The test recommended by NICE for the investigation of angina is 64-slice (or above) CT coronary angiography. This is offered as the first-line diagnostic investigation when stable angina cannot be excluded by clinical assessment alone, particularly in people with typical or atypical angina or non-anginal chest pain with ECG changes such as ST-T changes or Q waves.
If CT coronary angiography shows coronary artery disease (CAD) of uncertain functional significance or is non-diagnostic, NICE recommends non-invasive functional imaging for myocardial ischaemia (such as myocardial perfusion scintigraphy with SPECT, stress echocardiography, or cardiac MR perfusion imaging) as the next step.
Invasive coronary angiography is reserved as a third-line investigation when non-invasive functional imaging results are inconclusive.
Exercise ECG is not recommended to diagnose or exclude stable angina in people without known CAD.