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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e394 CLINICAL STATEMENTS AND GUIDELINES bedside by properly trained clinicians and technicians may be particularly useful. 2. The additional testing needed for intermediate-risk patients often requires more time than is appropriate for an ED visit and is often performed under “observation” outpatient status. These patients may be placed in an inpatient bed or managed in a dedicated observation unit. Relative to care in an inpatient bed, dedicated observation units have been shown to decrease hospital admissions, length of stay, and cost while improving inpatient bed availability and chest pain patient satisfaction.1-7 4.1.2.1 Intermediate-Risk Patients With Acute Chest Pain and No Known CAD Recommendations for Intermediate-Risk Patients With No Known CAD Referenced studies that support the recommendations are summarized in Online Data Supplements 14 and 15. COR LOE Recommendations Index Diagnostic Testing Anatomic Testing 1 A 1. For intermediate-risk patients with acute chest pain and no known CAD eligible for diagnostic testing after a negative or inconclusive evaluation for ACS, CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD.1-11 1 C-EO 2. For intermediate-risk patients with acute chest pain, moderate-severe ischemia on current or prior (≤1 year) stress testing, and no known CAD established by prior anatomic testing, ICA is recommended. 2a C-LD 3. For intermediate-risk patients with acute chest pain with evidence of previous mildly abnormal stress test results (≤1 year), CCTA is reasonable for diagnosing obstructive CAD.12,13 Stress Testing 1 B-NR 4. For intermediate-risk patients with acute chest pain and no known CAD who are eligible for cardiac testing, either exercise ECG, stress echocardiography, stress PET/SPECT MPI, or stress CMR is useful for the diagnosis of myocardial ischemia.1,4,10,14-36 Sequential or Add-on Diagnostic Testing 2a B-NR 5. For intermediate-risk patients with acute chest pain and no known CAD, with a coronary artery stenosis of 40% to 90% in a proximal or middle coronary artery on CCTA, FFR-CT can be useful for the diagnosis of vessel-specific ischemia and to guide decision-making regarding the use of coronary revascularization.37-43 2a C-EO 6. For intermediate-risk patients with acute chest pain and no known CAD, as well as an inconclusive prior stress test, CCTA can be useful for excluding the presence of atherosclerotic plaque and obstructive CAD. 2a C-EO 7. For intermediate-risk patients with acute chest pain and no known CAD, with an inconclusive CCTA, stress imaging (with echocardiography, PET/SPECT MPI, or CMR) can be useful for the diagnosis of myocardial ischemia. Synopsis For patients with recent prior testing and normal findings, no further testing is indicated, given adequate exercise levels were achieved or pharmacologic stress was performed and if imaging was of sufficient quality, provided there are no changes in symptom frequency or stability at the new visit. The intervals (1 year for stress testing, 2 years for CCTA without plaque or stenosis) differ because of a lack of CAD progression and the low number of incident events among patients with a normal CCTA, although patients with normal stress testing may still have significant plaque and a higher event rate.44-46 With a previously inconclusive or mildly abnormal stress test in the past year, CCTA is recommended, avoiding the potential for inconclusive results if the same type of test is repeated and enabling a more definitive ruleout of obstructive CAD. Among patients who present with acute chest pain who have had moderate-severe abnormalities on previous testing, but no interval anatomic testing, direct referral to ICA may be helpful for diagnosis of obstructive CAD. Among those without a previous diagnostic evaluation and no known CAD, CCTA or stress testing may be the initial method of testing. Second-line testing may be helpful for patients with an initial inconclusive stress test. Similarly, for intermediate-risk patients with an intermediate stenosis on CCTA, FFR-CT, or stress testing may also be indicated. ICA is indicated for patients categorized as high risk on a validated risk score (Figure 9). However, patients with an intermediate-risk score may also be candidates for CCTA or ICA if moderate-severe ischemia or significant left ventricular dysfunction is detected on index diagnostic testing. Although there are several acceptable testing modalities for intermediate-risk patients with acute chest pain, the decision to use one versus another should be guided by local expertise and availability. Recommendation-Specific Supportive Text Anatomic Testing 1. In the ED evaluation of patients with acute chest pain, CCTA contributes to a reduced time to diagnosis and prompt discharge, without impacting safety (ie, no difference in death, repeat ED visits, or ACS over 1 to 6 months of follow-up) compared with a standard evaluation including stress testing.1-4,8,47-50 Long-term prognostic data are limited, but the CATCH (Cardiac CT in the Treatment of Acute Chest Pain) trial showed a relative hazard for CAD events at ∼18 months of 0.62 (95% CI: 0.40–0.98; P=0.04) for CCTA versus a standard care strategy.48 Similar 40-month MACE rates were reported in the PROSPECT (Providing Regional Downloaded from http://ahajournals.org by on October 7, 2026