Specifically in patients in whom angina that is due to CAD was suspected, the SCOT-HEART investigators showed that CCTA clarified the diagnosis by providing added certainty, enabling targeted interventions, and potentially reducing the risk of future myocardial infarction [24]. The PROMISE investigators evaluated patients with stable chest pain to either CCTA or functional testing. Their work has shown that patients who underwent CCTA had a lower risk of death and lower risk of myocardial infarction (not leading to a fatality) compared to patients who underwent conventional functional testing. The investigators suggest that CCTA can be a safe alternative to functional testing in a low-risk population [25,26]. CCTA has also provided prognostic information beyond that of clinical risk scores [27]. Data from the CAPP and CONFIRM investigators have provided additional information. The CAPP investigators have shown that patients undergoing CCTA identified significant disease, underwent more revascularizations, less diagnostic testing, and fewer admissions for chest pain [28]. The CONFIRM investigators have also shown that CCTA better predicted risk compared to well-established clinical risk scores and reclassified approximately one [29]. CT Chest When CAD and other cardiac etiologies of chest pain, such as aortic disease pericardial disease, are suspected, a chest CT may be appropriate. SPECT or SPECT/CT MPI Stress SPECT MPI [41] is a central part of the diagnostic pathway when evaluating patients with CCP. A SPECT MPI scan is performed with either exercise-induced or pharmacologically induced stress to demonstrate myocardial perfusion or contraction abnormalities. Use of stress imaging can be performed rapidly and increasingly through protocol optimization, with lower radiation doses [42]. Patients who undergo SPECT imaging have outcomes similar to CCTA in terms of outcomes [25,43].
Chronic Chest Pain Noncardiac Etiology Unlikely Low to Intermediate Probability of Coronary Artery Disease PCAs. Specifically in patients in whom angina that is due to CAD was suspected, the SCOT-HEART investigators showed that CCTA clarified the diagnosis by providing added certainty, enabling targeted interventions, and potentially reducing the risk of future myocardial infarction [24]. The PROMISE investigators evaluated patients with stable chest pain to either CCTA or functional testing. Their work has shown that patients who underwent CCTA had a lower risk of death and lower risk of myocardial infarction (not leading to a fatality) compared to patients who underwent conventional functional testing. The investigators suggest that CCTA can be a safe alternative to functional testing in a low-risk population [25,26]. CCTA has also provided prognostic information beyond that of clinical risk scores [27]. Data from the CAPP and CONFIRM investigators have provided additional information. The CAPP investigators have shown that patients undergoing CCTA identified significant disease, underwent more revascularizations, less diagnostic testing, and fewer admissions for chest pain [28]. The CONFIRM investigators have also shown that CCTA better predicted risk compared to well-established clinical risk scores and reclassified approximately one [29]. CT Chest When CAD and other cardiac etiologies of chest pain, such as aortic disease pericardial disease, are suspected, a chest CT may be appropriate. SPECT or SPECT/CT MPI Stress SPECT MPI [41] is a central part of the diagnostic pathway when evaluating patients with CCP. A SPECT MPI scan is performed with either exercise-induced or pharmacologically induced stress to demonstrate myocardial perfusion or contraction abnormalities. Use of stress imaging can be performed rapidly and increasingly through protocol optimization, with lower radiation doses [42]. Patients who undergo SPECT imaging have outcomes similar to CCTA in terms of outcomes [25,43].