A newly published joint guideline from the American Heart Association (AHA) and the American College of Cardiology (ACC) offers clinical practice recommendations for the assessment and diagnosis of chest pain. The new guideline was published online in Circulation and simultaneously in the Journal of the American College of Cardiology.

According to the writing committee members, a heart issue, such as myocardial infarction (MI) or other cardiovascular (CV) event, is frequently associated with significant chest pain. Despite heart issues being a primary driver for chest pain, episodes of chest pain may sometimes not be related to a CV event, indicating the need for clinical practice guidelines on the appropriate assessment and identification of the source of the pain.

Given the urgency of treating MI or other heart complication, the new guideline recommends that clinicians employ standardized risk assessments, clinical pathways, as well as tools to assess the chest pain and quickly identify the source. The formation of the guideline was based on a comprehensive literature review comprising both randomized and non-randomized trials, observational studies, systematic reviews, registries, and other published evidence generated from humans.


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Initial Evaluation

Goals for evaluating chest pain in the emergency department (ED), according to the guideline, include identifying life-threatening causes and determining the need for hospital admission or further testing. The guideline states that a focused history should be obtained in patients presenting with chest pain. This history should include clinical characteristics as well as duration of chest pain symptoms and associated features. In addition, clinicians should perform a CV risk factor assessment in patients who present with chest pain.

Underdiagnosis of Chest Pain in Women and Cultural Diversity in Patients

While men and women both report chest pain during a serious CV event, the guideline writing committee notes that women may be at higher risk for underdiagnosis of chest pain. As such, the guideline recommends clinicians thoroughly consider potential cardiac causes of chest pain in women. Additionally, the guideline recommends obtaining a clinical history in women presenting with chest pain, with an emphasis on the assessment of accompanying symptoms that are more prevalent in women, including nausea and shortness of breath.

In patients aged 75 years or older who present with chest pain, the guideline recommends that clinicians consider a diagnosis of acute coronary syndrome (ACS) if these patients present with shortness of breath, syncope, or acute delirium. Also, the guideline recommends cultural competency training to optimize outcomes among patients of diverse racial and ethnic backgrounds who have chest pain. Addressing language barriers in racial and ethnic minorities who present with chest pain should also be a priority among EDs and other centers, according to the guideline.

Cardiac Testing Considerations

The AHA/ACC guideline recommends the use of an electrocardiogram (ECG) in the office setting in patients with stable chest pain, unless there is an evident noncardiac cause of the chest pain. In settings where an ECG is unavailable, clinicians should refer these patients to the ED to undergo testing. Regardless of the setting, patients with acute chest pain should undergo ECG for ST-elevation myocardial infarction (STEMI) within a 10-minute period of arrival.

Serial ECGs should be performed in patients with chest pain in which an initial ECG is nondiagnostic, as this could help identify potential ischemic changes, particularly in cases of high clinical suspicion for ACS. Current guidelines on STEMI and non-ST elevation-ACS should be used to guide treatment decisions in patients with chest pain who have an initial ECG consistent with ACS.

Patients who have clinical evidence of ACS or another life-threatening cause of the acute chest pain should be urgently transported to the ED by emergency medical services (EMS), according to the guideline. The authors of the guideline also recommend measuring cardiac Troponin (cTn) immediately after presentation in patients who present to the ED with acute chest pain and suspected ACS.

The guideline adds that high-sensitivity cTn is the preferred biomarker in patients with acute chest pain, as this biomarker enables rapid detection or exclusion of myocardial injury and improves diagnostic accuracy. Serial cTn I or cTn T levels could prove useful in identifying abnormal values and a rising or falling pattern suggestive of acute myocardial injury in patients who present with acute chest pain.

Evaluation of Patients With Stable Chest Pain

In patients with stable chest pain and no coronary artery disease (CAD) who present to an outpatient clinic, the guideline committee indicates that a model to estimate pretest probability of obstructive CAD could be effective in identifying patients at low risk for the condition.

Additionally, coronary artery calcium testing could be a reasonable first-line test to exclude calcified plaque and identify a low likelihood of obstructive CAD in low-risk patients who present with stable chest pain but no known CAD. The guideline states that exercise testing without imaging may also be a reasonable first-line test to exclude myocardial ischemia and identify functional capacity in low-risk patients with stable chest pain and no known CAD.

Coronary computed tomographic angiography (CCTA) may be effective to diagnose CAD in patients with chest pain who are classified as intermediate-high risk but have no known CAD. Also, CCTA could be effective in these patients for the purposes of risk stratification as well as treatment decision guidance.

The guideline also suggests that stress imaging may be effective for the diagnosis of myocardial ischemia and for estimating risk of major adverse CV events in intermediate-high risk patients with stable chest pain and no known CAD.

For the assessment of left ventricular function in intermediate-high risk patients with pathological Q waves or signs/symptoms of heart failure, transthoracic echocardiography (TTE) may be effective for the diagnosis of resting left ventricular systolic and diastolic ventricular function as well as the detection of myocardial, pericardial, and valvular abnormalities.

Evaluation of Stable Chest Pain in Patients With CAD

The guideline recommends invasive coronary angiography (ICA) for guiding treatment decision-making in patients with obstructive CAD and stable chest pain despite guideline-directed medical therapy and moderate-severe ischemia. Additionally, the guideline recommends ICA for guiding treatment decision-making in symptomatic patients with obstructive CAD and stable chest pain with CCTA-defined 50% or greater stenosis in the left main coronary artery, obstructive CAD with fractional flow reserve with CT 0.80 or greater, or severe stenosis (≥70%) in all 3 main vessels.

Reference

Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/ SCMR guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. Published online October 28, 2021. doi:10.1161/CIR.0000000000001029