Intended for healthcare professionals

Practice Rational Imaging

Investigating stable chest pain of suspected cardiac origin

BMJ 2013; 347 doi: (Published 22 July 2013) Cite this as: BMJ 2013;347:f3940
  1. Declan P O’Regan, consultant radiologist1,
  2. Stephen P Harden, consultant radiologist2,
  3. Stuart A Cook, professor of cardiology13
  1. 1Robert Steiner MRI Unit, MRC Clinical Sciences Centre, London W12 0NN, UK
  2. 2Department of Cardiothoracic Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  3. 3Department of Cardiology, National Heart Centre Singapore, Singapore
  1. Correspondence to: D P O’Regan declan.oregan{at}

This article describes how stable chest pain of suspected cardiac origin can be radiographically investigated according to the patient’s risk of coronary artery disease

Learning points

  • The National Institute for Health and Care Excellence (NICE) does not recommend exercise electrocardiography for investigating stable chest pain in patients without known coronary artery disease

  • NICE guidance recommends that the sequence of imaging tests be determined by the patient’s risk of coronary artery disease

  • Patients with a pre-test probability of 10-29% for coronary artery disease are initially investigated with coronary artery calcium scoring using computed tomography

  • Computed tomography coronary angiography is performed in patients with a calcium score of 1-400 to determine whether there are any coronary stenoses

  • Patients with a 30-60% risk are initially investigated with functional cardiac imaging to diagnose flow limiting coronary disease

  • Invasive coronary angiography, as a first line investigation, is reserved for symptomatic patients with a 61-90% pre-test probability of coronary artery disease when revascularisation is a treatment option

A 45 year old man, who was a non-smoker and did not have diabetes or hyperlipidaemia, presented to his doctor with chest discomfort after exercise. There were no relevant findings on clinical examination and resting electrocardiography (ECG) results were normal.

What is the next investigation?

Cardiovascular disease is a leading cause of death in the United Kingdom1; however, most first presentations with chest pain to primary care have a non-cardiac cause.2 It is important to establish which patients’ symptoms are caused by obstructive coronary artery disease, so that these patients can be optimally managed to control angina and reduce mortality.3 To support clinical decision making, the National Institute for Health and Care Excellence (NICE) published guidance in 2010 on the assessment of patients with chest pain of suspected cardiac origin.4 This advice proposed a major change in clinical practice by no …

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