174$, >50% lower cost
exercise ECG
with direct referral 2,755$ than 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.
Cost Considerations
Stress Stress
Stress CMR
Echocardiography Nuclear MPI
Increased cost-effectiveness Associated with favorable incremental

2-year cost was highest in PET
compared to exercise ECG cost-effectiveness
✓ Favorable cost-effectiveness ratio

✓ Cost effective in intermediate
✓ Similar cost at 3 years to CCTA (<$50,000 per quality-adjusted life
risk patients
years saved).
✓ (PROMISE trial): mean cost
✓ Similar cost to CCTA and
difference: –$363; 95% CI: – ✓ In the CE-MARC trial, CMR was more
exercise ECG
$1,562–$818) cost-effective than stress MPI, mainly
✓ In higher likelihood patients, due to diagnostic accuracy.
✓ Cost effective in intermediate
MPI SPECT was the most cost-
risk patients ✓ Most cost-effective strategy was tiered
effective.
testing 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.
Evidence Gaps and Future Research
Clinical
MINOCA/ Symptom Stratification &
ACS
INOCA Classification Decision Tools
Gaps in
Delays from Better diagnostic and
pathophysiology, Identify pretest
symptom onset to management options
diagnosis and probability
presentation
management
• RCT to assess utility and impact

• Emphasis on of stratification tools on
• Utilize technologies
complete testing to outcomes
that permit
diagnose Machine-learning
acquisition and • RCT to assess which diagnostic
MINOCA/INOCA algorithms may help
transmission of modality to eliminate to
ECGs from home • Research to reduce sex and racial
disparities in care streamline care and improve
understand cost-effectiveness
• Remote evaluations
pathophysiology
(e.g., telehealth) • Utility of high sensitivity troponin
and optimal therapy
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.
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
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.
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).
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.
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.
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
(ECG)
hs-cTn Based
T-0
T-0 hs-cTn below the assay limit of detection or “very • Troponin-confirmed acute myocardial injury
low” threshold if symptoms present for at least 3 h
T-0 hs-cTn and 1- or 2-h delta are both below the • New-onset left ventricular systolic
T-0 and 1- or 2-h Delta
assay “low” thresholds (>99% NPV for 30-d MACE) dysfunction (left ventricular ejection fraction
Clinical Decision Pathway Based
(LVEF) < 40%)
HEART Pathway (20)

HEART score <3, initial and serial cTn/hs-cTn < assay • Newly diagnosed moderate-severe ischemia
99th percentile
on stress testing
EDACS <16; initial and serial cTn/hs-cTn < assay 99th
EDACS (14)
percentile
• Hemodynamic instability
TIMI score 0, initial and serial cTn/hs-cTn < assay 99th
ADAPT (21)
percentile
TIMI score 0/1, initial and serial cTn/hs-cTn < assay
• High clinical decision pathway (CDP) risk score
mADAPT
99th percentile
NOTR (15) 0 factors
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.
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.
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.
Fractional flow reserve with computed tomography (FFR-CT) turnaround times may impact prompt
clinical care decisions.
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).
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.
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.

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Table 1. • Should be performed/administered/other

Recommendation Suggested phrases for writing recommendations:

Clinical Strategies, CLASS 2b (Weak) Benefit ≥ Risk

Treatments, or • May/might be considered

(Updated May 2019)* • Should not be performed/administered/other

CLASS 3: Harm (STRONG) Risk > Benefit

“Chest pain” suggestive of ischemia is not just discomfort in the

An initial assessment of chest pain is recommended to triage

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

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

Characteristics of chest pain: • Gradual in intensity

• Nature • Precipitating factors • Precipitated by stress

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

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

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

to any medical facility setting?

In all patients presenting to the ED with acute chest pain and

Diffuse ST-elevation 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;

With availability of cTn, creatine kinase myocardial (CK-MB) isoenzyme and

2. Capable of performing 3. High-risk unstable angina or ACS

Indications for Stress CMR MPI Contraindications to Stress CMR MPI

Iodinated contrast should be Lowest effective dose of

Gadolinium contrast with Alternative tests including

Refer to Figure 8. General Refer to Figure 8. General

Use Appropriate Pathway for Stable Chest Pain

Figure 9. Figure 13. Clinical Decision

History + Physical Examination

Obvious noncardiac Obvious nonischemic

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

Low Risk Intermediate Risk High Risk

No testing required Further diagnostic Invasive coronary

YES Prior testing NO

Nonobstructive CAD+ Option to defer Obstructive CAD High-risk

Prior CABG Dialysis Cocaine/

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.

Nonobstructive CAD Obstructive CAD

Evaluate adequacy of GDMT

Stable Chest Pain • Diabetes

CCTA CAC Exercise ECG

CAC had lower cost & higher

✓ Associated with reduced accuracy