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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e396 CLINICAL STATEMENTS AND GUIDELINES 1 A 2. For intermediate-risk patients with acute chest pain who have worsening frequency of symptoms with significant left main, proximal left anterior descending stenosis, or multivessel CAD on prior anatomic testing or history of prior coronary revascularization, ICA is recommended.3-8 2a B-NR 3. For intermediate-risk patients with acute chest pain and known nonobstructive CAD, CCTA can be useful to determine progression of atherosclerotic plaque and obstructive CAD.9-11 2a B-NR 4. For intermediate-risk patients with acute chest pain and coronary artery stenosis of 40% to 90% in a proximal or middle segment on CCTA, FFR-CT is reasonable for diagnosis of vessel-specific ischemia and to guide decision-making regarding the use of coronary revascularization.12-17 2a B-NR 5. For intermediate-risk patients with acute chest pain and known CAD who have new onset or worsening symptoms, stress imaging (PET/ SPECT MPI, CMR, or stress echocardiography) is reasonable.18-21 Synopsis Figure 10 includes the evaluation algorithm for patients with known CAD, including patients with nonobstructive and obstructive CAD. In patents with known nonobstructive CAD (ie, a luminal stenosis 1% to 49% on CCTA or ICA or calcified plaque on chest CT), repeat CCTA is recommended unless there is a large enough plaque burden where ischemia is suspected. The use of FFR-CT may be helpful to guide clinical decision-making regarding the use of coronary revascularization.16 For all other patients with known CAD, stress testing is recommended to guide decisions on optimizing medical management and revascularization. Recommendation-Specific Supportive Text 1. As shown in many secondary prevention trials, such as the Veterans Affairs Non-Q-Wave myocardial infarction (VANQUISH), COURAGE and ISCHEMIA, GDMT should be assessed in all patients with known CAD and optimized when symptomatic.2,22,23 Recommendations for Intermediate-Risk Patients With Acute Chest Pain and Known CAD (Continued) COR LOE Recommendations Figure 9. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With No Known CAD Test choice should be guided by local availability and expertise. *Recent negative test: normal CCTA ≤2 years (no plaque/no stenosis) OR negative stress test ≤1 year, given adequate stress. †High-risk CAD means left main stenosis ≥ 50%; anatomically significant 3-vessel disease (≥70% stenosis). ‡For FFR-CT, turnaround times may impact prompt clinical care decisions. However, the use of FFR-CT does not require additional testing, as would be the case when adding stress testing. CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed medical therapy; ICA, invasive coronary angiography; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission CT. Downloaded from http://ahajournals.org by on October 7, 2026