Noninvasive testing and imaging for diagnosis in patients at low to intermediate risk for acute coronary syndrome
- Prem Soman, MD, PhD, FACC, FRCP (UK)
Prem Soman, MD, PhD, FACC, FRCP (UK)
- Associate Professor of Medicine, and Clinical and Translational Science
- University of Pittsburgh School of Medicine
- Quynh A Truong, MD, MPH, FACC, FAHA, FSCCT
Quynh A Truong, MD, MPH, FACC, FAHA, FSCCT
- Director of Cardiac CT Research
- Dalio Institute of Cardiovascular Imaging
- New York Presbyterian Hospital
- Weill Cornell Medical College
- James E Udelson, MD, FACC
James E Udelson, MD, FACC
- Professor of Medicine and Radiology
- Tufts University School of Medicine
- Section Editors
- Jeroen J Bax, MD, PhD
Jeroen J Bax, MD, PhD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Cardiology
- Leiden University Medical Center, The Netherlands
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
Many patients who are evaluated for acute chest pain are felt to be at low to intermediate pre-test risk of an acute coronary syndrome (ACS) if they have resolution of symptoms, normal or nonischemic electrocardiograms, and initial troponin value(s) that are not diagnostic for myocardial infarction (MI). Ultimately, these individuals may have unstable angina, non-ischemic cardiac pain, or non-cardiac pain. Evaluation of these patients generally occurs in a hospital emergency department or observation unit.
Noninvasive cardiovascular testing can be used to further risk stratify those patients for whom the diagnosis of myocardial ischemia is still a concern, despite the absence of definitive proof of MI, and for whom discharge without exclusion of the diagnosis may be risky . The use of noninvasive cardiovascular testing generally helps determine further management decisions, such as discharge, the need for invasive coronary angiography, or evaluation for other causes of symptoms. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department", section on 'Impact of missed diagnosis'.)
The use of noninvasive cardiovascular testing to assess the likelihood of an ACS is discussed here. The initial evaluation of patients with chest pain at low to intermediate risk for ACS, including determination of whether noninvasive imaging during rest and/or provocative stress testing is indicated, is discussed separately. (See "Evaluation of patients with chest pain at low or intermediate risk for acute coronary syndrome", section on 'Noninvasive evaluation'.)
The various noninvasive cardiovascular diagnostic tests are broadly grouped into two categories: those acquired during the resting state or those requiring provocative stress testing.
Rest imaging — Diagnostic imaging tests that do not stress the heart are termed "rest tests." These are often performed on actively symptomatic patients. Three major rest imaging modalities are available to evaluate patients presenting to the emergency department (ED) with possible acute coronary syndrome (ACS), including radionuclide myocardial perfusion imaging, echocardiography, and coronary computed tomographic angiography. We do not recommend the use of the coronary artery calcium score to evaluate chest pain in the ED, since absence of coronary artery calcium does not exclude an ACS . (See "Diagnostic and prognostic implications of coronary artery calcification detected by computed tomography".)
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- AVAILABLE TESTS
- Rest imaging
- Provocative (stress) testing
- PATIENTS WITH ONGOING SYMPTOMS
- Radionuclide myocardial perfusion imaging
- Two-dimensional echocardiography
- rMPI versus echocardiography
- Cardiovascular magnetic resonance imaging
- Limitations of rest testing
- PATIENTS WHOSE SYMPTOMS HAVE RESOLVED
- Our approach
- Inpatient or outpatient
- Choice of stress type
- Imaging or no imaging
- Choice of imaging modality
- - Stress radionuclide myocardial perfusion imaging
- - Stress echocardiography
- - Stress CMR
- - Coronary computed tomography angiography
- - Comparison of tests
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS