American College of Radiology
ACR Appropriateness Criteria®

Chronic Chest Pain-Noncardiac Etiology Unlikely: Low to Intermediate Probability of Coronary Artery Disease

Variant 1: Chronic chest pain, noncardiac etiology unlikely: low to intermediate probability of coronary artery disease. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA coronary arteries with IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv 9 9 0 0 1 0 0 0 0 4 8
References Study Quality
10 (25984459) 4
11 (26782999) 4
12 (25844996) 4
13 (26112200) 4
14 (23684682) 3
15 (27081014) 3
16 (28973101) Good
17 (28329294) 2
18 (26892420) 4
19 (27043808) 4
20 (26746631) 1
21 (25714275) 4
22 (22830462) 1
23 (23517254) 2
24 (25788230) 1
25 (25773919) 1
26 (28389572) 2
27 (21565735) 3
28 (25473041) 1
29 (23727215) 3
30 (25125300) 2
31 (27318587) 4
32 (27502292) 3
33 (22032711) 2
34 (22922562) 1
35 (23562923) 4
36 (23934536) 4
37 (24110575) 3
38 (28444153) 3
39 (26330417) 1
40 (27470449) 2
US echocardiography transthoracic stress Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 1 0 4 5 2
References Study Quality
51 (15215802) 2
52 (17222734) Good
53 (25896850) 3
MRI heart with function and vasodilator stress perfusion without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 2 5 4 1
References Study Quality
55 (12403662) 3
56 (15289384) 2
57 (23578348) 4
58 (22196944) 3
59 (16580532) 3
60 (22084203) 1
Rb-82 PET/CT heart stress Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 1 1 0 11 1 1
References Study Quality
66 (16949498) 2
67 (20541718) 4
Tc-99m SPECT/CT MPI rest and stress Usually appropriate Limited ☢☢☢☢ 10-30 mSv 7 7 0 0 0 0 0 2 5 3 3
References Study Quality
25 (25773919) 1
41 (11397352) 3
42 (25745089) 2
43 (26052677) 2
44 (24026478) 3
Tc-99m SPECT/CT MPI stress only Usually appropriate Limited ☢☢☢ 1-10 mSv 7 7 0 0 1 0 2 3 6 1 0
References Study Quality
25 (25773919) 1
41 (11397352) 3
42 (25745089) 2
43 (26052677) 2
44 (24026478) 3
US echocardiography transthoracic resting May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 4 7 3 0 0
References Study Quality
54 (26455270) 4
MRI heart with function and inotropic stress without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 4 3 2 2 0
References Study Quality
55 (12403662) 3
56 (15289384) 2
57 (23578348) 4
58 (22196944) 3
59 (16580532) 3
60 (22084203) 1
MRI heart with function and inotropic stress without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 4 4 1 4 0
References Study Quality
55 (12403662) 3
56 (15289384) 2
57 (23578348) 4
58 (22196944) 3
59 (16580532) 3
60 (22084203) 1
CT coronary calcium May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 1 0 0 0 9 4 1 0 0
References Study Quality
45 (22825529) 4
46 (23733236) 3
47 (22919038) 4
48 (22461571) 2
49 (23370817) 3
50 (21067988) 4
MRI heart function and morphology without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 3 3 5 3 1 0 0
References Study Quality
55 (12403662) 3
56 (15289384) 2
57 (23578348) 4
58 (22196944) 3
59 (16580532) 3
60 (22084203) 1
CT chest with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 1 0 7 3 3 1 0 0
MRA coronary arteries without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 0 0 3 5 5 2 0 0 0
References Study Quality
61 (11756576) 1
62 (11471654) 1
63 (15931354) 4
CT chest without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 1 2 1 3 1 0 0 0
CT chest without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 2 7 2 0 1 0 0 0
Arteriography coronary Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 1 1 11 1 0 1 0 0 0
References Study Quality
64 (24139951) 2
Tc-99m SPECT/CT MPI rest only Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 2 1 10 2 0 0 0 0 0
References Study Quality
25 (25773919) 1
41 (11397352) 3
42 (25745089) 2
43 (26052677) 2
44 (24026478) 3
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.