 Introduction/Background Chronic chest pain (CCP) with low to intermediate probability of coronary artery disease (CAD) can arise from cardiac and noncardiac etiologies. While there are multiple potential noncardiac causes of CCP, such as costochondritis, arthritic or degenerative diseases, prior trauma, primary or metastatic tumors, pleural disease, or gastrointestinal causes, the scope of this document is focused on evaluating chest pain when a cardiac etiology is the concern. Multiple imaging tools can be used to evaluate CCP in symptomatic patients with low to intermediate probability for CAD. The imaging modalities available include: (1) multidetector coronary computed tomography angiography (CCTA); (2) stress and rest radionuclide single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI); (3) catheter-based invasive coronary angiography (ICA) with or without ventriculography; (4) chest radiography; (5) stress echocardiography; (6) PET; and (7) cardiac MRI and MR angiography (MRA). Special Imaging Considerations Advances in cardiac CT imaging technology have further reduced radiation dose in CCTA examinations [4]. New and available dose-reducing techniques include prospective triggering [5-7], iterative reconstruction algorithms [8], long z-axis coverage, and high-pitch spiral acquisition [9]. However, these newer low-dose techniques may not be available or appropriate for all patients. Although these techniques can reduce patient radiation dose, there may be patients for whom these radiation dose techniques are not optimal. 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. Variant 1: Chronic chest pain, noncardiac etiology unlikely: low to intermediate probability of coronary artery disease. Initial imaging.
Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs.  Introduction/Background Chronic chest pain (CCP) with low to intermediate probability of coronary artery disease (CAD) can arise from cardiac and noncardiac etiologies. While there are multiple potential noncardiac causes of CCP, such as costochondritis, arthritic or degenerative diseases, prior trauma, primary or metastatic tumors, pleural disease, or gastrointestinal causes, the scope of this document is focused on evaluating chest pain when a cardiac etiology is the concern. Multiple imaging tools can be used to evaluate CCP in symptomatic patients with low to intermediate probability for CAD. The imaging modalities available include: (1) multidetector coronary computed tomography angiography (CCTA); (2) stress and rest radionuclide single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI); (3) catheter-based invasive coronary angiography (ICA) with or without ventriculography; (4) chest radiography; (5) stress echocardiography; (6) PET; and (7) cardiac MRI and MR angiography (MRA). Special Imaging Considerations Advances in cardiac CT imaging technology have further reduced radiation dose in CCTA examinations [4]. New and available dose-reducing techniques include prospective triggering [5-7], iterative reconstruction algorithms [8], long z-axis coverage, and high-pitch spiral acquisition [9]. However, these newer low-dose techniques may not be available or appropriate for all patients. Although these techniques can reduce patient radiation dose, there may be patients for whom these radiation dose techniques are not optimal. 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. Variant 1: Chronic chest pain, noncardiac etiology unlikely: low to intermediate probability of coronary artery disease. Initial imaging.