Evaluation and diagnosis of chest pain- ACC, AHA publish first guideline

American Heart Association (AHA) and American College of Cardiology (ACC) have released a joint clinical practice guideline on evaluation and diagnosis of chest pain. The guidelines provide 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.

It is an evidence-based approach to evaluating patients that will assist clinicians who manage, diagnose, and treat patients who experience chest pain.

The guideline has been prepared on behalf of and approved by the AHA and ACC Joint Committee on Clinical Practice Guidelines. In addition to this five other partnering organizations also participated in and approved the guideline namely the American Society of Echocardiography (ASE), the American College of Chest Physicians (CHEST), the Society for Academic Emergency Medicine (SAEM), the Society of Cardiovascular Computed Tomography (SCCT), and the Society for Cardiovascular Magnetic Resonance (SCMR).

The guideline has been simultaneously published online October 28 in Circulation and the Journal of the American College of Cardiology.

According to the guidelines, 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.The guideline has been developed for the evaluation of acute or stable chest pain in outpatient as well as in emergency department emphasizing the diagnosis of chest pain with an ischemic etiology. The following are key points to remember.

1.Chest pain is the most common symptom among both men and women diagnosed with acute coronary syndrome (ACS)Chest Pain includes Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents.

Women more commonly have accompanying symptoms including nausea, palpitations, and shortness of breath.

2. Electrocardiography (ECG) is important in the evaluation of both acute and stable chest pain to assess for evidence of ACS.

3.High-Sensitivity Troponins is Preferred test as it allows rapid detection of myocardial injury and has increased diagnostic accuracy.

High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.

4.Early Care for Acute Symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek immediate medical care. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes.

5.Share the Decision-Making. Clinically stable patients presenting with chest pain should be included in decision-making; information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.

6.Testing Not Needed Routinely for Low-Risk Patients. For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed.The guideline authors emphasize there are opportunities to reduce unnecessary or inappropriate testing for some adults with chest pain, especially in the emergency department and for those patients screened as low risk for a cardiac event.

7.Pathways.Among patients with acute or with stable chest pain, the use of diagnostic testing should be based on a structured assessment of cardiac risk and targeted to patients most likely to benefit.Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.

8.Accompanying Symptoms. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath.

9.Identify Patients Most Likely to Benefit From Further Testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.

10.Noncardiac Is In. Atypical Is Out. "Noncardiac" should be used if heart disease is not suspected. "Atypical" is a misleading descriptor of chest pain, and its use is discouraged.

11.Structured Risk Assessment Should Be Used. For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols.