Imaging recommendation · Chest

Chest pain, adult — undifferentiated, imaging triage

Q: What's the alternative imaging for chest pain, adult — undifferentiated, imaging triage when pe on differential (wells / perc positive)?

CT — CTPA (see pe-suspected) (iv contrast).

Q: What's the alternative imaging for chest pain, adult — undifferentiated, imaging triage when aortic dissection suspected?

CT — ECG-gated CTA chest (see aortic-dissection) (iv contrast).

Q: What's the alternative imaging for chest pain, adult — undifferentiated, imaging triage when pneumothorax suspected?

XR — Upright PA CXR expiratory, or bedside lung US (no contrast).

Q: What's the alternative imaging for chest pain, adult — undifferentiated, imaging triage when pneumonia / consolidation suspected?

XR — CXR PA + lateral (see pneumonia) (no contrast).

Q: What's the alternative imaging for chest pain, adult — undifferentiated, imaging triage when stable acs workup, low-intermediate risk?

CT — Coronary CT angiogram or stress imaging (see cad-stable) (iv contrast).

Recommended: CXR (PA + lateral), then targeted CT by phenotype is the preferred imaging study for chest pain, adult — undifferentiated, imaging triage. Start with CXR — fast, broad differential (pneumothorax, effusion, consolidation, widened mediastinum, rib fracture).

Recommended study

CXR (PA + lateral), then targeted CT by phenotype

XR No contrast Preferred Chest EmergencyAcute inpatient Reviewed 2026-05

Start with CXR — fast, broad differential (pneumothorax, effusion, consolidation, widened mediastinum, rib fracture). Targeted CT follows the clinical phenotype: pleuritic + tachypnea / Wells-positive → CTPA; tearing or interscapular pain + HTN / widened mediastinum → ECG-gated CTA chest dissection protocol; exertional ischemic pattern → CCTA or stress imaging. Bedside lung US complements CXR (absent lung sliding, B-lines, consolidation).

If the default doesn't apply

PE on differential (Wells / PERC positive)

CT CTPA (see pe-suspected) IV contrast

Aortic dissection suspected

CT ECG-gated CTA chest (see aortic-dissection) IV contrast

Pneumothorax suspected

XR Upright PA CXR expiratory, or bedside lung US No contrast

Pneumonia / consolidation suspected

XR CXR PA + lateral (see pneumonia) No contrast

Stable ACS workup, low-intermediate risk

CT Coronary CT angiogram or stress imaging (see cad-stable) IV contrast

Watch-outs

Don't skip the CXR

Small pneumothorax, focal consolidation, or rib fracture often answers the question without advanced imaging.

Cocaine / sympathomimetic chest pain

Keep aortic dissection AND ACS on the differential — consider CTA chest and cardiac imaging.

Widened mediastinum on CXR ≠ dissection

Positive predictive value is modest; CTA confirms before quoting a diagnosis.

Pearls

Bedside lung US beats supine CXR for pneumothorax (absent lung sliding) and effusion.
Wells / PERC drive whether CTPA is the right next test — D-dimer guides the gate.
Negative CTPA + negative CTA chest doesn't rule out ACS — different test for different anatomy.