Patient with chest pain
Calculate pre-test probability
<10%
>60%
10-60%
Known ischaemic heart disease
(previous angiography)?
Coronary angiography or
manage as angina clinically if
angiography not appropriate*
Return to GP
No
Yes
10-29%
ETT if appropriate,
else follow “No”
pathway
Sinus rhythm, BMI <40, no
contra-indication to short
acting beta-blocker
Yes
*An ETT may be done in
addition
for prognostic
reasons
** This must be discussed
with OG/DB first
Coronary Angiography
ETT
Cardiac CT
Cardiac CT
No
Calcium score and re-risk
stratify. If still 10-30% and
concerned, then discuss
30-60%
ETT if appropriate,
else
BMI <40, no CIs to dobutamine
stress – Stress Echo
Unable to have stress echo, sinus
rhythm, BMI <40, no CIs to short
acting beta-blocker – Cardiac CT
Unable to have stress echo or CCT
– CT calcium score if no CIs and rerisk stratify
BMI >40, or unable to have stress
echo / CCT, no CIs to MRI –
Perfusion MRI**
Calcium Score
Stress Echo
Perfusion MRI
Coronary angiography or manage
as angina clinically if angiography
not appropriate