Chest pain means more than chest pain

Created by on Oct. 29, 2021

The FIRST-EVER clinical guideline from the ACC and American Heart Association (AHA) to focus solely on the evaluation and diagnosis of adult patients with chest pain, provides recommendations and algorithms for conducting initial assessments, general considerations for cardiac testing, choosing the right pathway for patients with acute chest pain, and evaluating patients with stable chest pain.

2021 Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. published Oct. 28 in both the Journal of the American College of Cardiology and Circulation, offers "an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. 

"Chest pain means more than chest pain"

Key highlights from the paper include a focus on signs and symptoms (including accompanying symptoms like nausea and shortness of breath in women) and the importance of early care for acute symptoms. "Chest pain means more than chest pain," is one of the top takeaways outlined in the Executive Summary, along with calling 911 immediately. 

Chest pain

In regards to call 911.

It’s very important to know that chest pain can feel like and the other symptoms of a heart attack so that you can recognize them. Other symptoms of a heart attack include nausea or vomiting, unusual tiredness, cold sweat, dizziness or weakness. If you think you or a loved one is having a heart attack, call 911 immediately. Time is muscle. Every second you delay means more damage to your heart – it could also be the difference between life and death.

In regards to the Test.

The guideline also recommends the use of high sensitivity cardiac troponins as the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. Additionally, urgent diagnostic testing for suspected coronary artery disease is not needed in low-risk patients with acute or stable chest pain, according to the guideline. While there is no one 'best test' for every patient, the guideline emphasizes the tests that may be most appropriate, depending on the individual situation.

Women and other symptoms

Women have chest pain as often as men when having a heart attack. But women are more likely to have additional accompanying symptoms, such as nausea and shortness of breath. Women are less likely to receive timely care for heart-related chest pain. Because women have been underdiagnosed, the guideline recommends that heart causes of chest pain should always be considered for women with chest pain.

Looking ahead

Looking ahead, the authors recognize that "the diagnosis and management of chest pain will remain a fertile area of investigation." As such, they highlight the need for further research and new approaches for reducing delays from chest pain symptom onset to presentation, as well as the need for continued research and best practices for reducing the differences in both sex, gender and racial differences in treatment and outcomes. Additionally, they point out the important role that registries will play as platforms within which to conduct randomized trials and note the need to evaluate the impact of accreditation activities coupled with registry participation on clinical outcomes and process improvement.

Here are some key points:

  • Recommendation of deferral of testing in low-risk individuals
  • Provides contemporary models to estimate risk/pre-test probability of CAD
  • Provides specific recommendations for the evaluation of non-obstructive CAD
  • Emphasizes more selective use of imaging and incorporation of contemporary imaging techniques
  • Emphasizes intensification of preventive therapies
  • Highlights the unique aspects of evaluating women with chest pain, including microvascular disease and ischemia with non-obstructive CAD
  • Moves away from atypical chest pain as a descriptor
  • Recommendation of incorporating prior test results when deciding on patient management and need/type of testing, including warranty period of prior normal CCTA and stress test results
  • Lists factors to consider when selecting between CCTA and stress testing
  • Detailed recommendations on evaluating non-cardiac causes of chest pain

The guideline includes a list of top 10 take-home messages for clinicians treating patients with chest pain:

  • 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. These patients should be given information about risk for adverse events, radiation exposure, costs and alternative options.
  • 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, not “atypical,” as it may be misleading.
  • Evidence-based diagnostic protocols should be used to assess risk for CAD and adverse events in patients with acute or stable chest pain.

In regards to the paper.

The paper was approved by the American College of Cardiology Clinical Policy Approval Committee in May 2021, the American Heart Association Science Advisory and Coordinating Committee in May 2021, the Society of Cardiovascular Computed Tomography in July 2021, the Society for Academic Emergency Medicine in June 2021, the Society for Cardiovascular Magnetic Resonance in June 2021, the American College of Chest Physicians in June 2021, the American Society of Echocardiography in June 2021, the American Heart Association Executive Committee in July 2021, and the American College of Cardiology Science and Quality Committee in July 2021.

Authors Writing: Committee Members Martha Gulati, MD, MS, FACC, FAHA Chair Phillip D. Levy, MD, MPH, FACC, FAHA Vice Chair Debabrata Mukherjee, MD, MS, FACC, FAHA Vice Chair Ezra Amsterdam, MD, FACC Deepak L. Bhatt, MD, MPH, FACC, FAHA Kim K. Birtcher, MS, PharmD, AACC Ron Blankstein, MD, FACC, MSCCT Jack Boyd, MD Renee P. Bullock-Palmer, MD, FACC, FAHA, FASE, FSCCT Theresa Conejo, RN, BSN, FAHA Deborah B. Diercks, MD, MSc, FACC Federico Gentile, MD, FACC John P. Greenwood, MBChB, PhD, FSCMR, FACC Erik P. Hess, MD, MSc Steven M. Hollenberg, MD, FACC, FAHA, FCCP Wael A. Jaber, MD, FACC, FASE Hani Jneid, MD, FACC, FAHA José A. Joglar, MD, FAHA, FACC David A. Morrow, MD, MPH, FACC, FAHA Robert E. O’Connor, MD, MPH, FAHA Michael A. Ross, MD, FACC Leslee J. Shaw, PhD, FACC, FAHA, MSCCT

Please see the document for full details on the new guidance for the evaluation and diagnosis of chest pain in the reference below:

Reference: Martha Gulati et al. Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.J Am Coll Cardiol. Oct 28, 2021. Epublished DOI: 10.1016/j.jacc.2021.07.053. 

Chest pain - Guideline - JACC