Evaluation of acute chest pain: Evolving paradigm of coronary risk scores and imaging

There is a broad differential diagnosis for patients presenting with acute chest pain. History, physical examination, electrocardiogram, and serial troponin assays are pivotal in assessing patients with suspected acute coronary syndrome. However, if the initial workup is equivocal, physicians are faced with a challenge to find the optimal strategy for further triage. Risk stratification scores have been validated for patients with known acute coronary syndrome, such as the TIMI and GRACE scores, but there may be limitations in undifferentiated chest pain patients. Advancements in imaging modalities such as coronary computed tomography angiography and the addition CT derived fractional flow reserve, have demonstrated utility in evaluating patients presenting with acute chest pain. With this article, we aim to provide a comprehensive review of the non-invasive modalities that are available to evaluate acute chest pain patients suspected of cardiac etiology in the emergency room. We also added a focus on new imaging modalities that have shown to have prognostic implications in stable ischemic heart disease.