The first-ever clinical guideline from the ACC and American Heart Association (AHA) to focus solely on the evaluation and diagnosis of adult patients with chest pain, provides recommendations and algorithms for conducting initial assessments, general considerations for cardiac testing, choosing the right pathway for patients with acute chest pain, and evaluating patients with stable chest pain.

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain, published Oct. 28 in both the Journal of the American College of Cardiology and Circulation, offers "an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain," while also incorporating cost-value considerations in diagnostic testing and shared decision-making with patients.

Key highlights from the paper include a focus on signs and symptoms (including accompanying symptoms like nausea and shortness of breath in women) and the importance of early care for acute symptoms. "Chest pain means more than chest pain," is one of the top takeaways outlined in the Executive Summary, along with calling 9-1-1 immediately.

"This standard approach provides clinicians with the guidance to better evaluate patients with chest pain, identify patients who may be having a cardiac emergency and then select the right test or treatment for the right patient," said Writing Committee Chair Martha Gulati, MD, MS, FACC.

The guideline also recommends the use of high sensitivity cardiac troponins as the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. Additionally, urgent diagnostic testing for suspected coronary artery disease is not needed in low-risk patients with acute or stable chest pain, according to the guideline. The authors, including Gulati and Vice Chairs Phillip D. Levy, MD, MPH, FACC, and Debabrata Mukherjee, MD, MS, FACC, note that "patients with acute or stable chest pain who are at intermediate risk or intermediate to high pretest risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing."

"While there is no one 'best test' for every patient, the guideline emphasizes the tests that may be most appropriate, depending on the individual situation, and which ones won't provide additional information; therefore, these tests should not be done just for the sake of doing them," said Gulati. "Appropriate testing is also dependent upon the technology and screening devices that are available at the hospital or health care center where the patient is receiving care. All imaging modalities highlighted in the guideline have an important role in the assessment of chest pain to help determine the underlying cause, with the goal of preventing a serious cardiac event."

Also of note, the use of "noncardiac" as a descriptor of chest pain is encouraged in place of "atypical," which the authors say is misleading. Other recommendations include leveraging routine use of clinical decision pathways for chest pain in the emergency department and outpatient settings, as well as the use of structured risk assessment using evidence-based protocols for patients presenting with acute or stable chest pain, or in those patients at risk for coronary artery disease or adverse events.

Looking ahead, the authors recognize that "the diagnosis and management of chest pain will remain a fertile area of investigation." As such, they highlight the need for further research and new approaches for reducing delays from chest pain symptom onset to presentation, as well as the need for continued research and best practices for reducing the differences in both sex, gender and racial differences in treatment and outcomes. Additionally, they point out the important role that registries will play as platforms within which to conduct randomized trials and note the need to evaluate the impact of accreditation activities coupled with registry participation on clinical outcomes and process improvement.

The AHA/ACC Chest Pain Guideline was approved by the American Society of Echocardiography, the American College of Chest Physicians, the Society for Academic Emergency Medicine, the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. Additionally, the writing group included representatives from each of the partnering organizations and experts in the field – cardiac intensivists, cardiac interventionalists, cardiac surgeons, cardiologists, emergency physicians and epidemiologists – and a lay/patient representative.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound

Keywords: Coronary Artery Disease, Outpatients, Patient Advocacy, Epidemiologists, Decision Making, Shared, Chest Pain, Myocardial Infarction, Echocardiography, Emergency Service, Hospital, Risk Assessment, Emergency Medicine, Hospitals, Registries, Magnetic Resonance Spectroscopy, Accreditation, Surgeons, Troponin, Nausea, Treatment Outcome, Dyspnea, Biomarkers, Diagnostic Techniques and Procedures, Delivery of Health Care, Tomography

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