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ESR Essentials: imaging in stable chest pain – practice recommendations by ESCR

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Abstract

Stable chest pain is a common symptom with multiple potential causes. Non-invasive imaging has an important role in diagnosis and guiding management through the assessment of coronary stenoses, atherosclerotic plaque, myocardial ischaemia or infarction, and cardiac function. Computed tomography (CT) provides the anatomical evaluation of coronary artery disease (CAD) with the assessment of stenosis, plaque type and plaque burden, with additional functional information available from CT fractional flow reserve (FFR) or CT myocardial perfusion imaging. Stress magnetic resonance imaging, nuclear stress myocardial perfusion imaging, and stress echocardiography can assess myocardial ischaemia and other cardiac functional parameters. Coronary CT angiography can be used as a first-line test for many patients with stable chest pain, particularly those with low to intermediate pre-test probability. Functional testing may be considered for patients with known CAD, where the clinical significance is uncertain based on anatomical testing, or in patients with high pre-test probability. This practice recommendations document can be used to guide the selection of non-invasive imaging for patients with stable chest pain and provides brief recommendations on how to perform and report these diagnostic tests.

Key Points

  • The selection of non-invasive imaging tests for patients with stable chest pain should be based on symptoms, pre-test probability, and previous history.

  • Coronary CT angiography can be used as a first-line test for many patients with stable chest pain, particularly those with low to intermediate pre-test probability.

  • Functional testing can be considered for patients with known CAD, where the clinical significance of CAD is uncertain based on anatomical testing, or in patients with high pre-test probability.

Key recommendations

  • Non-invasive imaging is an important part of the assessment of patients with stable chest pain. The selection of non-invasive imaging test should be based on symptoms, pre-test probability, and previous history. (Level of evidence: High).

  • Coronary CT angiography can be used as a first line test for many patients with stable chest pain, particularly those with low to intermediate pre-test probability. CT provides information on stenoses, plaque type, plaque volume, and if required functional information with CT fractional flow reserve or CT perfusion. (Level of evidence: High).

  • Functional testing can be considered for patients with known CAD, where the clinical significance of CAD is uncertain based on anatomical testing, or in patients with high pre-test probability. Stress MRI, SPECT, PET, and echocardiography can provide information on myocardial ischemia, along with cardiac functional and other information. (Level of evidence: Medium).

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Change history

  • 22 April 2024

    Source Line layout was corrected.

Abbreviations

CAD:

Coronary artery disease

CCTA:

Coronary computed tomography angiography

FFR:

Fractional flow reserve

ICA:

Invasive coronary angiography

IVUS:

Intravascular ultrasound

MACE:

Major adverse cardiovascular events

OCT:

Optical coherence tomography

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Acknowledgements

This paper was endorsed by the Executive Council of the European Society of Radiology (ESR) and the Executive Committee of the European Society of Cardiovascular Radiology (ESCR) in March 2024.

Funding

The authors state that this work has not received any funding.

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Authors and Affiliations

  1. Department of Radiology, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy

    Giuseppe Muscogiuri

  2. Department of Radiology, Royal Papworth Hospital, Cambridge, UK

    Jonathan R. Weir-McCall

  3. Department of Radiology, University of Cambridge, Cambridge, UK

    Jonathan R. Weir-McCall

  4. Department of Radiology, Amosov National Institute of Cardiovascular Surgery NAMS of Ukraine, Kyiv, Ukraine

    Mariia Tregubova

  5. Department of Radiology, Internistisches Klinikum München Süd, Munich, Germany

    Sebastian Ley

  6. Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Wien, Austria

    Christian Loewe

  7. Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland

    Hatem Alkadhi

  8. Department of Radiology, Antwerp University Hospital & Holy Heart Lier, Antwerp, Belgium

    Rodrigo Salgado

  9. Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

    Rozemarijn Vliegenthart

  10. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK

    Michelle C. Williams

Authors
  1. Giuseppe Muscogiuri
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  4. Sebastian Ley
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Corresponding author

Correspondence to Giuseppe Muscogiuri.

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Guarantor

The scientific guarantor of this publication is Giuseppe Muscogiuri.

Conflict of interest

GM received a travel grant by Bracco. MCW has given talks for Canon Medical Systems, Siemens Healthineers and Novartis and performed consultancy for FEOPS. MCW is supported by the British Heart Foundation (FS/ICRF/20/26002). JRWM is supported by the National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre (BRC-1215-20014). RV is supported by an institutional research grant from Siemens Healthineers, and has received honorarium by Siemens Healthineers and Bayer for invited lectures. CL has received speaker honorarium from Siemens Healthineers, GE Healthcare and Bracco. HA has given presentations for Siemens. Healthcare. HA receives institutional grants from Bayer, Canon, Guerbet, and Siemens. HA is deputy editor of European Radiology. He has not taken part in the review or selection process of this article. JWM is a member of the European Radiology Scientific Editorial Board (Cardiac). He has not taken part in the review or selection process of this article.

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No complex statistical methods were necessary for this paper.

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Written informed consent was not required.

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This article belongs to the ESR Essentials series guest edited by Mark Dewey (Berlin/Germany).

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Muscogiuri, G., Weir-McCall, J.R., Tregubova, M. et al. ESR Essentials: imaging in stable chest pain – practice recommendations by ESCR. Eur Radiol (2024). https://doi.org/10.1007/s00330-024-10739-y

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