Coronary CT Angiography for Acute Chest Pain in the Emergency Department

Acute chest pain poses a substantial burden on health care systems and is a common reason for emergency department visits worldwide. Although diagnostic pathways are available to triage patients-distinguishing those needing immediate intervention from those safe for discharge-accurately diagnosing acute coronary syndrome (ACS) remains challenging. ACS is present in only 5%-10% of acute chest pain cases; however, most patients undergo extensive investigations to rule it out due to the clinical and legal consequences of misdiagnosis. In response, coronary CT angiography (CCTA) has emerged as a promising diagnostic tool, gaining support from international societies over the past decade. The 2023 European Society of Cardiology guidelines recommend considering CCTA or functional imaging tests for the initial evaluation of patients without electrocardiographic changes and with uncertain high-sensitivity cardiac troponin levels (class IIa, level A). Similarly, U.S. guidelines support the use of CCTA or functional tests to exclude clinically significant coronary artery disease in patients with intermediate risk of ACS after inconclusive evaluations (class I, level A). This article examines the role of CCTA in managing different risk populations; the potential for CCTA to optimize resource utilization while maintaining diagnostic accuracy; and the impact of other diagnostic resources, such as high-sensitivity troponins, on established diagnostic pathways.