The Role of Cardiac CT in the 2021 Chest Pain Guidelines


“In particular, coronary CTA would be useful in patients who have no known coronary artery disease and who have an intermediate to high pre-test probability of having obstructive disease,” Blankstein explained.

He said there are many tests with a 1A recommendation, and a cardiac CT scan won’t always be the right test for everyone. But, factors that favor the use of CCTA include:
• Younger patients who are not on preventive therapies
• People whose purpose of the test is to identify non-obstructive or obstructive coronary artery disease
• This includes the examination of patients for whom a stress test was previously inconclusive

Guiding lines have also put a new emphasis on non-obstructive coronary artery disease.

“This guideline is the first time that non-obstructive CAD has now been classified as coronary artery disease, and there is a class 1 to optimize preventative therapies for these patients,” Blankstein said. “Coronary CT gives us the opportunity to identify non-obstructive disease, which we might not identify on other types of stress test imaging.”

In acute chest pain, coronary CT has a class 1 indication to rule out disease. But, for patients who have already been diagnosed with coronary artery disease, there is no need for coronary CTA. Blankstein said this is especially helpful in patients at intermediate risk for coronary heart disease.

The CTA can also be used as a gatekeeper for which patients are sent for diagnostic angiography imaging in the cath lab.

“In the new guidelines, especially for patients with stable chest pain, there is no longer a category of patients who should go straight to invasive angiography,” he said. “The use of imaging in general, including coronary CTA, should always be done, and that’s why these intermediate and high risk patients are both lumped into one group when we decide to do further testing.”

With the CCTA’s elevation to a 1A recommendation, there has been much more interest in cardiac CT since late last fall when the guidelines were released. This was evident at the 2022 American College of Cardiology (ACC) meeting last spring and with higher engagement than in previous years with SCCT vendors.

“I think there are a lot of hospitals looking to invest more in coronary CT, and that takes a lot of investment,” Blankstein said. “We’re seeing increased interest in coronary CTA, and frankly, we’re saying that even before the guidelines, but the guidelines will likely fuel that even more.”

He said investing hospitals need to make sure they have the right equipment and the right people in terms of radiologists or cardiologists who can read the studies.

Related coronary CT content:

VIDEO: The New Role of Cardiac CT Scanning in the 2021 Chest Pain Assessment Guidelines – Interview with Eric Williamson, MD

VIDEO: Cardiac CT scan now recommended as first-line chest pain assessment tool — Interview with Leslee Shaw, PhD

VIDEO: In-office Cardiac CT and FFR CT offer a new business model

VIDEO: The New Role of Cardiac CT in Assessing Chest Pain — Interview with Brian Ghoshhajra, MD

PHOTO GALLERY: Cardiac CT Advances at SCCT 2022

VIDEO: Cardiac CT Training Requirements for Radiologists and Technologists


1. Martha Gulati, Phillip D. Levy, Debabrata Mukherjee, et al. AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR 2021 guidelines for the assessment and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov, 78 (22) e187–e285.

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