title: ACR Appropriateness Criteria Acute Nonspecific Chest Pain-Low Probability of Coronary Artery Disease.
abstract: Primary imaging options in patients at low risk for coronary artery disease (CAD) who present with undifferentiated chest pain and without signs of ischemia are functional testing with exercise or pharmacologic stress-based electrocardiography, echocardiography, or myocardial perfusion imaging to exclude myocardial ischemia after rule-out of myocardial infarction and early cardiac CT because of its high negative predictive value to exclude CAD. Although possible, is not conclusive whether triple-rule-out CT (CAD, pulmonary embolism, and aortic dissection) might improve the efficiency of patient management. More advanced noninvasive tests such as cardiac MRI and invasive imaging with transesophageal echocardiography or coronary angiography are rarely indicated. With increased likelihood of noncardiac causes, a number of diagnostic tests, among them ultrasound of the abdomen, MR angiography of the aorta with or without contrast, x-ray rib views, x-ray barium swallow, and upper gastrointestinal series, can also be appropriate. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. This recommendation is based on excellent evidence, including several randomized comparative effectiveness trials and blinded observational cohort studies.
authors.affiliation: Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Electronic address: uhoffmann@partners.org.
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
authors.affiliation: VA Medical Center, Philadelphia, Pennsylvania.
authors.forename: Scott R
authors.initials: SR
authors.lastname: Akers
authors.affiliation: University Hospital, Ann Arbor, Michigan.
authors.forename: Richard K J
authors.initials: RK
authors.lastname: Brown
authors.affiliation: Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri.
authors.forename: Kristopher W
authors.initials: KW
authors.lastname: Cummings
authors.affiliation: Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida.
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.affiliation: Arkansas Children's Hospital, Little Rock, Arkansas.
authors.forename: S Bruce
authors.initials: SB
authors.lastname: Greenberg
authors.affiliation: Uniformed Services University of the Health Sciences, Bethesda, Maryland.
authors.forename: Vincent B
authors.initials: VB
authors.lastname: Ho
authors.affiliation: Diagnostic Imaging, Los Angeles, California.
authors.forename: Joe Y
authors.initials: JY
authors.lastname: Hsu
authors.affiliation: Cedars Sinai Medical Center, Los Angeles, California, American College of Cardiology.
authors.forename: James K
authors.initials: JK
authors.lastname: Min
authors.affiliation: University of Cincinnati Hospital, Cincinnati, Ohio.
authors.forename: Kalpesh K
authors.initials: KK
authors.lastname: Panchal
authors.affiliation: Emory University Hospital, Atlanta, Georgia.
authors.forename: Arthur E
authors.initials: AE
authors.lastname: Stillman
authors.affiliation: Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri.
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Woodard
authors.affiliation: New York University Medical Center, New York, New York.
authors.forename: Jill E
authors.initials: JE
authors.lastname: Jacobs
mesh_terms: D000208:Acute Disease; D002637:Chest Pain / Q000175:diagnosis*; D015331:Cohort Studies; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000175:diagnosis*; D003937:Diagnosis, Differential; D003952:Diagnostic Imaging / Q000379:methods*; D004452:Echocardiography / Q000379:methods; D017548:Echocardiography, Transesophageal / Q000379:methods; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000379:methods; D008297:Male; D064887:Observational Studies as Topic; D017410:Practice Guidelines as Topic; D013902:Radiography, Thoracic / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D012680:Sensitivity and Specificity; D012955:Societies, Medical / Q000592:standards; D014057:Tomography, X-Ray Computed / Q000379:methods; D014481:United States