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## Complete Summary

#### GUIDELINE TITLE

Acute chest pain - suspected myocardial ischemia.

#### BIBLIOGRAPHIC SOURCE(S)

Stanford W, Bettmann MA, Casciani T, Gomes AS, Grollman JH, Holtzman SR,
Polak JF, Sacks D, Schoepf J, Jaff M, Moneta GL, Expert Panel on
Cardiovascular Imaging. Acute chest pain\--suspected myocardial
ischemia. \[online publication\]. Reston (VA): American College of
Radiology (ACR); 2005. 5 p. \[44 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Stanford W, Bettmann MA, Boxt
LM, Gomes AS, Grollman J, Henkin RE, Higgins CB, Kelley MJ, Needleman L,
Pagan-Marin H, Polak JF. Acute chest pain\--suspected myocardial
ischemia. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):7-13. \[46 references\].

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Acute chest pain, suspected myocardial ischemia

#### GUIDELINE CATEGORY

Diagnosis

#### CLINICAL SPECIALTY

Cardiology\
Emergency Medicine\
Family Practice\
Internal Medicine\
Nuclear Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
acute chest pain, suspected myocardial ischemia

#### TARGET POPULATION

Patients with acute chest pain, suspected myocardial ischemia

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Chest x-ray

2.  Invasive (INV)

    -   Coronary angiography

    -   Left ventricular angiography

3.  Ultrasound (US)

    -   Transthoracic echocardiography (TTE)

    -   Transesophageal echocardiography (TEE)

4.  Nuclear medicine (NUC)

    -   Myocardial perfusion

    -   Ventriculogram

    -   Infarct avid imaging

5.  Computed tomography (CT), with contrast

    -   Conventional

    -   Electron beam

    -   Multidetector ultrafast

6.  Magnetic resonance angiography (MRA)

7.  Magnetic resonance imaging (MRI)

8.  Perfusion MRI

9.  Position emission tomography (PET)

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals, and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Acute Chest Pain, Suspected Myocardial Ischemia**

  ---------------------------------------------------------------------------
  **Radiologic Exam    **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                   Plain films are needed to exclude
                                           other causes for chest pain.

  INV, heart,          8                   Necessary to define extent of
  angiography,                             stenosis. Usually done late in the
  coronary                                 work-up.

  US, heart,           7                   Indicated as a screening test to
  echocardiography                         evaluate cardiac function.
  transthoracic (TTE)                      Inexpensive and portable.

  INV, heart,          7                   Indicated to define ventricular
  angiography, left                        function as part of the ischemia
  ventricular (LV)                         evaluation.

  NUC, heart,          6                   May be indicated to evaluate
  myocardial perfusion                     extent of ischemia. Usually done
                                           after initial screening tests
                                           suggest ischemia.

  NUC, heart,          6                   May be indicated to evaluate
  ventriculogram                           cardiac function.

  NUC, heart, infarct  5                   May be indicated in questionable
  avid imaging                             cases to confirm infarction.

  US, heart,           4                   May be indicated to evaluate
  echocardiography,                        cardiac function or to rule out
  transesophageal                          aortic dissection.
  (TEE)                                    

  CT, heart, electron  4                   Probably not indicated except for
  beam, multidetector                      quantifying ventricular function.
  ultrafast, with                          Noncontrast images may be useful
  contrast                                 in screening for coronary
                                           calcification.

  MRA, heart           4                    

  CT, heart, with      3                   Little indication except for
  contrast                                 documenting other sources of chest
                                           pain.

  MRI, heart           3                   Little indication except for
                                           screening for possible aortic
                                           dissection. May have some
                                           applicability in evaluating
                                           cardiac function.

  MRI, heart,          2                   Research studies show some promise
  perfusion studies                        in evaluating infarction. Not
                                           extensively used clinically

  PET, heart           2                   See comments on MR perfusion
                                           studies.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

Patients with acute chest pain frequently present with classical
symptoms consisting of chest tightness and left-arm pain. In the acute
setting if these symptoms are present, they heavily favor the diagnosis
of unstable angina, and a cardiac work-up is indicated. However, in
stable patients chest pain may masquerade as indigestion, muscle spasm,
or a myriad of other nonspecific complaints. In these patients the
object of imaging is to exclude myocardial ischemia as the etiology of
the chest pain.

In unstable patients myocardial infarction (MI) may be fatal, and
establishing the diagnosis rapidly and accurately may be life saving.
Thus the cardiac work-up usually consists of an electrocardiogram and
serum markers, namely, CK-MB and/or cardiac troponins. These studies are
widely and rapidly available. Imaging studies are indicated when there
is a question as to whether or not the chest pain is ischemic in origin.
The studies currently used in determining the etiology of acute chest
pain in stable patients are the noninvasive or minimally invasive tests,
including the chest film (CXR), transthoracic echocardiogram (TTE),
transesophageal echocardiogram (TEE), conventional CT, electron beam
(EBCT) and multidetector (MDCT) computed tomography, infarct avid
imaging, myocardial perfusion imaging, radionuclide ventriculography
(RNV), PET, and MRI wall motion and perfusion. In addition, cardiac
catheterization, including coronary arteriography, may be necessary.

**Chest Film**

The utility of the chest film in patients with acute chest pain is to
rule out pathological conditions that may masquerade as a myocardial
infarction and to aid in the diagnosis of pulmonary edema that may
accompany acute myocardial infarction. Among conditions that may mimic
myocardial infarction are pneumothorax, fractured ribs, and pneumonia,
all of which are usually diagnosable on the plain chest film. Other
entities, such as ruptured aneurysms, aortic dissections, and pulmonary
embolism, may be suggested from the plain chest film, but the
sensitivity is less. Myocardial infarction will generally not be
diagnosable on the CXR unless there is associated cardiac enlargement,
congestive heart failure, or pulmonary edema. These findings are
indicative of previous cardiac events, and the prevalence of ischemic
pain is frequently higher in this group. Overall, the primary utility of
the chest film is to raise the possibility of a nonmyocardial etiology
for the chest pain.

**Transthoracic Echocardiography**

Myocardial ischemia frequently presents with abnormalities of left
ventricular wall motion. Depending on the location, the wall motion
abnormality may be identifiable on a TTE. Additional findings that would
be helpful in establishing a diagnosis of ischemia would be the
identification of left ventricular aneurysm or the presence of valvular
dysfunction as a result of the ischemia (e.g., acute mitral
regurgitation). TTE may also be helpful in diagnosing pericarditis or
pericardial effusions as an etiology for the chest pain. If the cause of
the chest pain was pulmonary embolism, an intracardiac source for the
embolus might also be identifiable. The embolus is directly visualizable
in a central or peripheral pulmonary artery.

Exercise echocardiography or, if more appropriate for the patient,
stress echocardiography both have a major role in demonstrating
myocardium that becomes ischemic and has altered motion with increased
myocardial oxygen demand. These studies can also demonstrate changes in
both focal and global ventricular function and in valve function that
may indicate myocardium at risk.

**Transesophageal Echocardiography**

Transesophageal echocardiography has little utility in the evaluation of
acute chest pain of suspected myocardial ischemic origin. Its primary
use is in ruling out aortic dissection, valvular dysfunction,
intracardiac thrombus, and/or intracardiac shunts resulting from
ischemic events. Because the prevalence of these findings is low in
acute myocardial ischemia, TEE is generally not indicated in the work-up
of the acute chest pain-suspected myocardial ischemia patient.

**Conventional Computed Tomography**

Conventional CT is useful in identifying aortic aneurysms and
dissections and in verifying pulmonary parenchymal changes occurring
from pulmonary embolism or pneumonia. Emboli can frequently be
identified within pulmonary artery branches by CT. Pericardial effusions
and/or pericardial thickening should also be identifiable. Again, the
utility of CT would be in identifying or excluding nonischemic and
nonmyocardial etiologies for the acute chest pain.

**Electron Beam Computed Tomography, Helical (spiral) CT and
Multidetector CT**

MDCT and EBCT are probably also not indicated for the same reasons.
These more rapid CT imaging approaches can demonstrate lung parenchymal
disease, pericardial disease, and aneurysms and dissections of the
aorta, and they also have utility in demonstrating coronary artery
calcification as a manifestation of arteriosclerosis; however, because
the extent of coronary calcification is not site specific for coronary
artery stenosis, calcification should not be used as an indicator of the
etiology of the chest pain. Scientific data confirm that the presence of
calcification does correlate highly with the presence of coronary
atherosclerotic lesions, and the extent of calcification and the number
of vessels involved do correlate with an increased likelihood of
coronary events. Current data also suggest that if there is no calcium
in the coronary arteries, especially in patients presenting to the ER
with chest pain, the chances of the chest pain being from a cardiac
etiology are low. The ability to quantify cardiac function, demonstrate
left ventricular aneurysms, and quantify ventricular filling and show
coronary occlusion with CTA are additional advantages of MDCT and EBCT
imaging.

**Infarct Avid Imaging and Myocardial Enzymes**

Infarct avid imaging can identify an acute myocardial infarct by the
uptake of radioactive tracer in the area of the infarction. However, the
imaging may not become positive until approximately 12-36 hours after
the infarction. Cardiac enzymes, and specifically the CK-MB fraction and
cardiac troponins, are also indicative of infarcts, and these tests can
be performed with more rapid results and less expense to the patient.
Also, because the electrocardiogram and elevated cardiac enzymes can
give an indication of acute ischemia, infarct avid imaging may only have
utility in questionable cases. However, it does have substantial value
in quantifying infarct size and in determining stunned or hibernating
versus frankly infarcted myocardium.

**Myocardial Perfusion Imaging**

Myocardial perfusion using single photon emission computed tomography
(SPECT) thallium scintigraphy is one of the important tests in assessing
myocardial ischemia. A TL-201 perfusion deficit on exercise that
decreases in size at rest is a classic finding in myocardial ischemia.
SPECT studies have a long and attractive track record in assessing
myocardial ischemia, and TL-201 and sestamibi scintigraphy are some of
the better studies available. They are not expensive and are not
associated with a significant morbidity or mortality. They do, however,
require transport of the patient to the imaging suite, and false
positive and negative studies are not infrequent.

**Radionuclide Ventriculography**

Radionuclide ventriculography (RNV) is probably indicated in patients
with acute chest pain of ischemic origin. It is inexpensive and
reasonably accurate and can demonstrate decreases in left ventricular
cardiac function secondary to ischemia. Because of its accuracy, low
cost, wide availability, and minimal morbidity, RNV is indicated if
other studies for suspected myocardial ischemia are inconclusive, or if
assessment of left ventricular function is important in determining
appropriate therapy.

**Positron Emission Tomography**

Positron emission tomography (PET) can reliably show myocardial blood
flow using N13 ammonia. It can also document anaerobic metabolism using
imaging with F18 fluorodeoxyglucose. This technology, however, is
expensive, is not universally available, and is probably not indicated
in the work-up of a suspected myocardial ischemia patient.

**Magnetic Resonance Imaging**

Magnetic resonance imaging has some utility in demonstrating
abnormalities of wall motion and in demonstrating pericardial effusions.
At times MRI may show intracardiac thrombus. MRI has little utility in
the imaging of patients with suspected myocardial ischemia. Other tests
such as RNV, TTE, or stress TTE can provide similar information about
wall motion and at lesser expense. Magnetic resonance angiography (MRA)
and MR plaque characterization are still investigational and are not yet
in wide clinical use.

**Magnetic Resonance Perfusion**

Magnetic resonance perfusion imaging is also probably not indicated.
Present contrast agents can demonstrate normal myocardium and
demonstrate signal changes in areas of decreased perfusion. There is a
potential for the use of these agents, but their utility in this
clinical setting has not yet been proven. Access to the patient to deal
with arrhythmias, cardiovascular instability, and claustrophobia are
potential problems in using MR technology.

**Cardiac Catheterization and Coronary Angiography**

The gold standard in making a definitive diagnosis of coronary arterial
obstruction as the probable cause for the chest pain is cardiac
catheterization with coronary arteriography and left ventriculography.
Although these tests may be indicated, cardiac catheterization is
usually the last test that is performed. These tests are always
indicated before a definitive surgical procedure or angioplasty.

**Summary**

The consensus of the panel and the literature review support the chest
film in the initial screening of a patient with acute chest pain of
suspected myocardial ischemic origin. The panel supports use of
radionuclide scintigraphy in the evaluation of myocardial perfusion and
in the evaluation of ventricular function. It also supports use of 2D
echo in evaluating myocardial contractility. The definitive diagnosis is
made by cardiac catheterization with coronary angiography and
ventriculography. Continuing developments in the assessment of coronary
blood flow and myocardial perfusion using magnetic resonance and PET may
prove helpful in the future. The presence of coronary atherosclerosis
and stenosis can be documented by the newer rapid CT technologies, such
as EBCT or helical or MDCT, but their use in the evaluation of acute
coronary syndrome patients has not been established.

**Abbreviations**

-   CT, computed tomography

-   INV, invasive

-   LV, left ventricular

-   MRA, magnetic resonance angiography

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   PET, positron emission tomography

-   TEE, transesophageal echocardiography

-   TTE, transthoracic echocardiography

-   US, ultrasound

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Selection of appropriate initial radiologic exam procedures to aid
    in differential diagnosis of patients with acute chest pain with
    suspected myocardial ischemia

-   Myocardial infarction (MI) may be fatal, and establishing the
    diagnosis rapidly and accurately may be life saving.

#### POTENTIAL HARMS

-   In myocardial perfusion imaging the false positive and negative
    studies are not infrequent.

-   Potential problems in using magnetic resonance (MR) technology
    include access to the patient to deal with arrhythmias,
    cardiovascular instability, and claustrophobia.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Stanford W, Bettmann MA, Casciani T, Gomes AS, Grollman JH, Holtzman SR,
Polak JF, Sacks D, Schoepf J, Jaff M, Moneta GL, Expert Panel on
Cardiovascular Imaging. Acute chest pain\--suspected myocardial
ischemia. \[online publication\]. Reston (VA): American College of
Radiology (ACR); 2005. 5 p. \[44 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Cardiovascular
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: William Stanford, MD (*Principal Author*); Michael A.
Bettmann, MD (*Panel Chair*); Thomas Casciani, MD; Antoinette S. Gomes,
MD; Julius H. Grollman, MD; Stephen R. Holtzman, MD; Joseph F. Polak,
MD, MPH; David Sacks, MD; Joseph Schoepf, MD; ; Michael Jaff, MD;
Gregory L. Moneta, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Stanford W, Bettmann MA, Boxt
LM, Gomes AS, Grollman J, Henkin RE, Higgins CB, Kelley MJ, Needleman L,
Pagan-Marin H, Polak JF. Acute chest pain\--suspected myocardial
ischemia. American College of Radiology. ACR Appropriateness Criteria.
Radiology 2000 Jun;215(Suppl):7-13. \[46 references\].

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available (in Portable Document Format \[PDF\]) from
the [American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonCardiovascularImaging/AcuteChestPainSuspectedMyocardialIschemiaDoc3.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on February 20, 2001. The information
was verified by the guideline developer on March 14, 2001. This summary
was updated by ECRI on March 3, 2006.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008