New Clinical Guideline Focuses Solely on Chest Pain Evaluation, Diagnosis

The American College of Cardiology (ACC) and American Heart Association (AHA) have released the first-ever clinical guideline focusing on the evaluation and diagnosis of adult patients with chest pain.

The guidelines provide both recommendations and algorithms for clinicians in performing initial assessments and general considerations for cardiac testing, as well as assisting in selecting the right pathway for patients with acute chest pain and evaluations of patients with stable chest pain.

Key Highlights

In creating the guidelines, investigators performed a comprehensive literature search from November 2017 - May 2020 of randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence in relevant databases.

Additionally, the guidelines provide an evidence-based approach to risk stratification and diagnostic workup for the evaluation of chest pain, in addition to cost-value considerations in diagnostic testing and an increased focus on shared decision-making with patients.

The guidelines provided take-home messages for the clinician in the evaluation and diagnosis of chest pain.

One key highlight of the statement included the idea that chest pain means "more than pain in the chest” as well early care for acute symptoms, advocating to call emergency help or 9-1-1 immediately.

Further, the guidelines suggested the use of high sensitivity cardiac troponins as the preferred standard for an establishment of a biomarker diagnosis of acute myocardial infarction, noting more accurate detection and exclusion of myocardial injury.

The leveraging of the routine use of clinical decision pathways to chest pain in both the emergency and outpatient settings was also recommended.

The guidelines noted that urgent diagnostic testing for suspected coronary artery disease (CAD) may not be needed in low-risk patients with acute or stable chest pain, while it is important to identify patients who are more likely to benefit from further testing, including intermediate to high pretest risk of obstructive CAD.

Moreover, the guidelines identified “noncardiac” as a preferred descriptor of chest pain, in lieu of “atypical”, which was considered misleading and championed the use of structured risk assessment for CAD and adverse events.

Chest Pain in Specific Populations

The guideline statement made specific mention to focus on signs and symptoms in populations with chest pain, including women, older patients, and diverse patients,

Women

The recommendation noted the “uniqueness” of chest pain in women, indicating that most patients who present to the emergency department with chest pain are women.

Despite this, the statement remarked that women who present with chest pain are at risk for underdiagnosis of misclassification, despite data showing women with moderate-to-severe ischemia are more symptomatic than men. They noted that women are more likely to experience prodromal symptoms when seeking medical care, while presenting with accompanying symptoms including nausea and fatigue.

However, chest pain is still reported by women as the predominant symptoms in those who are diagnosed with acute coronary syndrome (ACS), at a frequency equivalent to men.

Older Patients

Although increased age is a significant risk factor for ACS, it is concurrently a risk factor for comorbidities associated with alternative diagnoses to chest pain. Data show that despite patients aged >75 years accounting for 33% of all cases of ACS, an alternative diagnosis is still more common than chest pain at presentation.

As a result, the guideline stated that clinicians should have heightened awareness in order to understand the symptoms associated with ACS.

Racial and Ethnic Differences

Another factor of the recommendation included cultural competency training to achieve the best outcomes in patients from diverse and ethnic backgrounds presenting with chest pain.

Although data show a higher number of Black patients who present with angina pectoris, in relation to other races, they are less likely to be treated urgently or have an ECG or cardiac monitoring performed, with similar disparities in those who are Hispanic.

Further, the statement recommended addressing language barriers with the use of formal translation services, particularly in those in whom English may not be their primary language.

Future Research

The statement noted specific targets of future research into chest pain, including a reduction in delay from symptom onset to presentation.

“Further research is needed to develop approaches to shorten this interval including studies of other methods of evaluating patients with chest pain using technologies that permit acquisition and transmission of ECGs from home and remote evaluations (e.g., telehealth) for those with acute symptoms,” investigators wrote.

They noted the challenge of symptom classification in the evaluation of patients with chest pain, which may be aided with machine-learning algorithms in order to elicit clusters of symptoms.

“It is already clear that some common dogma about chest pain descriptions, such as differences between men and women, may not be as prevalent as has been reported and may impede care of both sexes if they do not fit preconceived notions of the clinical significance of their symptoms,” they wrote.

Due to this, the guideline outlined a need for further investigation into reducing differences in treatment and outcomes stratified by both differences in race and sex.

Additionally, investigators pointed out the use of randomized trials in determining which diagnostic tests can be eliminated from care, to both streamline management algorithms and decrease healthcare cost. This approach may improve evaluation of where initiation evaluation and monitoring should take place for patients with chest pain.

Conclusion

“Thus, the diagnosis and management of chest pain will remain a fertile area of investigation, with randomized evaluations complementing insights provided by registries of patients presenting with chest pain,” investigators wrote.

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain was published online in the Journal of American College of Cardiology.