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Noninvasive testing and imaging for diagnosis in patients at low to intermediate risk for acute coronary syndrome

Prem Soman, MD, PhD, FACC, FRCP (UK)
Quynh A Truong, MD, MPH, FACC, FAHA, FSCCT
James E Udelson, MD, FACC
Section Editors
Jeroen J Bax, MD, PhD
Patricia A Pellikka, MD, FACC, FAHA, FASE
Deputy Editor
Gordon M Saperia, MD, FACC


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 [1]. 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 [2]. (See "Diagnostic and prognostic implications of coronary artery calcification detected by computed tomography".)


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Literature review current through: Sep 2016. | This topic last updated: Sep 27, 2016.
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  1. Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163.
  2. Pursnani A, Chou ET, Zakroysky P, et al. Use of coronary artery calcium scanning beyond coronary computed tomographic angiography in the emergency department evaluation for acute chest pain: the ROMICAT II trial. Circ Cardiovasc Imaging 2015; 8.
  3. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 1987; 59:23C.
  4. Jeroudi MO, Cheirif J, Habib G, Bolli R. Prolonged wall motion abnormalities after chest pain at rest in patients with unstable angina: a possible manifestation of myocardial stunning. Am Heart J 1994; 127:1241.
  5. Gerber BL, Wijns W, Vanoverschelde JL, et al. Myocardial perfusion and oxygen consumption in reperfused noninfarcted dysfunctional myocardium after unstable angina: direct evidence for myocardial stunning in humans. J Am Coll Cardiol 1999; 34:1939.
  6. Bilodeau L, Théroux P, Grégoire J, et al. Technetium-99m sestamibi tomography in patients with spontaneous chest pain: correlations with clinical, electrocardiographic and angiographic findings. J Am Coll Cardiol 1991; 18:1684.
  7. Varetto T, Cantalupi D, Altieri A, Orlandi C. Emergency room technetium-99m sestamibi imaging to rule out acute myocardial ischemic events in patients with nondiagnostic electrocardiograms. J Am Coll Cardiol 1993; 22:1804.
  8. Kontos MC, Jesse RL, Schmidt KL, et al. Value of acute rest sestamibi perfusion imaging for evaluation of patients admitted to the emergency department with chest pain. J Am Coll Cardiol 1997; 30:976.
  9. Heller GV, Stowers SA, Hendel RC, et al. Clinical value of acute rest technetium-99m tetrofosmin tomographic myocardial perfusion imaging in patients with acute chest pain and nondiagnostic electrocardiograms. J Am Coll Cardiol 1998; 31:1011.
  10. Tatum JL, Jesse RL, Kontos MC, et al. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med 1997; 29:116.
  11. Udelson JE, Beshansky JR, Ballin DS, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA 2002; 288:2693.
  12. Hauser AM, Gangadharan V, Ramos RG, et al. Sequence of mechanical, electrocardiographic and clinical effects of repeated coronary artery occlusion in human beings: echocardiographic observations during coronary angioplasty. J Am Coll Cardiol 1985; 5:193.
  13. Wohlgelernter D, Cleman M, Highman HA, et al. Regional myocardial dysfunction during coronary angioplasty: evaluation by two-dimensional echocardiography and 12 lead electrocardiography. J Am Coll Cardiol 1986; 7:1245.
  14. Beller GA. Myocardial perfusion imaging for detection of silent myocardial ischemia. Am J Cardiol 1988; 61:22F.
  15. Sabia P, Afrookteh A, Touchstone DA, et al. Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction. A prospective study using two-dimensional echocardiography. Circulation 1991; 84:I85.
  16. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18:1440.
  17. Peels CH, Visser CA, Kupper AJ, et al. Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room. Am J Cardiol 1990; 65:687.
  18. Sasaki H, Charuzi Y, Beeder C, et al. Utility of echocardiography for the early assessment of patients with nondiagnostic chest pain. Am Heart J 1986; 112:494.
  19. Kontos MC, Arrowood JA, Paulsen WH, Nixon JV. Early echocardiography can predict cardiac events in emergency department patients with chest pain. Ann Emerg Med 1998; 31:550.
  20. Lewis WR. Echocardiography in the evaluation of patients in chest pain units. Cardiol Clin 2005; 23:531.
  21. Lim SH, Sayre MR, Gibler WB. 2-D echocardiography prediction of adverse events in ED patients with chest pain. Am J Emerg Med 2003; 21:106.
  22. Paventi S, Parafati MA, Luzio ED, Pellegrino CA. Usefulness of two-dimensional echocardiography and myocardial perfusion imaging for immediate evaluation of chest pain in the emergency department. Resuscitation 2001; 49:47.
  23. Fram DB, Azar RR, Ahlberg AW, et al. Duration of abnormal SPECT myocardial perfusion imaging following resolution of acute ischemia: an angioplasty model. J Am Coll Cardiol 2003; 41:452.
  24. Kontos MC, Haney A, Ornato JP, et al. Value of simultaneous functional assessment in association with acute rest perfusion imaging for predicting short- and long-term outcomes in emergency department patients with chest pain. J Nucl Cardiol 2008; 15:774.
  25. Anderson, JL, Adams, CD, Antman, EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1. www.acc.org/qualityandscience/clinical/statements.htm (Accessed on July 28, 2008).
  26. Richards D, Meshkat N, Chu J, et al. Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial. CJEM 2007; 9:435.
  27. Meyer MC, Mooney RP, Sekera AK. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. Ann Emerg Med 2006; 47:427.
  28. Manini AF, Gisondi MA, van der Vlugt TM, Schreiber DH. Adverse cardiac events in emergency department patients with chest pain six months after a negative inpatient evaluation for acute coronary syndrome. Acad Emerg Med 2002; 9:896.
  29. Stein RA, Chaitman BR, Balady GJ, et al. Safety and utility of exercise testing in emergency room chest pain centers: An advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation 2000; 102:1463.
  30. Zalenski RJ, McCarren M, Roberts R, et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med 1997; 157:1085.
  31. Amsterdam EA, Kirk JD, Diercks DB, et al. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol 2002; 40:251.
  32. Conti A, Gallini C, Costanzo E, et al. Early detection of myocardial ischaemia in the emergency department by rest or exercise (99m)Tc tracer myocardial SPET in patients with chest pain and non-diagnostic ECG. Eur J Nucl Med 2001; 28:1806.
  33. Candell-Riera J, Oller-Martínez G, de León G, et al. Yield of early rest and stress myocardial perfusion single-photon emission computed tomography and electrocardiographic exercise test in patients with atypical chest pain, nondiagnostic electrocardiogram, and negative biochemical markers in the emergency department. Am J Cardiol 2007; 99:1662.
  34. Fesmire FM, Hughes AD, Fody EP, et al. The Erlanger chest pain evaluation protocol: a one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes. Ann Emerg Med 2002; 40:584.
  35. Depuey EG, Mahmarian JJ, Miller TD, et al. Patient-centered imaging. J Nucl Cardiol 2012; 19:185.
  36. Shoyeb A, Bokhari S, Sullivan J, et al. Value of definitive diagnostic testing in the evaluation of patients presenting to the emergency department with chest pain. Am J Cardiol 2003; 91:1410.
  37. Trippi JA, Lee KS, Kopp G, et al. Dobutamine stress tele-echocardiography for evaluation of emergency department patients with chest pain. J Am Coll Cardiol 1997; 30:627.
  38. Bergeron S, Ommen SR, Bailey KR, et al. Exercise echocardiographic findings and outcome of patients referred for evaluation of dyspnea. J Am Coll Cardiol 2004; 43:2242.
  39. Buchsbaum M, Marshall E, Levine B, et al. Emergency department evaluation of chest pain using exercise stress echocardiography. Acad Emerg Med 2001; 8:196.
  40. Bholasingh R, Cornel JH, Kamp O, et al. Prognostic value of predischarge dobutamine stress echocardiography in chest pain patients with a negative cardiac troponin T. J Am Coll Cardiol 2003; 41:596.
  41. Miller CD, Hwang W, Hoekstra JW, et al. Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients with emergent chest pain: a randomized trial. Ann Emerg Med 2010; 56:209.
  42. Miller CD, Hwang W, Case D, et al. Stress CMR imaging observation unit in the emergency department reduces 1-year medical care costs in patients with acute chest pain: a randomized study for comparison with inpatient care. JACC Cardiovasc Imaging 2011; 4:862.
  43. Miller CD, Case LD, Little WC, et al. Stress CMR reduces revascularization, hospital readmission, and recurrent cardiac testing in intermediate-risk patients with acute chest pain. JACC Cardiovasc Imaging 2013; 6:785.
  44. Miller CD, Hoekstra JW, Lefebvre C, et al. Provider-directed imaging stress testing reduces health care expenditures in lower-risk chest pain patients presenting to the emergency department. Circ Cardiovasc Imaging 2012; 5:111.
  45. Goldstein JA, Gallagher MJ, O'Neill WW, et al. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 2007; 49:863.
  46. Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol 2011; 58:1414.
  47. 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; 366:1393.
  48. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 2012; 367:299.
  49. 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 2013; 61:880.
  50. Takakuwa KM, Keith SW, Estepa AT, Shofer FS. A meta-analysis of 64-section coronary CT angiography findings for predicting 30-day major adverse cardiac events in patients presenting with symptoms suggestive of acute coronary syndrome. Acad Radiol 2011; 18:1522.
  51. Wang Y, Zhang Z, Kong L, et al. Dual-source CT coronary angiography in patients with atrial fibrillation: comparison with single-source CT. Eur J Radiol 2008; 68:434.
  52. Hollander JE, Gatsonis C, Greco EM, et al. Coronary Computed Tomography Angiography Versus Traditional Care: Comparison of One-Year Outcomes and Resource Use. Ann Emerg Med 2016; 67:460.
  53. Conti A, Sammicheli L, Gallini C, et al. Assessment of patients with low-risk chest pain in the emergency department: Head-to-head comparison of exercise stress echocardiography and exercise myocardial SPECT. Am Heart J 2005; 149:894.
  54. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 63:380.
  55. Rybicki FJ, Udelson JE, Peacock WF, et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853.