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OBJECTIVE: To compare different methods for investigation of stable, low-risk chest pain and identify the best first-line test for patients at low or intermediate risk of coronary artery disease (CAD). SOURCES OF INFORMATION: The MEDLINE database was searched for articles on chest pain investigation from 1978 to 2019 using the following key terms: chest pain, exercise electrocardiography, nuclear perfusion imaging, stress echocardiography, cardiovascular magnetic resonance imaging, coronary computed tomography angiography, and catheter angiography. Results were limited to English-language, peer-reviewed journal publications. MAIN MESSAGE: Chest pain is a common chief concern among patients presenting to primary care physicians. Several investigative options exist, and each method has inherent strengths and limitations resulting in variable performance depending on the pretest likelihood of CAD. Controversy exists regarding which is the best first-line test among low- or intermediate-risk patients. Coronary computed tomography angiography is emerging as the best first-line test for chest pain investigation in patients who are at low or intermediate risk of CAD. Invasive catheter angiography remains the reference standard, although it is usually reserved for high-risk patients or for confirmation of positive noninvasive test results. CONCLUSION: Several investigative options exist for the evaluation of stable, low-risk chest pain. A review of the literature reveals an emerging role for CCTA as a first-line test, particularly in low- or intermediate-risk populations without known CAD. |
