By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

The American College of Cardiology and American College of Radiology have issued new recommendations that define when diagnostic imaging is appropriate — or not — for patients presenting to the emergency department with chest pain.

The document, published in the Journal of the American College of Cardiology, covers 20 clinical scenarios encompassing four clinical entry points: suspected non-ST-segment elevation acute coronary syndromes, pulmonary embolism, acute aortic syndromes, and cases in which leading diagnoses are not possible.

With the assumption that all chest pain patients will initially undergo a history, physical exam, electrocardiography, and, potentially, biomarker testing, the groups’ conclusions include:

  • When the initial workup or chest radiography yields a likely noncardiac diagnosis (e.g., pneumothorax), cardiac imaging is rarely appropriate.
  • When ECG or biomarker testing is “unequivocally” positive for ischemia, catheter-based coronary angiography is appropriate; other rest imaging procedures are rarely appropriate.
  • If the clinician suspects non-ST-elevation MI but the initial ECG is normal or nonischemic and the initial troponin finding is normal, then coronary CT angiography is appropriate, rest single-photon emission computed tomography may be appropriate, and rest echocardiography, rest coronary magnetic resonance, and catheter angiography are rarely appropriate.


Dr. Harlan Krumholz of NEJM Journal Watch Cardiology weighed in: “We all know that imaging is overused for chest pain evaluations — in part because of an environment that punishes acts of omission over acts of commission and a litigious culture that pushes doctors to be overly cautious (neglecting the harms of overtesting). And then there is the financial incentive. This document will provide support for decision-making … the key thing is to listen to the patient, carefully consider all evidence, and understand and communicate the trade-offs of the diagnostic choices.”


JACC article (Subscription required)

Background: NEJM Journal Watch Emergency Medicine coverage of myocardial infarction after an ED visit for chest pain (Free)