Summary

Multisociety guideline on evaluation and diagnosis of acute and stable chest pain in adults, emphasizing structured risk stratification, high-sensitivity cardiac troponin (hs-cTn), clinical decision pathways, and selective use of anatomic (CCTA) versus functional (stress) testing. Key shifts include preferring hs-cTn over conventional troponin/CK-MB, abandoning the term “atypical” chest pain in favor of “cardiac/possible cardiac/noncardiac,” routine use of CDPs in the ED, deferring testing in low-risk patients, and incorporating shared decision-making and cost-value considerations.

Key Recommendations

Obtain and interpret a 12-lead ECG within 10 minutes of arrival for any patient with acute chest pain.
Use high-sensitivity cardiac troponin (hs-cTn) as the preferred biomarker for diagnosing or excluding acute myocardial injury; do not add CK-MB or myoglobin.
Apply a validated clinical decision pathway (HEART, EDACS, ADAPT, NOTR, or ESC 0/1-h hs-cTn) routinely in the ED rather than unstructured assessment.
For low-risk patients (<1% 30-day MACE) identified by CDP or hs-cTn algorithm, do not perform urgent stress testing or cardiac imaging — discharge with outpatient follow-up.
Transport patients with acute chest pain by EMS rather than private vehicle; 1 in 300 self-transported chest pain patients suffers cardiac arrest en route.
For intermediate-risk patients with no known CAD, choose CCTA (preferred <65 years, not on optimal preventive therapy) or stress imaging (preferred ≥65 years) based on local expertise.
For suspected acute aortic syndrome in stable patients, CT angiography is the diagnostic test of choice; chest x-ray cannot rule it out.
For suspected PE, use clinical pretest probability with age-adjusted D-dimer; CT pulmonary angiography is first-line imaging in stable patients.
Proceed directly to invasive coronary angiography in high-risk patients (new ischemic ECG changes, troponin-confirmed injury, EF <40%, moderate-severe ischemia, hemodynamic instability, high CDP score).
Use CMR with late gadolinium enhancement to evaluate suspected myopericarditis or MINOCA within 2 weeks of presentation.
For stable chest pain with no known CAD, use contemporary pretest probability (not Diamond-Forrester); defer testing if low-risk or CAC = 0.
For patients with known obstructive CAD and stable chest pain, optimize GDMT first; reserve ICA for frequent/daily angina, refractory symptoms, or high-risk noninvasive findings.
Abandon the descriptor ‘atypical’ chest pain; classify symptoms as cardiac, possible cardiac, or noncardiac.
Engage clinically stable patients in shared decision-making using tools such as Chest Pain Choice for testing/disposition decisions.

Thresholds & Doses

Low-risk chest pain: <1% 30-day risk of death or MACE.
HEART score ≤3 with negative serial troponin = low risk; 4–6 = intermediate; 7–10 = high.
EDACS score <16 with negative 0- and 2-hour hs-cTn and no ischemic ECG changes = low risk.
ADAPT/mADAPT: TIMI 0 (or 0–1) with negative 0- and 2-hour troponin = low risk.
hs-cTn single-sample rule-out valid only if symptoms started ≥3 hours before ED arrival.
cTn >99th percentile upper reference limit indicates myocardial injury; assay coefficient of variation at 99th percentile should be ≤10%.
Repeat troponin beyond 3 hours (hs-cTn) or 6 hours (conventional cTn) if uncertainty persists.
Warranty period: 2 years for normal CCTA (no plaque/stenosis); 1 year for normal stress test with adequate stress.
Obstructive CAD = ≥50% stenosis; high-risk CAD = left main ≥50% or 3-vessel ≥70% stenosis; nonobstructive = 1–49% stenosis.
CCTA effective dose: 3–5 mSv; invasive coronary angiography: 4–10 mSv; Rb-82 PET: ~3 mSv; Tc-99m SPECT: ~10 mSv.
Stress testing requires ability to achieve ≥5 METs; >10 METs with negative ECG confers low CAD event risk.
Pretest probability >15% for obstructive CAD = benefit from noninvasive testing; ≤15% = consider deferring.
FFR-CT most useful for coronary stenoses of 40–90% in proximal/mid segments; FFR ≤0.80 or iFR ≤0.89 indicates lesion-specific ischemia.
Severe symptomatic aortic stenosis and SBP ≥200/110 mm Hg are contraindications to exercise stress testing.
CMR contraindicated if GFR <30 mL/min/1.73 m².

Citations

Top 10 Take-Home Messages — overarching principles including hs-cTn preference and discouragement of ‘atypical’ terminology
Section 2.3.2 (Electrocardiogram) — 10-minute ECG acquisition standard
Section 2.3.4 (Biomarkers) — hs-cTn as preferred biomarker; superiority over CK-MB/myoglobin
Section 4.1 and Table 6 (Clinical Decision Pathways) — HEART, EDACS, ADAPT, NOTR, ESC 0/1-h algorithms
Section 4.1.1 and Table 8 — definition and management of low-risk acute chest pain
Section 4.1.2.1, Figure 9 — intermediate-risk evaluation algorithm with no known CAD
Section 4.1.3 — high-risk patient management and direct ICA referral
Section 4.2.1 — acute aortic syndrome CTA as first-line
Section 4.2.2 — PE evaluation with D-dimer and CTPA
Section 5.1.2 / Figure 11 — pretest probability and CAC scoring for stable chest pain
Section 5.2.1 / Figure 13 — known obstructive CAD with stable chest pain pathway
Table 5 — contraindications by imaging modality and stress protocol
Section 4.1.7 — shared decision-making with Chest Pain Choice decision aid