CCTA receives Multiple Class 1, Level A recommendations in 2021 Guideline for the Evaluation and Diagnosis of Chest Pain

Arlington, VA (Oct 28, 2021) — Coronary computed tomographic angiography (CCTA) has been recommended as a frontline testing strategy by the American College of Cardiology (ACC), American Heart Association (AHA), and other groups in the evaluation of patients with stable and acute chest pain who have no known coronary artery disease (CAD). CCTA was given a Class 1 recommendation with level of evidence of A for patients with stable and acute chest pain in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain, co-published today in the Journal of the American College of Cardiology and Circulation.

Class 1 is the strongest recommendation available for a medical test. Level A indicates there is high-quality evidence from more than one randomized clinical trial (RCT) that CCTA is beneficial, useful, and effective.

This is a shift from previous versions of U.S. clinical practice guidelines, which did not provide class 1 recommendations for CCTA. However, the updated guideline now aligns with similar recommendations for CCTA published in the European Society of Cardiology guidelines in 2019.

“The new guideline shows that coronary CT angiography should be used as a first-line test for individuals with chest pain symptoms who have no prior history of coronary artery disease,” explains Eric Williamson, MD, MSCCT, a cardiovascular radiologist with the Mayo Clinic and president of the Society of Cardiovascular Computed Tomography, which is a co-sponsor of the guideline. “We now have more than a decade of clinical trial evidence to show that coronary CTA is a highly-effective, non-invasive and cost-saving test. By using CT, we can better diagnose and treat our patients without putting them through unnecessary procedures.”

CCTA is a quick, non-invasive test for women and men that uses a specialized CT scanner to obtain high-resolution three-dimensional images of the coronary arteries. CCTA allows a physician to see whether or not plaque has developed in the coronary arteries, and whether plaque had caused stenosis, a narrowing of arteries that might cause symptoms or increase the patient’s risk of a future heart attack or death related to heart issues.

Per the guideline, CCTA should be used for exclusion of atherosclerotic plaque and obstructive coronary artery disease (CAD) in intermediate-risk patients with acute chest pain and no known CAD. CCTA should also be used for diagnosis of CAD, risk stratification and guiding treatment decisions for patients with stable chest pain who have an intermediate-high risk of obstructive CAD. These recommendations could include some 15 – 20 million U.S. patients.

The guideline also provides a Class 1 recommendation for stress testing for both groups of patients, including either exercise ECG, stress echocardiography, stress positron emission tomography (PET)/single photon emission computed tomography (SPECT), myocardial perfusion imaging (MPI) or stress CMR. The guideline labels the evidence supporting the use of these tests in cases of acute chest pain as B-NR, or “moderate-quality evidence … from non-randomized studies” and for patients with stable chest pain as B-R, or “moderate-quality evidence from 1 or more RCTs.”

According to Ron Blankstein, MD, MSCCT, FACC, a cardiologist with Brigham & Women’s Hospital and one of the guideline authors: “CCTA is useful to decide that the coronary arteries are not the cause of chest discomfort or shortness of breath. CCTA is able to identify severe blockages, as well as any plaque buildup in the coronary arteries that may lead to heart problems in the future. CCTA has an important advantage by being able to directly visualize early stage plaque that may be missed by traditional approaches. This fosters an approach of early prevention and lifestyle changes to reduce risk of major cardiac events.”

The guideline will be reprinted in the Journal of Cardiovascular Computed Tomography (JCCT). To learn more about the Chest Pain Guidelines, visit or join the free SCCT webinars on Friday, Oct. 29 and Friday, Nov. 5, both at 12:00 pm Eastern.

About the Society of Cardiovascular Computed Tomography

Founded in 2005, the Society of Cardiovascular Computed Tomography (SCCT) is the international professional society devoted to improving health outcomes through effective use of cardiovascular computed tomography (CCT), with members from over 85 countries. SCCT is a community of physicians, scientists and technologists advocating for access, research, education and clinical excellence in the use of CCT. For more information, please visit