Chest pain other diagnostic studies

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3]

Overview

Invasive Coronary Angiography (ICA) is used to determine the presence and severity of a luminal obstruction of an epicardial coronary artery, including its location, length, and diameter, as well as coronary blood flow. ICA provides the characterization of high-grade obstructive stenosis and possibility for percutaneous or surgical revascularization. (IFR and FFR) provide physiologic characteristic of stenosis. Radiation exposure to the patient during an interventional procedure varied 4 to 10 mSv and is dependent on procedural duration and complexity. The spatial resolution of ICA is 0.3 mm, so, visualization of arterioles (diameter of 0.1 mm) that regulate myocardial blood flow is impossible. Coronary vascular functional studies can be performed during coronary angiography. In normal coronary angiography there may be evident abnormal coronary vascular function. Assessment of coronary microcirculation and coronary vasomotion by coronary function testing are reasonable.

Other Diagnostic Studies

Invasive Coronary Angiography (ICA) is used to determine the presence and severity of a luminal obstruction of an epicardial coronary artery, including its location, length, and diameter, as well as coronary blood flow.
ICA provides the characterization of high-grade obstructive stenosis and the possibility for percutaneous or surgical revascularization.
(IFR and FFR) provide physiologic characteristic of stenosis.
Radiation exposure to the patient during an interventional procedure varied 4 to 10 mSv and is dependent on procedural duration and complexity.
The spatial resolution of ICA is 0.3 mm; as such, it is impossible to visualize arterioles (diameter of 0.1 mm) that regulate myocardial blood flow.
Coronary vascular functional studies can be performed during coronary angiography.
In normal coronary angiography there may be evidence of abnormal coronary vascular function.
Assessment of coronary microcirculation and coronary vasomotion by coronary function testing are reasonable.

Contraindications of stress test for diagnosis of acute chest pain

Exercise ECG	Stress Nuclear	Stress Echocardiography	Stress CMR	Coronary CT Angiography
Abnormal ST changes on resting ECG, digoxin, left bundle branch block, Wolff-Parkinson-White pattern, ventricular paced rhythm (unless test is performed to establish exercise capacity and not for diagnosis of ischemia)	High-risk unstable angina, complicated ACS or AMI (<2 d)	Limited acoustic windows (in COPD patients) Inability to reach target heart rate	Reduced GFR (<30 mL/min/1.73 m2)	Allergy to iodinated contrast
Unable to achieve ≥5 METs or unsafe to exercise High-risk unstable angina or AMI (<2 days), ative ACS, Uncontrolled heart failure	Contraindications to vasodilator administration	Uncontrolled heart failure	Contraindications to vasodilator administration	Inability to cooperate with scan acquisition and/or holding breath
Significant cardiac arrhythmias (VT, complete atrioventricular block) or high risk for arrhythmias caused by QT prolongation	Significant arrhythmias (VT, second- or third-degree atrioventricular block) or sinus bradycardia <45 bpm	High-risk unstable angina, active ACS or AMI (<2 d) Serious ventricular arrhythmia or high risk for arrhythmias attributable to QT prolongation	Avoiding CMR in the presence of implanted device due to producing artifact limiting scan quality interpretatrion	Clinical instability (acute respiratory distress, severe hypotension, unstable arrhythmia)
Severe symptomatic aortic stenosis	Significant hypotension (SBP <90 mm Hg)	Respiratory failure Severe COPD, acute pulmonary embolism, severe pulmonary hypertension	Significant claustrophobia	Renal impairment
Severe systemic arterial hypertension≥200/110 mmHg	Known or suspected bronchoconstriction or bronchospastic disease Severe systemic arterial hypertension (≥200/110 mm Hg)	Contraindications to dobutamine (if pharmacologic stress test needed) Atrioventricular block, uncontrolled atrial fibrillation	Caffeine use within past 12 hours	Contraindication to beta blockade in the presence of an elevated heart rate and no alternative medications available for achieving target heart rate
Acute illness ( acute pulmonary embolism, acute myocarditis, acute pericarditis, acute aortic dissection	Recent use of dipyridamole or dipyridamole containing medications Use of methylxanthines ( aminophylline, caffeine) within 12 h Known hypersensitivity to adenosine, regadenoson	Critical aortic stenosis Acute illness (acute pulmonary embolism, acute myocarditis, acute pericarditis, acute aortic dissection)		Heart rate variability, arrhythmia
		Hemodynamically significant LV outflow tract obstruction Contraindications of atropine use: Narrow-angle glaucoma Myasthenia gravis Obstructive uropathy Obstructive gastrointestinal disorders Severe systemic arterial hypertension ≥200/110mmHg		Contraindication to nitroglycerin (if indicated)

The above table adopted from 2021 AHA/ACC/ASE Guideline^[1]

References

↑ Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O’Connor RE, Ross MA, Shaw LJ (November 2021). “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).

[pmid34709879-1] Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O’Connor RE, Ross MA, Shaw LJ (November 2021). “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines”. Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).

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