Coronary CT Angiography Receives Multiple Class 1, Level A Recommendations in 2021 Chest Pain Guideline

October 28, 2021—The Society of Cardiovascular Computed Tomography (SCCT) advised that coronary CT angiography (CCTA) has been recommended as a frontline testing strategy with a class 1 recommendation with level of evidence of A for patients with stable and acute chest pain in the newly published Comprehensive Clinical Practice Guideline on Chest Pain.

SCCT noted that this is a shift from previous versions of United States clinical practice guidelines, which did not provide class 1 recommendations for CCTA. However, the updated guideline now aligns with similar recommendations for CCTA published in the European Society of Cardiology guidelines in 2019.

The guideline was developed and issued by the American College of Cardiology and the American Heart Association and cosponsored by SCCT, the American Society of Echocardiography, the American College of Chest Physicians, the Society for Academic Emergency Medicine, and the Society for Cardiovascular Magnetic Resonance. The guideline was published in Circulation and the Journal of the American College of Cardiology. It will be reprinted in the Journal of Cardiovascular Computed Tomography, noted SCCT.

SCCT President Eric Williamson, MD, commented in the society’s press release, “The new guideline shows that CCTA should be used as a first-line test for individuals with chest pain symptoms who have no prior history of coronary artery disease (CAD). We now have more than a decade of clinical trial evidence to show that CCTA is a highly effective, noninvasive, and cost-saving test. By using CT, we can better diagnose and treat our patients without putting them through unnecessary procedures.”

According to SCCT, the guideline states that CCTA should be used for exclusion of atherosclerotic plaque and obstructive CAD in intermediate-risk patients with acute chest pain and no known CAD. CCTA should also be used for diagnosis of CAD, risk stratification, and guiding treatment decisions for patients with stable chest pain who have an intermediate-high risk of obstructive CAD.

The guideline also provides a class 1 recommendation for stress testing for both groups of patients, including either exercise electrocardiogram, stress echocardiography, stress positron emission tomography/single photon emission CT, myocardial perfusion imaging, or stress cardiac magnetic resonance imaging. The guideline labels the evidence supporting the use of these tests in cases of acute chest pain as B-NR, or “moderate-quality evidence…from nonrandomized studies” and for patients with stable chest pain as B-R, or “moderate-quality evidence from one or more randomized controlled trials.”

Ron Blankstein, MD, one of the guideline authors, commented in the SCCT announcement, “CCTA is useful to decide that the coronary arteries are not the cause of chest discomfort or shortness of breath. CCTA is able to identify severe blockages, as well as any plaque buildup in the coronary arteries that may lead to heart problems in the future. CCTA has an important advantage by being able to directly visualize early-stage plaque that may be missed by traditional approaches. This fosters an approach of early prevention and lifestyle changes to reduce risk of major cardiac events.”