Inaugural chest pain guideline addresses treatment gaps, promotes patient-first strategy
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The inaugural chest pain guideline, from the American College of Cardiology/American Heart Association, redefines how physicians discuss chest pain with patients and provides a detailed clinical decision pathway for diagnosis and management.
Chest pain is the second most common cause of ED admission in the U.S., behind injury, and accounts for more than 6.5 million ED presentations, or approximately 4.7% of all ED visits, according to the guideline, which was published in Circulation and the Journal of the American College of Cardiology in October.
“These are the first guidelines for the management of chest pain,” Martha Gulati, MD, MS, FACC, FAHA, FASPC, 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, told Cardiology Today. “Our hope is that we have provided an evidence-based approach to evaluating patients who present with chest pain that will assist all of us who manage, diagnose and treat patients who experience chest pain. This includes emergency room staff, internists, family physicians, radiologists and cardiologists, among others. As our imaging technologies have evolved, we needed a contemporary approach to which patients need further testing, and which do not, in addition to what testing is effective” Gulati told Cardiology Today.
According to Gulati, “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,” she and co-authors wrote in a commentary posted on Healio in November.
The new guideline is backed by the AHA, ACC, American Society of Echocardiography, American College of Chest Physicians, Society for Academic Emergency Medicine, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance.
“The new guideline has nicely laid out clinical decision pathways to help clinicians evaluate patients with either acute or stable chest pain. It helps clinicians select functional testing or anatomic testing based on level of risk and prior CAD status,” Janet Wei, MD, FACC, assistant professor of cardiology in the Barbra Streisand Women’s Heart Center at the Cedars-Sinai Smidt Heart Institiute, told Cardiology Today. “For the first time, there’s a specific clinical decision pathway for ischemia in the setting of no obstructive coronary arteries, a condition which is more prevalent in women compared with men.”
Wei noted that rather than lumping all patients as either low, intermediate or high risk, the guideline aims to better categorize patients with chest pain.
“Not everybody has the same symptoms,” Wei said. “Not everybody has traditional risk factors for a heart attack. I’d like to commend the committee for writing specifically on the evaluation of women and the evaluation of patients with suspected ischemia and no obstructive coronary arteries, to hopefully bridge some of the treatment gaps that we see in these populations.”
Relabeling chest pain
A notable development from the new guideline is the recommendation for physicians to change the way chest pain is labeled, and discuss it with their patients.
According to the guideline, chest pain should be described as “noncardiac” rather than “atypical” if CVD is not suspected as a cause.
“Chest pain is a broad term that includes sensations of chest discomfort, pressure, tightness or burning, as well as chest pain equivalents, and the guideline recommends that it is described as ‘cardiac,’ ‘possibly cardiac’ or ‘noncardiac,’ rather than the more traditional descriptions of ‘typical’ or ‘atypical,’” Wei told Cardiology Today. “We now know that atypical angina may be more prevalent than typical angina in women with ischemia and no obstructive coronary arteries. The word 'atypical' may contribute to misdiagnosis, delayed recognition and treatment of ischemia in women. Therefore, it’s a very important take-home message for all clinicians to move towards a new terminology when they describe chest pain.”
Harmony R. Reynolds, MD, FACC, FACP, FAHA, associate professor of medicine, associate director of the Cardiovascular Clinical Research Center and director of the Sarah Ross Soter Center for Women’s Cardiovascular Disease at NYU Langone Health, said the guideline has useful information for internists as well as cardiologists.
“There’s certainly value here for cardiologists, but cardiologists are thinking about the evaluation of chest pain every day,” Reynolds told Cardiology Today. “I recently gave a lecture to internists about this guideline. The ISCHEMIA trial results have important downstream implications for testing and management of chest pain. The ISCHEMIA trial highlights the value of a conservative management strategy, and that places the management of chest pain back in the hands of internists. I encourage internists to use this guideline to think about test selection and how the results of a test will be used.”
CT- and stress-testing strategies
For patients with intermediate to high risk who present with stable chest pain and no known CAD, either coronary CT angiography, based on local availability and clinician expertise, or stress testing, based on the patient’s exercise capacity and presence of resting ECG abnormalities, are recommended.
“The new guideline supports the use of CT coronary angiography in capable centers in the diagnosis of coronary artery disease,” Cardiology Today Editorial Board Member Joseph S. Alpert, MD, professor of medicine at the University of Arizona Sarver Heart Center, said in an interview. “This test has been gaining popularity rapidly, and it may become the diagnostic test of choice in certain populations, exceeding the use of stress testing. Coronary artery calcium scores are also stressed for the diagnosis and prognosis of patients with possible coronary artery disease.”
Coronary CT angiography is preferable in patients with chest pain and no known CAD who are younger than 65 years and not on optimal preventive therapies, according to the document.
Stress testing is the favored pathway for patients aged 65 years and older due to the higher likelihood of ischemia, according to the guideline.
“I agree with the idea that there should be a greater role for CT angiography based in part on the important outcome studies SCOT-HEART and PROMISE. SCOT-HEART, in particular, showed there was a reduction in MI over 5 years with the CT-first strategy,” Reynolds told Cardiology Today.
Main takeaways
The top takeaways for clinicians treating patients with chest pain include:
- Other sensations including chest pressure or tightness, in addition to discomfort in the chest, shoulders, arms, neck, back, upper abdomen or jaw, and shortness of breath and fatigue should be considered anginal equivalents.
- Measurement of high-sensitivity cardiac troponin is the standard for establishing a diagnosis of acute MI and is more accurate for the detection of myocardial injury.
- Patients with acute chest pain or equivalent symptoms should seek immediate care by calling 911.
- Stable patients who present to the ED with chest pain should be included in the decision-making process and should be given information about risk for adverse events, radiation exposure, costs and alternative options.
- CAD is now defined as more than obstructive CAD, and includes nonobstructive CAD.
- For patients who present with chest pain and are identified as low risk, urgent diagnostic testing for CAD is not needed.
- Clinical decision pathways for chest pain should be routine in the ED and outpatient settings.
- Chest pain is the most frequent symptom of ACS for both men and women, and women may be more likely to present with concomitant symptoms including nausea and shortness of breath.
- Patients who are at intermediate or intermediate-to-high risk for obstructive CAD may benefit the most from cardiac imaging and testing.
- The term “noncardiac” should be used to describe chest pain if CVD is not suspected, instead of “atypical,” which may be misleading.
“We also highlight the need to assess women when they present with chest pain. They are often overlooked, despite more often than not, having the same symptoms of chest pain as men when they present with ischemia. In fact, the majority of women often report chest pain or chest discomfort; close to 90% of men and women,” Gulati told Cardiology Today. “The difference is that women are more likely to have accompanying symptoms with their chest discomfort. Research continues to demonstrate a difference in our care of women compared with men when they present with symptoms suggestive of ischemia. We hope that these guidelines and the current evidence will change how we talk about chest pain, because words matter, and how we approach it in our patients, regardless of sex, race or ethnicity.”
Questions that remain
While the inaugural chest pain guidance received praise for its support of coronary CT angiography, clarified definitions for chest pain and distilled clinical decision-making pathways, it also drew questions and comments.
“The task force for the universal definition of myocardial infarction were disappointed that this was not mentioned in the guideline since it is being universally quoted and employed throughout the world,” Alpert, a member of that task force, told Cardiology Today.
In a preprint editorial, the American Society of Nuclear Cardiology (ASNC) highlighted the addition of fractional flow reserve coronary CT (HeartFlow FFRct Analysis, HeartFlow) for the diagnosis of chest pain, which received a class 2A recommendation in four categories, citing its limited availability, efficacy, level of adoption, cost and inconsistent insurance coverage. For this and other reasons, the ASNC withheld its endorsement of the chest pain guideline. In a company press release, HeartFlow praised the addition of its artificial intelligence-enabled imaging modality in the chest pain guideline.
During a town hall held in November to discuss ASNC’s decision to withhold endorsement of the new guideline, Randall C. Thompson, MD, MASNC, ASNC president and cardiologist at Saint Luke’s Mid America Heart Institute, said “FFR-CT was overprominently displayed. There’s a fair amount of dispute about exactly how useful it is in the patients that need it the most: those who have a lesion that appears to be in the 40% to 70% stenosis range. We also pointed out that there was no mention of the limitations or contraindications.”
Thompson also said the society’s concerns about FFR-CT include that it may be costly and that it is provided by only one manufacturer.
The ASNC also highlighted a need for greater emphasis on patient-first imaging; emphasis on the benefits of multimodality testing; that all stress testing modalities should not be lumped together; and concerns regarding the unintended effect on payers and potential test substitution.
The relative costs, charges and downstream impact of various approaches to chest pain is under active study.
According to the guideline, if obstructive coronary disease is identified with coronary CT, then FFR-CT or stress testing should be performed. If flow limitation or moderate to severe ischemia is found during this step, the guideline recommends invasive coronary angiography.
“That directly contradicts the results of the ISCHEMIA trial. That’s the exact patient population that we enrolled in ISCHEMIA,” Reynolds told Cardiology Today. “It’s not clear to me why the chest pain guideline seems to say that all patients with moderate to severe ischemia and obstructive disease in the CT-first pathway need to go for invasive coronary angiography and potentially revascularization.
“Similarly, in the known coronary disease pathway, if we have someone with obstructive coronary disease and they have no high-risk coronary disease and no frequent angina, they go to stress testing. If they have moderate to severe ischemia, the pathway goes straight to invasive coronary angiography,” Reynolds told Cardiology Today. “This again, contradicts the results of the ISCHEMIA trial in which there was no mortality benefit.”
A patient-centric approach
Going forward, the guideline’s “patient-centric” approach to chest pain diagnosis and specific recommendations for certain patient subgroups will be helpful to clinicians, Wei said.
“The committee members did a wonderful job of summarizing how a clinician should approach the evaluation and diagnosis of chest pain,” Wei told Cardiology Today. “They had patient-centric considerations, for example, patient with prior known CAD; those who have certain risk factors like cocaine and methamphetamine use; and, importantly, more specific testing considerations for women. It helps us understand different categories for better phenotyping of patients and assessing their risk.”
The recommendations for the evaluation of patients with chest pain and nonobstructive CAD could change over time, she said.
Gulati said the committee hopes the new recommendations will influence the future of chest pain diagnosis.
“I hope clinicians take from our guidelines the understanding that low-risk patients often do not need additional testing. And if we communicate this effectively with our patients — meaning incorporating shared decision-making into our practice — we can reduce overtesting in low-risk patients,” Gulati said.
- References:
- Abovich A, et al. Inaugural chest pain guideline offers ‘standard approach to evaluating patients.’ www.healio.com/news/cardiology/20211111/inaugural-chest-pain-guideline-offers-standard-approach-to-evaluating-patients. Published Nov. 11, 2021. Accessed Jan. 11, 2022.
- Cardiovascular Imaging Organizations Denounce Test Substitution, Outline Principles for Patient-centered Noninvasive Testing. www.prweb.com/releases/cardiovascular_imaging_organizations_denounce_test_substitution_outline_principles_for_patient_centered_noninvasive_testing/prweb18210350.htm. Published Nov. 2, 2021. Accessed Jan. 10, 2022.
- Chest pain may extend outside the chest, often needs to be checked by a professional. newsroom.heart.org/news/chest-pain-may-extend-outside-the-chest-often-needs-to-be-checked-by-a-professional. Published Oct. 28, 2021. Accessed Jan. 10, 2022.
- Gulati M, et al. Circulation. 2021;doi:10.1161/CIR.0000000000001029.
- Gulati M, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.07.053.
- HeartFlow Analysis is First AI-Enabled Technology to be Recognized by the American College of Cardiology and American Heart Association Guidelines as an Important Tool in Diagnosing and Treating Heart Disease. www.globenewswire.com/en/news-release/2021/10/28/2323169/0/en/HeartFlow-Analysis-is-First-AI-Enabled-Technology-to-be-Recognized-by-the-American-College-of-Cardiology-and-American-Heart-Association-Guidelines-as-an-Important-Tool-in-Diagnosin.html. Published on Oct. 28, 2021. Accessed Jan. 10, 2022.
- Thompson RC, et al. J Am Coll Cardiol. 2021;doi:10.1016/j.jacc.2021.07.043.
- Thompson RC, et al. Zenodo. 2021;doi:10.5281/zenodo.5608812.
- For more information:
- Joseph S. Alpert, MD, can be reached at jalpert@shc.arizona.edu.
- Martha Gulati, MD, MS, FACC, FAHA, FASPC, can be reached at martha.gulati@gmail.com; Twitter: @drmarthagulati.
- Harmony R. Reynolds, MD, FACC, FACP, FAHA, can be reached at harmony.reynolds@nyulangone.org.
- Randall C. Thompson, MD, MASNC, can be reached at rthompson@saint-lukes.org.
- Janet Wei, MD, FACC, can be reached at janet.wei@cshs.org; Twitter: @janetweimd.
Editor’s Note: This article was updated on Feb. 21, 2022 to change the header of one section to clarify that both CT-related and stress-testing-related strategies were being discussed.
Editor’s Note: The headline of this article was updated on Feb. 23, 2022 to clarify the key messages of the chest pain guideline.
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