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4.1.2. Intermediate-Risk Patients With Acute Chest Pain
COR LOE
Recommendations
1 C-EO 1. For intermediate-risk patients with acute chest pain, TTE
is recommended as a rapid, bedside test to establish baseline
ventricular and valvular function, evaluate for wall motion
abnormalities, and to assess for pericardial effusion.
2a A 2. For intermediate-risk patients with acute chest pain,
management in an observation unit is reasonable to shorten
length of stay and lower cost relative to an inpatient admission.
4.1.2.1. Intermediate-Risk Patients With No Known (CAD)
COR LOE
Recommendations
Anatomic Testing
1 A 1. For intermediate-risk patients with acute chest pain and no
known CAD eligible for diagnostic testing after a negative
or inconclusive evaluation for ACS, CCTA is useful for
exclusion of atherosclerotic plaque and obstructive CAD.
1 C-EO 2. For intermediate-risk patients with acute chest pain,
moderate-severe ischemia on current or prior (≤1 year) stress
testing, and no known CAD established by prior anatomic
testing, ICA is recommended.
2a C-LD 3. For intermediate-risk patients with acute chest pain with
evidence of previous mildly abnormal stress test results (≤1
year), CCTA is reasonable for diagnosing obstructive CAD.
Stress Testing
1 B-NR 4. For intermediate-risk patients with acute chest pain and no
known CAD who are eligible for cardiac testing, either exercise
ECG, stress echocardiography, stress PET/SPECT MPI, or
stress CMR is useful for the diagnosis of myocardial ischemia.
Sequential or Add-on Diagnostic Testing
2a B-NR 5. For intermediate-risk patients with acute chest pain and no
known CAD, with a coronary artery stenosis of 40% to 90% in a
proximal or middle coronary artery on CCTA, FFR-CT can be
useful for the diagnosis of vessel-specific ischemia and to guide
decision-making regarding the use of coronary revascularization.
2a C-EO 6. For intermediate-risk patients with acute chest pain and
no known CAD, as well as an inconclusive prior stress
test, CCTA can be useful for excluding the presence of
atherosclerotic plaque and obstructive CAD.
2a C-EO 7. For intermediate-risk patients with acute chest pain and no
known CAD, with an inconclusive CCTA, stress imaging
(with echocardiography, PET/SPECT MPI, or CMR) can be
useful for the diagnosis of myocardial ischemia.
