Chest Pain Evaluation - Chronic Coronary Syndrome (ESC 2024)

Algorithm Steps

1. ▶

   Start

   Chest Pain Presentation

   Suspected chronic coronary syndrome

   1. ●

      Action

      Step 1: Initial Assessment

      Rule out ACS and non-cardiac causes

      • History: pain character, triggers, relief
      • Rule out ACS first
      • 12-lead ECG
      • Basic labs (troponin if recent symptoms)
      1. ◆

         Decision

         ACS Suspected?

         Acute presentation, dynamic ECG, troponin rise

         If Yes:

         1. ⚠

            Warning

            ACS Pathway

            Use STEMI/NSTEMI algorithms

         If No:

         1. ●

            Action

            Step 2: Cardiac Examination

            Echo + estimate clinical likelihood

            • Resting echocardiography
            • Assess LV function, wall motion
            • Estimate PTP of obstructive CAD
            • Based on age, sex, symptom type
            1. ◆

               Decision

               Pre-Test Probability?

               Clinical likelihood of CAD

               1. ✓

                  Outcome

                  Very Low PTP

                  Defer further testing

               2. ●

                  Action

                  Step 3: Diagnostic Testing

                  Functional or anatomical

                  • CTCA: Preferred low-intermediate PTP
                  • Stress imaging: Intermediate PTP
                  • ICA: High PTP or high-risk stress test
                  1. ●

                     Action

                     Functional Testing

                     Stress echo, stress CMR, PET

                     • Assess ischemia
                     • Exercise ECG only if others unavailable
                     1. ●

                        Action

                        Step 4: Establish Management

                        Based on test results

                        • Lifestyle modification
                        • Risk factor control
                        • Antianginal therapy if needed
                        • Revascularization if refractory or high-risk
                  2. ●

                     Action

                     Anatomical Testing

                     CT Coronary Angiography

                     • Preferred for low-intermediate PTP
                     • High NPV for ruling out CAD