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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e398 CLINICAL STATEMENTS AND GUIDELINES noted as an incidental finding on chest CT) who present to an ED for evaluation of chest pain where concern exists with regard to the extent of noncalcified plaque and potential for underlying obstructive stenosis. However, for patients with extensive plaque, a stress test is preferred. 4. Patients with acute chest pain who have coronary artery stenosis from 40% to 90% on CCTA may benefit from measurement of FFR-CT, especially when the stenosis is proximal or mid-coronary artery.12-17,25 From 1 large clinical registry, the deferral of coronary revascularization with a normal FFR-CT was safe, with no difference in MACE at 90 days.16 5. Most randomized trials that examined the role of stress testing in the ED enrolled patients with no known CAD, with few including patients with obstructive CAD (range: 7%–15%).18-20 Despite this, assessing the functional significance of obstructive CAD is an important part of ischemia-guided management.26 4.1.3 High-Risk Patients With Acute Chest Pain Recommendations for High-Risk Patients With Acute Chest Pain Referenced studies that support the recommendations are summarized in Online Data Supplements 18 and 19. COR LOE Recommendations Recommendations for High-Risk Patients, Including Those With High-Risk Findings on CCTA or Stress Testing 1 B-NR 1. For patients with acute chest pain and suspected ACS who have new ischemic changes on electrocardiography, troponinconfirmed acute myocardial injury, newonset left ventricular systolic dysfunction (ejection fraction <40%), newly diagnosed moderate-severe ischemia on stress testing, hemodynamic instability, and/or a high clinical decision pathway (CDP) risk score should be designated as high risk for short-term MACE.1-3 1 C-EO 2. For patients with acute chest pain and suspected ACS who are designated as high risk, ICA is recommended.4-7 2a B-NR 3. For high-risk patients with acute chest pain who are troponin positive in whom obstructive CAD has been excluded by CCTA or ICA, CMR or echocardiography can be effective in establishing alternative diagnoses.8-12 Synopsis Patients with symptoms suggestive of ACS who are at high risk of short-term MACE include those with new ischemic changes on the ECG, troponin-confirmed acute myocardial injury, new-onset left ventricular systolic dysfunction (ejection fraction <40%), newly diagnosed moderate-severe ischemia on stress imaging, and/or a high risk score on CDP.4,13,14 ICA is indicated for patients with confirmed ACS based on a robust body of randomized trial evidence and clinical practice guideline indications.4-7 In the patients with a negative initial evaluation, ICA is also indicated for those categorized as high risk on a validated risk stratification instrument. For high-risk patients with a documented AMI on the index ED evaluation and who demonstrate on CCTA or ICA normal or nonobstructive CAD, CMR and echocardiography are useful for examining alternative causes for symptoms such as nonischemic cardiomyopathy or myocarditis.8-11 Recommendation-Specific Supportive Text 1. Patients with acute chest pain and suspected ACS are considered at high risk for short-term MACE if they have new ischemic changes on electrocardiography, troponin-confirmed acute myocardial injury, new-onset left ventricular systolic dysfunction (ejection fraction <40%), newly diagnosed moderate-severe ischemia on stress testing, hemodynamic instability, and/or a high CDP risk score. Risk scores are recommended in guidelines to facilitate the management of patients who present with ACS.3,15,16 2. Among patients categorized as high risk, ICA provides a comprehensive assessment of the extent and severity of obstructive CAD. Moreover, the determination of the severity of anatomic CAD is critical to guide the use of coronary revascularization.6 3. Approximately 6% to 15% of troponin-positive ACS occurs in the absence of obstructive CAD.17,18 Additional testing may be helpful to identify the cause that may alter an ensuing therapeutic strategy.19 Evidence supports that CMR can identify wall motion abnormalities and myocardial edema and distinguish infarct-related scar from non-CAD causes such as myocarditis and nonischemic cardiomyopathy. When performed within 2 weeks of ACS, CMR can be useful to identify MI with nonobstructive CAD (MINOCA) from other causes.8-11 4.1.4 Acute Chest Pain in Patients With Prior Coronary Artery Bypass Graft (CABG) Surgery Recommendations for Acute Chest Pain in Patients With Prior CABG Surgery COR LOE Recommendations 1 C-LD 1. In patients with prior CABG surgery presenting with acute chest pain who do not have ACS, performing stress imaging is effective to evaluate for myocardial ischemia or CCTA for graft stenosis or occlusion.1-7 1 C-LD 2. In patients with prior CABG surgery presenting with acute chest pain, who do not have ACS8-14 or who have an indeterminate/nondiagnostic stress test, ICA is useful.8 Synopsis There are many potential causes of acute chest pain in the months after CABG. Musculoskeletal pain from sternotomy remains the most common. However, other Downloaded from http://ahajournals.org by on October 7, 2026