Acute chest pain is a common cause of attendance at emergency departments and of emergency admission. Some patients have coronary artery disease or some other life-threatening condition, but many do not. Some have other conditions, but not all have an identifiable cause. There is an increasing drive to avoid unnecessary admission to hospital and to reduce length of stay when admission does occur, and new ways to do so are constantly being looked for. Simple clinical assessment in the patient with acute chest pain permits estimation of the likelihood of coronary disease but is not sufficiently sensitive to use in isolation for exclusion of an acute coronary syndrome1 ,2 without additional diagnostic testing. The ECG is a pivotal early diagnostic test and should be undertaken as soon as possible even before a detailed clinical history, and ideally before arrival at hospital. In those with clear ECG changes consistent with an acute coronary syndrome, appropriate treatment can be initiated, and in the case of those with ST elevation, triage to primary percutaneous coronary intervention (PCI). However, those with a normal or non-diagnostic ECG require further testing that will include serial ECGs and cardiac biomarkers. A high proportion will have no diagnostic ECG changes and negative biomarkers.

In aiming to make an early diagnosis in such patients with a low to intermediate probability of coronary artery disease, recent studies have examined the effectiveness of contrast-enhanced coronary computed tomographic angiography (CCTA). In patients with stable chest pain and with suspected or known coronary artery disease, CCTA has a high sensitivity and specificity for the detection of clinically significant coronary artery disease when compared with invasive coronary angiography,3 and recent studies have examined the added value of incorporating CCTA into the early diagnostic evaluation of patients with suspected acute coronary syndrome. …