Tailoring Chest Pain Diagnostics to Patients, with Kyle Fortman, PA-C, MBA

The 2021 joint American Heart Association and American College of Cardiology (AHA/ACC) chest pain evaluation and diagnosis guidelines provided a well-evidenced, modernized approach to interpreting cardiac risks and best recourse to referring patients for outpatient versus hospitalization care based on their presentation and clinical / demographic makeup.¹ The guideline also helped to identify 2 areas of improvement in chest pain diagnostics going forward: shared decision making practices between the clinician and patient, and research toward establishing cost-effectiveness with cardiac screening tools.

In the second segment of an interview² with HCPLive at the American Academy of Physician Associates (AAPA) 2024 Conference & Expo in Houston, TX, this week, Kyle Fortman, PA-C, MBA, director of the Marcus Heart Valve Center at Piedmont Healthcare, discussed the progress going into the ventures of both shared decision making and cost-effective assessment in chest pain screening.

Beginning with shared decision making, Fortman said this has been a strategy emphasized by the ACC, American Medical Association (AMA) and other leading organizations well before the 2021 guidelines.

“It's something that we should have been doing all along—it's just bringing it to the forefront to make sure that we keep it top of mind,” Fortman said. “And it's not just shared decision making about coming to the hospital, but also testing risks and benefit options in your recommendation, and why you've recommended that for the patient.”

Fortman stressed finer details of communication between his diagnosing peers and their patients—establishing their preferred language before discussing results and options, and setting a plan for continuum of long-term care based on the strategy decided upon in the acute setting.

“It starts at one point, whether it's a shared decision making conversation about chest pain, but then it moves to medications, then it moves to follow-up,” Fortman said. “In a year's time it may be repeat testing, in a year's time, it may be other things. But it should be a continuum the whole time through the hospitalization as well as through your your care of that patient.”

Regarding testing modality cost-effectiveness, Fortman described the matter as a “moving target,” largely due to the role of circumstances including CMS reimbursement.

“But what I would tell you is that we are at a point where the advanced testing that’s coming out—with cardiac stress MR, cardiac stress PET which has been here awhile, cardiac nuclear stress testing and cardiac CTA—are all coming to a head where we have testing that is very sensitive and specific, but it isn't maybe the most cost-effective testing and we often have to balance what are we looking for,” Fortman said.

Inroads can continued to be made at a finer detail. For example, ischemia with no obstructive coronary artery disease (INOCA) is recommended to be tested with cardiac MR stresses over a nuclear stress test in order to interpret cardiac myofunctional disease at the cellular level, Fortman explained. Refined utility of all these tools is not yet at that level.

“We are not quite there yet, maximizing cost effectiveness with testing relative to that patient,” he said. “I’ll tell you that one thing we are doing better at that will overall help the economics of healthcare is sending the low-risk chest patients home, being able to evaluate them outpatient where we are saving the hospital resources for people who are more in need—saving the hospital resources for the patients that more appropriately need to be there.”

References

1. ^{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 [published correction appears in Circulation. 2021 Nov 30;144(22):e455] [published correction appears in Circulation. 2023 Dec 12;148(24):e281]. Circulation. 2021;144(22):e368-e454. doi:10.1161/CIR.0000000000001029}
2. ^{Kunzmann K. Kyle Fortman, PA-C, MBA: Troponin and Heart Injury Risk Screening Recommendations. HCPLive. Published May 20, 2024. https://www.hcplive.com/view/kyle-fortman-troponin-heart-injury-risk-screening-recommendations}