Depending on the situation you can choose first stress. Test or directly goto ct angio
final decision based on patients clinical parameters, if stable then only go for further investigation..
This depends on the patient population, and pre-test probability of disease.
In low risk chest pain patients, CT coronary angiography has been evaluated in three large high profile clinical trials in the USA, which have suggested there may be a role for this investigation early in the patient pathway (J Am Coll Cardiol 2011;58:1414–22 / N Engl J Med 2012;367:299-308 / N Engl J Med 2012;366:1393-403). Of note, the majority of patients allocated to routine care in these studies underwent stress testing in the ED prior to discharge.
However, in the UK, for patients with low risk chest pain presenting to emergency departments, a more conservative strategy is taken, with the majority of low risk patients being discharged following normal clinical examination, normal ECG, normal troponin, and following review by a senior clinician.
A clinical trial is currently underway in the UK investigating the role of CTCA in intermediate risk chest pain patients who would normally be admitted to hosital, i.e. those with ECG abnormalities, a history of ischaemic heart disease, or an elevated troponin. This is the RAPID-CTCA trial (http://www.nets.nihr.ac.uk/projects/hta/1304108). This should inform future use of this technology in the intermediate risk chest pain population, but will not report for some time.
I hope these comments are helpful.
In Low risk CAS, predictive negative is cuasi 100%. Good CTCoronary.....other strategy,low cost, is Score clinic EDACP-ADP (Than et al) : Score
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