Inaugural chest pain guideline offers ‘standard approach to evaluating patients’
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The American Heart Association and American College of Cardiology recently released the first chest pain guideline written under their purview.
Martha Gulati, MD, MS, president-elect of the American Society for Preventive Cardiology and chair of the 2021 Guideline for the Evaluation and Diagnosis of Chest Pain from the AHA, ACC and five other societies, spoke on behalf of her co-authors when she stated that “creating a standard approach to evaluating patients will help identify the emergent patients but also help us select the right test for the right patients, improving outcomes, and also reduce cost to our entire health system.”
Unmet needs addressed
Given that chest pain is the one of the most common presenting issue of patients in the ED and in the outpatient setting, the new guideline addresses a much-needed area that was lacking. Phillip D. Levy, MD, MPH, Edward S. Thomas Endowed Professor, assistant vice president for Translational Sciences and Clinical Research Innovation and associate chair for research in the department of emergency medicine at Wayne State University and co-chair of the guideline, stated that the committee’s work “provides a basis for standardization of care, which will help improve health outcomes and right-size resource utilization.” Shared decision-making aids, such as Chest Pain Choice, are recommended for improving patient understanding and reducing low-value testing.
One of the key messages is that chest pain may encompass more than simply pain in the chest. Notably, pain, pressure, tightness or discomfort in the chest, shoulder, arms, neck, back, upper abdomen or jaw, as well as shortness of breath and fatigue, should all be considered anginal equivalents. The authors emphasize that “atypical chest pain” should not be used to describe chest pain. This term has been misused and is often interpreted as noncardiac chest pain, rather than an atypical presentation.
Nonetheless, more recent research has found that women with ischemia often experience the classic symptoms of chest pain. The difference between men and women is that women are more likely to present with three or more accompanying symptoms when experiencing ischemia or MI. Even though women are equally as likely as men to present with chest pain, traditional risk score tools and physician assessments often underestimate risk in women and misclassify their pain as nonanginal.
Gulati said she advocates that “we need to listen to women, and ensure we hear what they are experiencing. Women and their symptoms have been discounted too often and for too long.” The authors also urge avoiding use of the term “atypical” chest pain to describe symptoms that are thought to be noncardiac in origin; instead, clinicians should use descriptors such as “cardiac,” “possible cardiac” and “noncardiac” to more a specifically describe the suspected cause of chest pain.
The authors of the chest pain guideline also emphasize the recommendation for a risk-based approach to evaluating chest based on pretest probability of CAD. Debabrata Mukherjee, MD, MS, chair of the department of internal medicine and chief of cardiovascular medicine at Texas Tech University Health Sciences Center El Paso and co-chair of the guideline, reasons that “for patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease in the hospital is not needed.” Patients are deemed low risk if their 30-day pretest probability of death or a major adverse cardiac event such as MI is less than 1% based on a clinical decision pathway, such as that proposed by Juarez-Orozco and colleagues (Figure 1).
Role of CAC testing
For low-risk patients who are symptomatic and have certain risk factors or would like to obtain follow-up testing through shared-decision making, it may be reasonable to obtain a coronary artery calcium score. A CAC score of 0 identifies a cohort of patients who often do not require additional testing, as most events occur in patients with detectable CAC, and it may also help motivate patients to optimize atherosclerotic CVD prevention through lifestyle improvements. The acknowledgement of the “Power of Zero” in patients with low-risk chest discomfort is pivotal in shifting towards more value-based health care landscape.
Mukherjee also states that “patients with acute or stable chest pain who are at intermediate risk or intermediate to high pretest risk for obstructive CAD, respectively, will benefit the most from cardiac imaging and testing.” For those who are recommended to undergo follow-up testing for chest pain, the new guideline provides recommendations for which anatomic or functional modality would be recommended. The options include a CAC scan, exercise ECG, nuclear (PET or SPECT) stress test, stress echocardiography, stress CV MRI, coronary CTA, or invasive coronary angiography. The guideline is categorized by pre-test probability of major CAD events and by whether the patient’s chest pain is acute or stable. (Figure 2; see the guideline for full details)
References:
- Budoff MJ, et al. Circulation. 2017;doi:10.1161/CIRCULATIONAHA.117.030578.
- Chest Pain Choice Decision Aid. YouTube; 2016. Available at: www.youtube.com/watch?v=LgOagKX_-nA. Accessed Nov. 5, 2021.
- DeFilippis EM, et al. Eur Heart J. 2020;doi:10.1093/eurheartj/ehaa662.
- Ferry AV, et al. J Am Heart Assoc. 2019;doi:10.1161/JAHA.119.012307.
- Gulati M, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.07.053.
- Hemal K, et al. JACC Cardiovasc Imaging. 2016;doi:10.1016/j.jcmg.2016.02.001.
- Hess EP, et al. Circ Cardiovasc Qual Outcomes. 2012;doi:10.1161/CIRCOUTCOMES.111.964791.
- Juarez-Orozco LE, et al. Eur Heart J Cardiovasc Imaging. 2019;doi:10.1093/ehjci/jez054.
- Kreatsoulas C, et al. e-Cardiology/Digital Health. Presented at: European Society of Cardiology Congress; Aug. 31-Sept. 4, 2019; Paris.
- Lichtman JH, et al. Circulation. 2018;doi:10.1161/CIRCULATIONAHA.117.031650.
- Lubbers M, et al. Eur Heart J. 2016;doi:10.1093/eurheartj/ehv700.
- Nasir K, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.09.593.
- Rui P, et al. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. National Center for Health Statistics. Available at:
- cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf. Accessed Nov. 5, 2021.
- Winther S, et al. J Am Coll Cardiol. 2020;doi:10.1016/j.jacc.2020.09.585.
For more information:
Arielle Abovich, MD, MPH, is an internal medicine resident at Johns Hopkins Medicine.
Martha Gulati, MD, MS, is the president-elect of the American Society of Preventive Cardiology and chair of the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Twitter: @drmarthagulati.
Roger S. Blumenthal, MD, is director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease and professor of medicine at Johns Hopkins University School of Medicine. He is also the editor of the Prevention section of the Cardiology Today Editorial Board. Twitter: @rblument1.
The authors can be reached at Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Halsted 560, Baltimore, MD 21827.
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