Diagnosis & Evaluation of Chest Pain in Adults: Top Ten Take-Away Points
The American Heart Association (AHA) and American College of Cardiology (ACC) released an updated clinical practice guideline addressing the diagnosis and evaluation of chest pain in adults based on a comprehensive literature review conducted by the AHA and ACC’s Joint Committee on Clinical Practice Guidelines. The guidelines were published simultaneously online in Circulation and the Journal of the American College of Cardiology.
In developing the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain, the AHA/ACC Joint Committee first reviewed previous published guidelines and related statements. The committee’s goal was to develop a guideline for the evaluation of acute or stable chest pain or other anginal equivalents, in various clinical settings, emphasizing diagnosis of ischemic causes. The guideline will not provide recommendations on whether revascularization is appropriate or what modality is indicated. Such recommendations can be found in the forthcoming ACC/AHA coronary artery revascularization guideline.
One of the points the updated guideline seeks to highlight is the definition of “chest pain.” Although chest pain is the second most common reason for adults to present to the emergency department (ED) in the United States, and leads to nearly 4 million outpatient visits annually, chest pain has been an abstract idea lacking a specific definition or specific guidance. Although the cause of chest pain is often noncardiac, coronary artery disease (CAD) affects more than 18.2 million US adults and remains the leading cause of death for men and women, accounting for more than 354,000 deaths annually. Thus, distinguishing between serious and benign causes of chest pain is imperative. The lifetime prevalence of chest pain in the United States is 20% to 40%, and women experience this symptom more often than men. “Of all ED patients with chest pain, only 5.1% will have an acute coronary syndrome, and more than half will ultimately be found to have a noncardiac cause,” the guideline states. “Nonetheless, chest pain is the most common symptom of CAD in both men and women.”1
The new guideline provides clinicians with guidance to better evaluate patients presenting with chest pain, identify patients who may be having a cardiac emergency, and then select the right test or treatment for the right patient. Martha Gulati, MD, MS, professor of cardiology at the University of Arizona, and chair of the guideline’s writing committee, said, “We wanted to give the breadth of what people experience when they say ‘chest pain.’ Chest pain is more than pain in the chest.”1
The top 10 “take away” recommendations in the new guidelines are as follows:
- Chest pain means more than pain in the chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents. Patients with acute chest pain or chest pain equivalent symptoms should immediately seek care.
- High-sensitivity cardiac troponins are the preferred standard biomarker for diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.
- Early care should be sought for acute symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek emergency care immediately by calling 9-1-1. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification/exclusion of life-threatening causes. “This message is for patients, but also for clinicians,” Dr. Gulati notes. Everyone should be educated regarding their risk for a cardiac event, and patients should be educated about the need for timely care if a heart attack is suspected. Education is essential regarding the need to call 9-1-1, provide transportation by emergency medical services to the nearest ED, initiate early assessment and management of suspected ACS, including transmittal of prehospital electrocardiograms, and intervene if complications occur on the way to the ED.
- Share the decision making. Clinically stable patients presenting with chest pain should be included in decision-making. Information about risk of adverse events, radiation exposure, and alternative options should be provided to facilitate discussion. There is abundant data showing that shared decision-making helps both patients and the healthcare community, Dr. Gulati said.
- Testing is not routinely needed for low-risk patients. For patients with acute or stable chest pain that is determined to be low risk, urgent diagnostic testing for suspected CAD is not needed. There is an enormous amount of data showing these low-risk patients do not require testing, Dr. Gulati states. “We are testing low-risk patients too much.”
- Use clinical decision pathways. Clinical-decision pathways for chest pain in the ED and outpatient settings should be used routinely.
- Women may be more likely to present with accompanying symptoms. Although chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome, women may be more likely to present with accompanying symptoms such as nausea and shortness of breath. Women usually have three or more additional symptoms beyond chest pain, Dr. Gulati said. Shared decision-making between clinician and patient regarding the need for admission, observation, discharge, or further evaluation in an outpatient setting is recommended for improving patient understanding and reducing low-value testing.
- Identify patients most likely to benefit from further testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive CAD, respectively, will benefit the most from cardiac imaging and testing.
- “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain and its use is discouraged. Chest pain that is more likely associated with ischemia consists of substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin. The more classic the chest discomfort is based on quality, location, radiation, and provoking and relieving factors, the more likely it is to be of cardiac ischemic origin. “Atypical chest pain” is a problematic term. Although it was intended to indicate angina without typical chest symptoms, it is more often used to state that the symptom is noncardiac. Therefore, the use of “atypical” is to be discouraged. Emphasis is more constructively placed on specific aspects of symptoms that suggest their origin in terms of probable ischemia. In fact, use of “atypical” delays care for women, Dr. Gulati noted.
- Structured risk assessment should be used. For patients presenting with acute or stable chest pain, risk for CAD and adverse events should be estimated using evidence-based diagnostic protocols.
Finally, the committee concludes that increasingly, randomized trials will be performed to determine which diagnostic tests can be eliminated from initial and follow-up care, both to streamline management algorithms and to decrease healthcare costs. In part, this approach will encompass evaluation of where patients with chest pain should be initially evaluated and monitored. Comparison of various imaging modalities in randomized trials should help refine test selection and use. The diagnosis and management of chest pain will remain an important area of investigation. Assessment of long-term outcomes, patient-centered metrics, and cost will be integrated into these studies to enhance the evidence base for care of patients presenting with chest pain with greater precision.
1. Practical Cardiology. Take Home Messages from New Chest Pain Guidelines, with Martha Gulati, MD. October 29, 2021. https://www.practicalcardiology.com/view/take-home-messages-from-new-chest-pains-guidelines-with-martha-gulati-md