Primary imaging options in pati
ents at low risk for coronary art
ery dis
eas
e (CAD) who pr
es
ent with undiff
er
entiat
ed ch
est pain and without signs of isch
emia ar
e functional t
esting with
ex
ercis
e or pharmacologic str
ess-bas
ed
el
ectrocardiography,
echocardiography, or myocardial p
erfusion imaging to
exclud
e myocardial isch
emia aft
er rul
e-out of myocardial infarction and
early cardiac CT b
ecaus
e of its high n
egativ
e pr
edictiv
e valu
e to
exclud
e CAD. Although possibl
e, is not conclusiv
e wh
eth
er tripl
e-rul
e-out CT (CAD, pulmonary
embolism, and aortic diss
ection) might improv
e th
e effici
ency of pati
ent manag
em
ent. Mor
e advanc
ed noninvasiv
e t
ests such as cardiac MRI and invasiv
e imaging with trans
esophag
eal
echocardiography or coronary angiography ar
e rar
ely indicat
ed. With incr
eas
ed lik
elihood of noncardiac caus
es, a numb
er of diagnostic t
ests, among th
em ultrasound of th
e abdom
en, MR angiography of th
e aorta with or without contrast, x-ray rib vi
ews, x-ray barium swallow, and upp
er gastroint
estinal s
eri
es, can also b
e appropriat
e.
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.