Chest Pain Suggestive of Acute Coronary Syndrome

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American College of Radiology
ACR Appropriateness Criteria®
Clinical Condition: Chest Pain Suggestive of Acute Coronary Syndrome
Radiologic Procedure Rating Comments RRL*
This procedure is appropriate for
Tc-99m SPECT MPI rest and stress 8 intermediate-to-high likelihood for ☢ ☢ ☢ ☢
coronary artery disease. There is abundant
literature available on clinical utility.
Arteriography coronary 8 This procedure is the gold standard and is ☢ ☢ ☢
In the setting of ongoing chest pain, this
Tc-99m SPECT MPI rest only procedure has a high negative predictive ☢ ☢ ☢
7 value. Tc-99m is the most commonly used
radionuclide agent for this test. RRL may
be higher if Thallium (TI-201) used.
US echocardiography transthoracic stress 7 Consider this procedure when resting echo O
and cardiac enzymes are normal.
This procedure is primarily used for
US echocardiography transthoracic resting 6 evaluating wall-motion abnormalities and O
aortic dissection.
Consider this procedure for those patients
with low-to-intermediate likelihood for ☢ ☢ ☢
CTA coronary arteries with IV contrast 6 coronary artery disease, in the absence of
cardiac enzyme elevation and ischemic ST
X-ray chest 5 This procedure is primarily a survey for
noncardiac etiologies of chest pain.
This procedure is primarily for noncardiac ☢ ☢ ☢
CT chest with IV contrast 5 etiologies such as pulmonary embolism
and aortic dissection.
MRI heart function with stress without For this procedure there is limited
5 experience in the clinical setting and lack O
and with IV contrast
of availability.
MRI heart function with stress without IV For this procedure there is limited
4 experience in the clinical setting and lack O
of availability.
Rb-82 PET heart stress 4 For this procedure there is lack of ☢ ☢ ☢
widespread use and availability.
MRI heart function and morphology 4 This procedure is primarily for the O
without and with IV contrast possibility of aortic dissection.
CT chest without and with IV contrast 3 ☢ ☢ ☢
MRI heart function and morphology 3 This procedure is primarily for the O
without IV contrast possibility of aortic dissection.
This procedure has a relative
US echocardiography transesophageal 3 contraindication for acute coronary O
CT coronary calcium 2 This procedure is not validated in the ☢ ☢ ☢
acute setting.
MRA coronary arteries without IV This procedure is technically challenging
2 and there is a lack of widespread use as O
well as protocol availability.
MRA coronary arteries without and with This procedure is technically challenging,
2 and there is a lack of widespread use as O
IV contrast
well as protocol availability.
CT chest without IV contrast 2 ☢ ☢ ☢
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level




Expert Panel on Cardiac Imaging: Leena Mammen, MD1; Suhny Abbara, MD2; Sharmila Dorbala, MD3; Cylen Javidan-Nejad, MD4; Paul R. Julsrud, MD5; Jacobo Kirsch, MD6; Christopher M. Kramer, MD7; Rajesh Krishnamurthy, MD8; Archana T. Laroia, MD9; Amar B. Shah, MD10; Jens Vogel-Claussen, MD11; Richard D. White, MD12; Pamela K. Woodard, MD.13


Summary of Literature Review




Acute chest pain is a frequent presenting complaint in emergency departments. Along with other important disease entities such as aortic dissection and pulmonary embolus, such patient symptoms may question the possibility of acute myocardial ischemia. Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non -STEMI (NSTEMI), and unstable angina (UA) [1]. Being able to establish the diagnosis rapidly and accurately may be lifesaving. The immediate cardiac workup consists of an electrocardiogram (ECG) and cardiac biomarkers. In the acute setting, even if there are no ischemic changes on ECG, a cardiac workup is often indicated. Because research has demonstrated that patients having a STEMI have improved outcomes if percutaneous intervention is performed within 90 minutes of arrival to a hospital, if the patient is suspected of having an ACS the patient will be urgently transferred to a cardiac catheterization laboratory for invasive angiography and potential coronary revascularization [2- 4]. Depending on institutional policy, non- STEMI patients with ACS may only undergo coronary angiography during conventional operating hours of the catheterization laboratory.


In stable patients without ST elevation, an initially conservative approach may be considered [5]. In patients with active chest pain, an ECG with no ischemic changes, and an initial negative troponin, rest single -photon emission computed tomography (SPECT) has been demonstrated to be useful [6,7]. However, it has been shown to be less sensitive than stress SPECT imaging if the chest pain has subsided. Stress echocardiography may be equally considered in acute chest pain patients as well. Noninvasive imaging may be indicated for risk stratification before discharge in both low-risk and intermediate-risk patients who have been free of ischemia for a minimum of 12–24 hours. This approach also serves to identify patients with latent ischemia who could benefit from more aggressive revascularization [5,8-11].


In clinically stable UA/NSTEMI patients, cardiac catheterization in a nonemergent setting has advantages that may outweigh the benefits of performing urgent intervention. This select group of patients with UA/NSTEMI may be selected for “early but nonurgent angiography/intervention,” also referred to as “upstream therapy.” In the interval prior to angiography, these patients may benefit from aggressive antiplatelet therapy. In this group of patients selected for nonurgent invasive angiography, noninvasive imaging may be the intermediate step between the emergency department and discharge, improving confidence regarding the safety of the discharge [5].


Noncoronary etiologies for chest pain can also be established with imaging, the results of which may alter the patient’s postdischarge care altogether. It is not uncommon for a patient to have acute chest pain occurring from other cardiovascular causes or noncardiac etiologies. Patients may have predisposing cardiac risk factors and pain characteristics that place them in the triage category of intermediate probability for coronary artery disease (CAD). Further cardiac risk stratification of this subgroup of patients is recommended before discharge, and noninvasive imaging is often necessary to exclude ischemia as an etiology [12-15].


The available noninvasive cardiac imaging modalities include chest radiography (CXR), rest SPECT myocardial perfusion imaging (MPI), stress SPECT MPI, echocardiography (transthoracic and transesophageal), multidetector computed tomography (MDCT), positron emission tomography (PET) (metabolic and perfusion), and magnetic resonance imaging (MRI).


Chest Radiography


The utility of the CXR is primarily for ruling out conditions that may masquerade as acute myocardial ischemia as well as defining secondary findings that may accompany acute myocardial infarction. Acute pulmonary edema can be seen on a CXR without enlargement of the cardiac silhouette in patients with acute myocardial infarction and no prior history of ischemic damage or associated mitral valve disease. However, CXR is insufficient to confirm or exclude the presence of significant CAD. Other cardiovascular entities, such as aortic aneurysms, aortic dissections, and pulmonary embolism may be suggested from the CXR but with far lower sensitivity than other imaging modalities such as MDCT [16-18]. Noncardiac findings associated with chest pain that can be identified on the CXR include pneumothorax, fractured ribs, pleural effusions, and pneumonia.


Single-Photon Emission Computed Tomography/Myocardial Perfusion Imaging


SPECT perfusion scintigraphy is an important test in the assessment for myocardial ischemia. In patients with active chest pain, an ECG with no ischemic changes, and an initial negative troponin, rest SPECT has been demonstrated to be the test of choice [6,7,19]. It has been shown to be less sensitive than stress SPECT imaging, however, if performed after the chest pain has subsided. The commonly used radionuclide agents are TI-201 (Thallium) chloride and (Technetium) Tc- 99m-labeled agents (eg, sestamibi, tetrofosmin). There is abundant literature describing the use of SPECT in ACS. The absence of a perfusion defect on an acute rest study is associated with a very high negative predictive value for ACS evaluation. A perfusion defect that becomes apparent or becomes larger during exercise stress or pharmacologic stress defines ischemic myocardium.


Recently new software algorithms such as iterative reconstruction, maximum a posteriori noise regularization, and resolution recovery, and new hardware and detector materials have become available, allowing for image acquisitions at significantly shorter acquisition times (one-fifth to one-half of previous acquisition times) or alternatively at lower doses compared to conventional algorithms [20].




Stress echocardiography has been shown to be a modality equivalent to stress SPECT MPI in the acute setting in low-to- intermediate risk patients, with a stress pharmacologic agent (such as dobutamine) inducing focal wall-motion abnormalities in the region(s) of ischemia [20-22]. Overall left ventricular function can also be assessed. The presence of left ventricular aneurysms, pseudoaneurysms, effusions, and valvular dysfunction can be determined as well.


The primary utility of transesophageal echocardiography (TEE) in the setting of acute chest pain is in ruling out aortic dissection in unstable patients. TEE is also used to further define valvular dysfunction or intracardiac thrombus, which can be sequelae of ischemic events in the subacute setting. Because of the semi-invasive nature of TEE and because there is limited information that can be added in the setting of acute chest pain, this modality is generally not indicated in the workup of patients with acute chest pain [23,24].


Multidetector Computed Tomography


In stable patients with suggested ACS with a low or intermediate probability of CAD, in whom follow -up ECG and cardiac biomarker measurements are normal, performance of a noninvasive coronary imaging test (ie, coronary CT angiography [CCTA]) is reasonable as an alternative to stress testing or selective coronary angiography [5,25,26]. CCTA has a very high negative predictive value for the detection of coronary atherosclerosis with or without significant stenosis and may be a potential alternative to stress imaging in the emergency department setting in patients at low to intermediate risk for CAD [25,27- 35]. Although some of these studies have been criticized for including patients that have a very low pretest probability of CAD, large prospective trials attest to the high negative predictive value and good prognosis of a “normal” CTA in patients with low-risk acute chest pain. The advantages of cost and time savings while maintaining safety in the emergency department have also been pursued [36-41]. In addition, CT has a well-established role in identifying aortic aneurysms, aortic dissections, pulmonary embolism, pericardial disease, and lung parenchymal disease, all of which can also present with acute chest pain [13,42,43].

Evaluation of patients with CCTA results may be limited in patients with high heart rates (>65 beats/min) uncontrolled by beta blocker or other rate-limiting agents, and in patients who have intractable arrhythmias. Patients who have calcium scores greater than 400–600 Agatson Units have limitations, although the role of calcium score in the acute setting has not been established [44,45].

Recent advances in cardiac CT imaging technology allow for further radiation dose reduction in CCTA examinations [46]; new and available dose- reducing techniques include prospective triggering [47-49], adaptive statistical iterative reconstruction [50], and high -pitch spiral acquisition [51]. However, these newer low-dose techniques may not be appropriate in all patients due to their dependency on a combination of factors, including heart rate, rhythm, and large body size. Thus, although these techniques are promising in terms of reducing patient radiation dose, there may be patients for whom these radiation dose techniques are not optimal, such as an obese, elderly patient with an arrhythmia who might best benefit from retrospective gating in order to allow assessment of the coronary arteries at multiple phases of the cardiac cycle. In addition, not all scanners are capable of all radiation dose reduction techniques. In all cases, the imaging physician must select the appropriate combination of imaging parameters to acquire a diagnostic examination at a radiation dose that is as low as reasonably achievable (ALARA).


Positron Emission Tomography


A stress PET examination can reliably demonstrate myocardial blood flow using Rubidium-82 (Rb-82) or Nitrogen-13 (N-13) ammonia. Limited data are available for PET perfusion studies in the setting of acute chest pain, although there is growing evidence for diagnostic and prognostic applications in chronic coronary disease


  • PET can also document anaerobic metabolism using fluorine-18-2-fluoro-2-deoxy-D-glucose and other metabolic tracers. This technology is not universally available and, therefore, is less well studied in the workup of the acute chest pain patient [53].


Magnetic Resonance Imaging


MRI has modest utility in patients with suspected ischemia in the acute setting. The principal limitations to this technique are equipment availability and the high level of expertise required of technologists and interpreting physicians. Access to the patient may be more difficult in the magnetic environment if the patient’s stability should deteriorate.


However, cardiac MRI with delayed postcontrast imaging and edema-weighted imaging provides definitive assessment of the size, distribution, and transmural extent of acute or remote myocardial infarction. Cine MRI has utility in demonstrating wall-motion abnormalities, which may accompany acute or chronic ischemic heart disease, and first-pass stress contrast-enhanced perfusion cardiac MRI can demonstrate myocardial perfusion abnormalities [54-58].


MRI, like CT, can also identify noncardiac findings of chest pain, such as aortic dissection. Cardiac MR has been shown to be cost- effective in the workup of intermediate-risk chest pain patients in the emergency department [59,60]. Although MR coronary angiography has not been established in general practice, both angiographic and phase-contrast flow continue to be developed for coronary artery assessment in research centers [61].




A number of imaging modalities may be used in evaluating stable patients with chest pain suggestive of ACS and who are not selected for urgent cardiac catheterization.


Although cardiac catheterization is the mainstay for evaluation of patients in whom a diagnosis of NSTEMI is made, in the clinically stable patient with angina or UA, alternative noninvasive imaging modalities may be appropriate.


Noninvasive imaging in this setting includes MPI, coronary CT angiography, cardiac MRI, and stress echocardiography. These tests may be performed as an intermediate step and may improve confidence regarding the safety of discharge from the emergency department.


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, both because of 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 to 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 Pediatric Effective Dose Estimate
Range 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 (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies”.


Supporting Documents


For additional information on the Appropriateness Criteria methodology and other supporting documents go to




  1. Cannon CP, Battler A, Brindis RG, et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol. 2001;38(7):2114-2130.
  2. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004;44(3):E1-E211.
  3. Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. 2008;117(2):296-329.
  4. Nallamothu BK, Bates ER, Herrin J, Wang Y, Bradley EH, Krumholz HM. Times to treatment in transfer patients undergoing primary percutaneous coronary intervention in the United States: National Registry of Myocardial Infarction (NRMI)-3/4 analysis. 2005;111(6):761-767.
  5. 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(7):e1-e157.
  6. Kontos MC, Fratkin MJ, Jesse RL, Anderson FP, Ornato JP, Tatum JL. Sensitivity of acute rest myocardial perfusion imaging for identifying patients with myocardial infarction based on a troponin definition. J Nucl 2004;11(1):12-19.
  7. 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. 2002;288(21):2693-2700.
  8. Cantor WJ, Goodman SG, Cannon CP, et al. Early cardiac catheterization is associated with lower mortality only among high-risk patients with ST- and non-ST-elevation acute coronary syndromes: observations from the OPUS-TIMI 16 trial. Am Heart J. 2005;149(2):275-283.
  9. de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med. 2005;353(11):1095-1104.
  10. Fox KA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. 2005;366(9489):914-920.
  11. Mehta SR, Cannon CP, Fox KA, et al. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. 2005;293(23):2908-2917.
  12. Pryor DB, Shaw L, Harrell FE, Jr., et al. Estimating the likelihood of severe coronary artery disease. Am J 1991;90(5):553-562.
  13. Rubinshtein R, Halon DA, Gaspar T, et al. Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin. Am J Cardiol. 2007;100(10):1522-1526.
  14. Solinas L, Raucci R, Terrazzino S, et al. Prevalence, clinical characteristics, resource utilization and outcome of patients with acute chest pain in the emergency department. A multicenter, prospective, observational study in north-eastern Italy. Ital Heart J. 2003;4(5):318-324.
  15. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. 2010;122(17):1756-1776.
  16. Buenger RE. Five thousand acute care/emergency department chest radiographs: comparison of requisitions with radiographic findings. J Emerg Med. 1988;6(3):197-202.
  17. Butcher BL, Nichol KL, Parenti CM. High yield of chest radiography in walk-in clinic patients with chest symptoms. J Gen Intern Med. 1993;8(3):115-119.
  18. Templeton PA, McCallion WA, McKinney LA, Wilson HK. Chest pain in the accident and emergency department: is chest radiography worthwhile? Arch Emerg Med. 1991;8(2):97-101.
  19. 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(7):1804-1808.
  20. Di Pasquale P, Cannizzaro S, Scalzo S, et al. Sensitivity, specificity and predictive value of the echocardiography and troponin-T test combination in patients with non-ST elevation acute coronary syndromes. Int J Cardiovasc Imaging. 2004;20(1):37-46.
  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(2):106-110.
  22. Tong KL, Kaul S, Wang XQ, et al. Myocardial contrast echocardiography versus Thrombolysis In Myocardial Infarction score in patients presenting to the emergency department with chest pain and a nondiagnostic electrocardiogram. J Am Coll Cardiol. 2005;46(5):920-927.
  23. Kuhl HP, Hanrath P. The impact of transesophageal echocardiography on daily clinical practice. Eur J 2004;5(6):455-468.
  24. Peres M, Pitta Mda L, Alcaravela J, et al. Transesophageal echocardiography in an emergency setting. A district general hospital experience. Rev Port Cardiol. 2005;24(7-8):971-979.
  25. Hendel RC, Patel MR, Kramer CM, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48(7):1475-1497.
  26. Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009;53(18):1642-1650.
  27. Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O’Neill WW, O’Neil B. The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients. Ann Emerg Med. 2007;49(2):125-136.
  28. Goldstein JA, Gallagher MJ, O’Neill WW, Ross MA, O’Neil BJ, Raff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49(8):863-871.
  29. Hoffmann U, Nagurney JT, Moselewski F, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. 2006;114(21):2251-2260.
  30. Hoffmann U, Pena AJ, Cury RC, et al. Cardiac CT in emergency department patients with acute chest pain. 2006;26(4):963-978; discussion 979-980.
  31. Kuettner A, Trabold T, Schroeder S, et al. Noninvasive detection of coronary lesions using 16-detector multislice spiral computed tomography technology: initial clinical results. J Am Coll Cardiol. 2004;44(6):1230-1237.
  32. Mochizuki T, Hosoi S, Higashino H, Koyama Y, Mima T, Murase K. Assessment of coronary artery and cardiac function using multidetector CT. Semin Ultrasound CT MR. 2004;25(2):99-112.
  33. Rubinshtein R, Halon DA, Gaspar T, et al. Usefulness of 64-slice multidetector computed tomography in diagnostic triage of patients with chest pain and negative or nondiagnostic exercise treadmill test result. Am J 2007;99(7):925-929.
  34. Stanford W, Thompson BH, Weiss RM. Coronary artery calcification: clinical significance and current methods of detection. AJR Am J Roentgenol. 1993;161(6):1139-1146.
  35. Stillman AE, Oudkerk M, Ackerman M, et al. Use of multidetector computed tomography for the assessment of acute chest pain: a consensus statement of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology. Eur Radiol. 2007;17(8):2196-2207.
  36. 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(14):1414-1422.
  37. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367(4):299-308.
  38. 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.
  39. Marwan M, Pflederer T, Schepis T, et al. Accuracy of dual-source CT to identify significant coronary artery disease in patients with uncontrolled hypertension presenting with chest pain: comparison with coronary angiography. Int J Cardiovasc Imaging. 2012;28(5):1173-1180.
  40. 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(12):1522-1528.
  41. van Velzen JE, de Graaf FR, Kroft LJ, et al. Performance and efficacy of 320-row computed tomography coronary angiography in patients presenting with acute chest pain: results from a clinical registry. Int J Cardiovasc Imaging. 2012;28(4):865-876.
  42. White CS, Kuo D, Kelemen M, et al. Chest pain evaluation in the emergency department: can MDCT provide a comprehensive evaluation? AJR Am J Roentgenol. 2005;185(2):533-540.
  43. Urbania TH, Hope MD, Huffaker SD, Reddy GP. Role of computed tomography in the evaluation of acute chest pain. J Cardiovasc Comput Tomogr. 2009;3(1 Suppl):S13-22.
  44. Chang AM, Le J, Matsuura AC, Litt HI, Hollander JE. Does coronary artery calcium scoring add to the predictive value of coronary computed tomography angiography for adverse cardiovascular events in low-risk chest pain patients? Acad Emerg Med. 2011;18(10):1065-1071.
  45. Laudon DA, Behrenbeck TR, Wood CM, et al. Computed tomographic coronary artery calcium assessment for evaluating chest pain in the emergency department: long-term outcome of a prospective blind study. Mayo Clin Proc. 2010;85(4):314-322.
  46. Gerber TC, Kantor B, McCollough CH. Radiation dose and safety in cardiac computed tomography. Cardiol 2009;27(4):665-677.
  47. Earls JP, Berman EL, Urban BA, et al. Prospectively gated transverse coronary CT angiography versus retrospectively gated helical technique: improved image quality and reduced radiation dose. 2008;246(3):742-753.
  48. Husmann L, Valenta I, Gaemperli O, et al. Feasibility of low-dose coronary CT angiography: first experience with prospective ECG-gating. Eur Heart J. 2008;29(2):191-197.
  49. Stolzmann P, Leschka S, Scheffel H, et al. Dual-source CT in step-and-shoot mode: noninvasive coronary angiography with low radiation dose. 2008;249(1):71-80.
  50. Leipsic J, Labounty TM, Heilbron B, et al. Estimated radiation dose reduction using adaptive statistical iterative reconstruction in coronary CT angiography: the ERASIR study. AJR Am J Roentgenol. 2010;195(3):655-660.
  51. Achenbach S, Marwan M, Ropers D, et al. Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram-triggered high-pitch spiral acquisition. Eur Heart J. 2010;31(3):340-346.
  52. Osborne AD, Moore B, Ross MA, Pitts SR. The feasibility of Rubidium-82 positron emission tomography stress testing in low-risk chest pain protocol patients. Crit Pathw Cardiol. 2011;10(1):41-43.
  53. Gropler RJ. Imaging to distinguish between viable and nonviable myocardium: pathophysiologic basis and importance of positron emission tomography. AJR Am J Roentgenol. 1993;161(3):497-500.
  54. Steel K, Broderick R, Gandla V, et al. Complementary prognostic values of stress myocardial perfusion and late gadolinium enhancement imaging by cardiac magnetic resonance in patients with known or suspected coronary artery disease. 2009;120(14):1390-1400.
  55. Vogel-Claussen J, Skrok J, Dombroski D, et al. Comprehensive adenosine stress perfusion MRI defines the etiology of chest pain in the emergency room: Comparison with nuclear stress test. J Magn Reson Imaging. 2009;30(4):753-762.
  56. Lerakis S, McLean DS, Anadiotis AV, et al. Prognostic value of adenosine stress cardiovascular magnetic resonance in patients with low-risk chest pain. J Cardiovasc Magn Reson. 2009;11:37.
  57. 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 2012;5(1):111-118.
  58. Cury RC, Shash K, Nagurney JT, et al. Cardiac magnetic resonance with T2-weighted imaging improves detection of patients with acute coronary syndrome in the emergency department. 2008;118(8):837-844.
  59. 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(7):785-794.
  60. 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(8):862-870.
  61. Bluemke DA, Achenbach S, Budoff M, et al. Noninvasive coronary artery imaging: magnetic resonance

angiography and multidetector computed tomography angiography: a scientific statement from the american heart association committee on cardiovascular imaging and intervention of the council on cardiovascular radiology and intervention, and the councils on clinical cardiology and cardiovascular disease in the young. Circulation. 2008;118(5):586-606.


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.

1Principal Author, Advanced Radiology Services, Grand Rapids, Michigan. 2Panel Vice-chair, Massachusetts General Hospital, Boston, Massachusetts. 3Brigham and Women’s Hospital, Boston, Massachusetts, Society of Nuclear Medicine and Molecular Imaging. 4Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri. 5Mayo Clinic, Rochester, Minnesota. 6Cleveland Clinic, Weston, Florida. 7University of Virginia Health System, Charlottesville, Virginia, American College of Cardiology. 8Texas Children’s Hospital, Houston, Texas. 9University of Iowa Hospitals and Clinics, Iowa City, Iowa. 10Westchester Medical Center, Valhalla, New York. 11Johns Hopkins Hospital, Baltimore, Maryland. 12Ohio State University Wexner Medical Center, Columbus, Ohio. 13Panel Chair, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

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