AHA / ACC Releases New Guidelines to Identify Non-Cardiac Chest Pain Versus Cardiac Chest Pain
A recently published joint guideline by 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 directive was published online in Circulation and simultaneously in the Journal of the American College of Cardiology.
According to members of the editorial board, a heart problem, such as a myocardial infarction (MI) or other cardiovascular event (CV), is frequently associated with significant chest pain. Although heart problems are a major contributor to chest pain, episodes of chest pain sometimes may not be related to a CV event, indicating the need for clinical practice guidelines on assessment and identification. appropriate to the source of the pain.
Given the urgency of treating MI or another cardiac complication, the new guideline recommends that clinicians use standardized risk assessments, clinical pathways, as well as tools to assess chest pain and quickly identify The source. Guideline formation was based on a comprehensive literature review including both randomized and non-randomized trials, observational studies, systematic reviews, registers and other published evidence generated from humans .
The goals of assessing chest pain in the emergency department (ED), according to the guideline, include identifying life-threatening causes and determining the need for hospitalization or further testing. The guideline states that a focused history should be obtained in patients with chest pain. This history should include clinical features as well as duration of chest pain symptoms and associated features. In addition, clinicians should perform a CV risk factor assessment in patients with chest pain.
Underdiagnosis of chest pain in women and cultural diversity in patients
While men and women both report chest pain during a severe CV event, the guidelines writing committee notes that women may be at higher risk for underdiagnosing chest pain. As such, the guideline recommends that clinicians carefully consider the potential cardiac causes of chest pain in women. Additionally, the guideline recommends obtaining a clinical history in women with chest pain, with an emphasis on assessing associated symptoms that are more common in women, including nausea and shortness of breath.
In patients 75 years of age or older who present with chest pain, the guideline recommends that clinicians consider a diagnosis of acute coronary syndrome (ACS) if these patients experience shortness of breath, syncope, or acute delirium. In addition, the guideline recommends training in cultural skills to optimize outcomes in patients of diverse racial and ethnic backgrounds who suffer from chest pain. Addressing language barriers in racial and ethnic minorities who experience chest pain should also be a priority among emergency services and other centers, according to the directive.
Cardiac Testing Considerations
The AHA / ACC guideline recommends the use of an office electrocardiogram (ECG) in patients with stable chest pain, unless there is an obvious non-cardiac cause for the chest pain. In settings where an ECG is not available, clinicians should refer these patients to the emergency department for testing. Regardless of the setting, patients with acute chest pain should have an ST-segment elevation myocardial infarction (STEMI) ECG within 10 minutes of arrival.
Serial ECGs should be performed in patients with chest pain for whom an initial ECG is not diagnostic, as this could help identify potential ischemic changes, especially if there is a high clinical suspicion of ACS. Current guidelines for STEMI and non-ST segment elevation ACS should be used to guide treatment decisions in patients with chest pain who have an initial ECG compatible with ACS.
Patients with clinical signs of ACS or another life-threatening cause of acute chest pain should be rushed to the emergency room by Emergency Medical Services (EMS), as directed. The authors of the guideline also recommend measuring cardiac troponin (cTn) immediately after presentation in patients presenting to the emergency department 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 allows rapid detection or exclusion of myocardial damage and improves diagnostic accuracy. Serial cTn I or cTn T levels could be useful in identifying abnormal values ââand an upward or downward trend suggesting acute myocardial injury in patients with acute chest pain.
Assessment of patients with stable chest pain
In patients with stable chest pain and without coronary artery disease (CAD) who present to an outpatient clinic, the guidelines committee says that a model for estimating the likelihood of pretesting for obstructive coronary artery disease might be effective in identifying obstructive coronary artery disease. patients at low risk for the disease.
Additionally, coronary artery calcium testing may be a reasonable first-line test to rule out calcified plaque and identify a low likelihood of obstructive coronary artery disease in low-risk patients who have stable chest pain but no known coronary artery disease. The guideline states that stress testing without imaging may also be a reasonable first-line test to rule out myocardial ischemia and identify functional capacity in low-risk patients with stable chest pain and no known coronary artery disease.
Coronary computed tomography angiography (CCTA) may be effective in diagnosing coronary artery disease in patients with chest pain who are classified as intermediate-high risk but have no known coronary artery disease. Additionally, ACCT may be effective in these patients for risk stratification as well as for guiding treatment decision.
The guideline also suggests that stress imaging may be effective for the diagnosis of myocardial ischemia and for estimating the risk of major adverse CV events in intermediate to high risk patients with stable chest pain and no known coronary artery disease. .
For the assessment of left ventricular function in high intermediate risk patients with pathologic Q waves or signs / symptoms of heart failure, transthoracic echocardiography (TTE) may be effective for the diagnosis of systolic ventricular function and diastolic of the left ventricle at rest as well as the detection of myocardial, pericardial and valve abnormalities.
Assessment of stable chest pain in patients with coronary artery disease
The guideline recommends invasive coronary angiography (ACI) to guide treatment decision making in patients with obstructive coronary artery disease and stable chest pain despite guideline-directed medical treatment and moderate to severe ischemia. Additionally, the guideline recommends the ICA to guide treatment decision making in symptomatic patients with obstructive coronary artery disease and stable chest pain with 50% or greater stenosis defined by ACCT in the left main coronary artery. , obstructive coronary artery disease with fractional flow reserve with a CT scan of 0.80 or more, or severe stenosis (â¥ 70%) in all 3 major vessels.
Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA / ACC / ASE / CHEST / SAEM / SCCT / SCMR Guideline for the Assessment and Diagnosis of Chest Pain: A Report of the American College of Cardiology / American Heart Joint Clinical Practice Guidelines Committee Association. Circulation. Published online October 28, 2021. doi: 10.1161 / CIR.0000000000001029