Chest pain evaluation — viva

Stem

Practice viva. You are the cardiology registrar covering the emergency department. The examiner works through the first 10 minutes, troponin strategy, risk strata and disposition, imaging choices, and stable chest pain in clinic. Answer for a non-pregnant adult unless stated.

Branch A — The first 10 minutes

Examiner: A 60-year-old man arrives with acute chest pain. What happens first, and how fast?

Strong answer:

• AHA/ACC 2021: in all patients who present with acute chest pain regardless of the setting, an ECG should be acquired and reviewed for STEMI within 10 minutes of arrival (COR 1, LOE C-LD).^[1]
• ESC 2023, in patients with suspected ACS: twelve-lead ECG recording and interpretation is recommended as soon as possible at the point of first medical contact, with a target of under 10 min (Class I, Level B), and patients with suspected STEMI should be immediately triaged for an emergency reperfusion strategy (Class I, Level A).^[2]
• In patients with suspected ACS, ESC 2023 recommends prompt assessment of vital signs at first medical contact, at the same time as acquisition of an initial ECG.^[2]
• AHA/ACC 2021: in patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other potentially serious causes of chest pain (e.g. aortic dissection, PE or oesophageal rupture) and to identify complications (COR 1, LOE C-EO).^[1]
• AHA/ACC 2021: in all patients presenting to the ED with acute chest pain and suspected ACS, cTn should be measured as soon as possible after presentation (COR 1, LOE C-LD).^[1]

Follow-up: The first ECG is normal. Does that reassure you?^[1]

• No. AHA/ACC 2021 states that an initial normal ECG does not exclude ACS and that a patient with an initial normal ECG should have a repeat ECG, if symptoms are ongoing, until other diagnostic testing rules out ACS.^[1]
• Up to 6% of patients with evolving ACS are discharged from the ED with a normal ECG.^[1]
• In patients with chest pain and intermediate-to-high clinical suspicion for ACS in whom the initial ECG is nondiagnostic, supplemental leads V7 to V9 are reasonable to rule out posterior MI (COR 2a, LOE B-NR).^[1]

Branch B — Troponin strategy

Examiner: Which troponin, and which algorithm?

Strong answer:

• AHA/ACC 2021: in patients presenting with acute chest pain, high-sensitivity cTn is the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy (COR 1, LOE B-NR).^[1]
• In patients with suspected ACS, ESC 2023 recommends measuring cardiac troponins with high-sensitivity assays immediately after presentation and obtaining the results within 60 min of blood sampling (Class I, Level B), and using an ESC algorithmic approach with serial hs-cTn measurements (0 h/1 h or 0 h/2 h) to rule in and rule out NSTEMI (Class I, Level B).^[2]
• ESC 2023 calls the 0 h/1 h algorithm the best option and the 0 h/2 h algorithm the second-best option; its 0 h/3 h algorithm is an alternative for cases where these are not available.^[2]
• NHFA/CSANZ 2025 (summary), for people with suspected ACS: a high-sensitivity troponin-based CDP is recommended, using the 0/1- or 0/2-h strategy or the High-STEACS algorithm (consensus), and it calls the 0/2-h strategy currently the most pragmatic option in most settings.^[5]

Follow-up: How were the ESC rule-out and rule-in cut-offs chosen, and are they the same for every assay?^[2]

• Rule-out thresholds were selected to allow a sensitivity and NPV of at least 99%, and rule-in thresholds to allow a PPV of at least 70% (ESC 2023).^[2]
• No: the cut-off concentrations within the 0 h/1 h and 0 h/2 h algorithms are assay specific.^[2]
• Also creditable: AHA/ACC 2021 recommends that clinicians be familiar with the analytical performance and the 99th percentile upper reference limit that defines myocardial injury for the cTn assay used at their institution (COR 1, LOE C-EO).^[1]

Follow-up: Should the 99th percentile be sex-specific?^[2][5][9]

• The bodies differ. ESC 2023 says data on sex-specific hs-cTn values in the diagnosis of MI have been controversial and failed to show a clear clinical benefit, so uniform cut-off concentrations should remain the standard of care for the early diagnosis of MI until automated tools incorporating age, eGFR, time from chest pain onset and sex are available.^[2]
• The 2025 NHFA/CSANZ summary recommends defining elevated hs-cTn values using sex-specific >99th percentiles (consensus).^[5]
• The 2025 ACC/AHA ACS guideline notes that men and women may have different cutoff values with hs-cTn assays.^[4]
• The current Fifth Universal Definition of MI (2026) uses sex-specific 99th percentile upper reference limits to define myocardial injury, to avoid systematic bias and the under-recognition of both MI and other cardiac conditions associated with myocardial injury in female patients.^[9]
• It notes that the uniform thresholds in accelerated pathways such as the ESC 0/1- and 0/2-hour pathways are often not based on the 99th percentile and are used for risk stratification.^[9]
• Under that definition, the final diagnosis of MI rests on a rise and/or fall in cTn with at least one value above the 99th percentile upper reference limit, where sex-specific thresholds apply.^[9]

Branch C — Risk strata and disposition

Examiner: NSTEMI is ruled out. How do you decide who goes home?

Strong answer:

• AHA/ACC 2021: in patients presenting with acute chest pain and suspected ACS, CDPs should categorise patients into low-, intermediate- and high-risk strata to facilitate disposition and subsequent diagnostic evaluation (COR 1, LOE B-NR).^[1]
• Patients with acute chest pain and a 30-day risk of death or MACE below 1% should be designated as low risk (COR 1, LOE B-NR), and in those with suspected ACS deemed low risk it is reasonable to discharge home without admission or urgent cardiac testing (COR 2a, LOE B-R).^[1]
• Two of the AHA/ACC 2021 Table 8 low-risk definitions are a HEART score of 3 or less with initial and serial cTn/hs-cTn below the assay 99th percentile, and an EDACS score of 16 or less with the same troponin condition.^[1]
• AHA/ACC 2021: for patients with acute chest pain and suspected ACS who are deemed low risk by a CDP, patient decision aids are beneficial to improve understanding and effectively facilitate risk communication (COR 1, LOE B-R).^[1]
• ESC 2023 adds that assignment to the rule-out pathway does not always equal outpatient management.^[2]

Follow-up: Should low-risk patients have a stress test before discharge?^[1]

• AHA/ACC 2021 found no evidence that stress testing or cardiac imaging within 30 days of the index ED visit improves outcomes in this low-risk subset, a change from previous guidance that broadly recommended stress testing within 72 hours.^[1]
• Pathways to facilitate outpatient follow-up for further evaluation and guideline-directed management of cardiac risk factors should be considered (AHA/ACC 2021).^[1]
• NHFA/CSANZ 2025 (summary): in people at low risk who remain symptom-free, further cardiac testing for CAD is not routinely required (consensus).^[5]

Follow-up: Who is high risk, and what then?^[1]

• AHA/ACC 2021: patients with acute chest pain and suspected ACS who have new ischaemic changes on electrocardiography, troponin-confirmed acute myocardial injury, new-onset left ventricular systolic dysfunction (ejection fraction below 40%), newly diagnosed moderate-severe ischaemia on stress testing, haemodynamic instability, and/or a high CDP risk score should be designated as high risk for short-term MACE (COR 1, LOE B-NR).^[1]
• For patients with acute chest pain and suspected ACS who are designated as high risk, ICA is recommended (COR 1, LOE C-EO).^[1]

Branch D — Imaging in acute chest pain

Examiner: Should every ED patient with possible ACS have a CT coronary angiogram?

Strong answer:

• No. ESC 2023: routine, early CCTA in patients with suspected ACS is not recommended (Class III, Level B).^[2]
• ESC 2023: in patients with suspected ACS, non-elevated (or uncertain) hs-cTn levels, no ECG changes and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered (Class IIa, Level A).^[2]
• AHA/ACC 2021: for intermediate-risk patients with acute chest pain and no known CAD eligible for diagnostic testing after a negative or inconclusive evaluation for ACS, CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD (COR 1, LOE A).^[1]
• RAPID-CTCA randomised 1748 participants with suspected or provisional ACS and one or more of previous coronary heart disease, raised troponin or abnormal ECG to early CT coronary angiography plus standard of care or standard of care only.^[8]
• Its primary endpoint (all-cause death or subsequent type 1 or 4b MI at one year) occurred in 5.8% versus 6.1% (adjusted HR 0.91, 95% CI 0.62 to 1.35, P=0.65).^[8]

Follow-up: When is CT the first test regardless of coronary questions?^[2]

• ESC 2023: on clinical presentation, CT is often the diagnostic tool of choice for ruling out alternative potentially life-threatening differential diagnoses of ACS, like PE or aortic dissection; this should be an ECG-gated contrast CT angiogram with full coverage of the thoracic aorta and the proximal head and neck vessels. Generally, CT has no role in patients presenting with suspicion of ongoing acute coronary occlusion, for whom emergency ICA is the priority.^[2]
• AHA/ACC 2021: in patients with acute chest pain where there is clinical concern for aortic dissection, CT angiography of the chest, abdomen and pelvis is recommended for diagnosis and treatment planning (COR 1, LOE C-EO); in stable patients with acute chest pain with high clinical suspicion for PE, CTA using a PE protocol is recommended (COR 1, LOE B-NR).^[1]

Branch E — Stable chest pain in clinic

Examiner: A 55-year-old woman has stable exertional chest pain. Chronic coronary syndrome is suspected; acute coronary syndrome is not. How do you choose her first test?

Strong answer:

• ESC 2024, suspected CCS: it recommends estimating the pre-test likelihood of obstructive epicardial CAD using the Risk Factor-weighted Clinical Likelihood model (Class I, Level B).^[3]
• ESC 2024, suspected CCS: in individuals with a very low (5% or less) pre-test likelihood of obstructive CAD, deferral of further diagnostic tests should be considered (Class IIa, Level B).^[3]
• ESC 2024, suspected CCS: in symptomatic patients whose pre-test likelihood of obstructive CAD by clinical assessment is above 5%, CCTA or non-invasive functional imaging for myocardial ischaemia is recommended as the initial diagnostic test (Class I, Level B).^[3]
• ESC 2024, suspected CCS: it recommends selecting the initial non-invasive diagnostic test based on pre-test likelihood of obstructive CAD, other patient characteristics that influence the performance of non-invasive tests (characteristics determining ability to exercise, likelihood of good image quality, expected radiation exposure, and risks or contraindications), and local expertise and availability (Class I, Level C).^[3]
• If she has no known CAD and is judged intermediate-high risk, AHA/ACC 2021 applies its rows for intermediate-high risk patients with stable chest pain and no known CAD: CCTA is effective for diagnosis of CAD, for risk stratification and for guiding treatment decisions (COR 1, LOE A), and stress imaging (stress echocardiography, PET/SPECT MPI or CMR) is effective for diagnosis of myocardial ischaemia and for estimating risk of MACE (COR 1, LOE B-R).^[1]

Follow-up: What did PROMISE show?^[6]

• PROMISE randomised 10,003 symptomatic patients to initial anatomical testing with coronary CTA or to functional testing (exercise ECG, nuclear stress testing or stress echocardiography).^[6]
• Over a median follow-up of 25 months, the composite primary end point (death, MI, hospitalisation for unstable angina or major procedural complication) occurred in 3.3% with CTA and 3.0% with functional testing (adjusted HR 1.04, 95% CI 0.83 to 1.29, P=0.75).^[6]
• The authors concluded that, in symptomatic patients with suspected CAD who required noninvasive testing, initial CTA did not improve clinical outcomes over a median follow-up of 2 years compared with functional testing.^[6]