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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/nondiagnostic 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".)

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Literature review current through: Nov 2017. | This topic last updated: Jul 24, 2017.
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