Disclosures: Gulati reports no relevant financial disclosures. Please see the full statement for all other authors’ relevant financial disclosures. Thompson reports no relevant financial disclosures. Dorbala reports receiving research grants from the AHA, Attralus, GE Healthcare, the NIH and Pfizer and honoraria from GE Healthcare, Ionetix and Pfizer. Rogers is an employee of HeartFlow.
October 28, 2021
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ACC, AHA publish first guideline for evaluation, diagnosis of chest pain

Disclosures: Gulati reports no relevant financial disclosures. Please see the full statement for all other authors’ relevant financial disclosures. Thompson reports no relevant financial disclosures. Dorbala reports receiving research grants from the AHA, Attralus, GE Healthcare, the NIH and Pfizer and honoraria from GE Healthcare, Ionetix and Pfizer. Rogers is an employee of HeartFlow.
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For the first time, the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines published recommendations for the evaluation and diagnosis of patients who present to the ED with chest pain.

The new evidence-based guideline, published in Circulation, is backed by the AHA, ACC, American Society of Echocardiography, the American College of Chest Physicians, the Society for Academic Emergency Medicine, the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance.

Graphic represents the theme of the article.
Data were derived from Gulati M, et al. Circulation. 2021;doi:10.1161/CIR.0000000000001029.
Martha Gulati

“These are the first guidelines for the management of chest pain. 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 and cardiologists, among others,” Martha Gulati, MD, MS, FACC, FAHA, professor of cardiology, former academic division chief of the division of cardiology at the University of Arizona and chair of the guideline writing group, told Healio. “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.”

Chest pain common

According to the document, 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.

“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 told Healio. “I also hope that these guidelines highlight that words matter and we need to move away from describing chest pain as ‘atypical,’ because it has resulted in confusion when these words are used. Rather than meaning a different way of presenting, it has taken on a meaning to imply it is not cardiac. It is more useful to talk about the probability of the pain being cardiac vs. noncardiac.”

According to the guideline, “chest pain” is used to describe a variety of unpleasant or uncomfortable sensations in the anterior chest.

“When some people arrive in the emergency department with chest pain, they often won’t need additional or immediate testing, and the health care team should explain to the patient and their family the various initial tests and risk assessment and their risk level,” Gulati said in the release. “Often, patients have additional concerns because they fear a heart attack or other severe cardiac event, which is understandable. However, we have advanced tools that help us determine whether a cardiac emergency or severe heart event is likely or not.”

The committee wrote that chest pain should be considered acute when either new onset or involving a change in pattern, intensity or duration if it is in a patient with recurrent symptoms. Moreover, chest pain should be considered stable when symptoms are chronic and associated with physical exertion or emotional stress.

Top 10 takeaways for clinicians

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.

“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 Healio. “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.”

Please see the document for full details on the new guidance for the evaluation and diagnosis of chest pain.

Concerns voiced

In a preprint editorial, the American Society of Nuclear Cardiology voiced its concerns regarding several unresolved issues with the new chest pain guideline, including 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.

According to the editorial, a major concern was the large role given to fractional flow reserve coronary CT, given its limited availability, efficacy, level of adoption, substantial cost and inconsistent insurance coverage.

As a result, the ASNC did not give its endorsement to the chest pain guideline.

"FFR-CT was over prominently displayed. There's only one company that supplies that service; it is not widely available; and it's reported with a temporary category 3 code, so it's not widely covered by insurance. 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,” Randall C. Thompson, MD, MASNC, President of the ASNC and cardiologist at Saint Luke’s Mid America Heart Institute, said during a town hall meeting held to discuss the ASNC’s decision to not endorse the chest pain guideline. “We also pointed out that there was no mention of the limitations or contraindications. Every modality has limitations and contraindications … We sent to the guideline writers some documents about the limitations, asking them to put them in there but, for some reason, they did not want to.”

In a company press release, HeartFlow praised the addition of its AI-enabled imaging modality to the chest pain guideline.

“This evolution of the guidelines, and its impact to patients and clinicians, marks a watershed moment in CAD diagnosis and treatment,” Campbell Rogers, MD, FACC, chief medical officer at HeartFlow, said in the release. “The recommendations crystallize coronary CTA as the ascendent front-line test to diagnose CAD accurately and indicate the critical role our HeartFlow Analysis should play in making patient-specific decisions about when to go to the catheterization lab and what revascularization treatment strategies to employ.”

The ASNC cited four other unresolved issues with the new guideline that also influenced it decision not to give its endorsement, including the need for greater emphasis on patient-first imaging; emphasis needed 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.

In a prior policy statement published in the Journal of the American College of Cardiology, the ACC Imaging Council, American Society of Echocardiography, ASNC, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance and the Society of Nuclear Medicine and Molecular Imaging criticized test substitution policies and endorsed patients-centered approaches to noninvasive testing.

“Cardiovascular test selection is highly nuanced and needs to reflect numerous variables, including individual patient factors, local expertise and access, and technology-related details,” Sharmila Dorbala, MD, MPH, MASNC, senior author of the policy statement and immediate past president of the ASNC, said in a press release. “Test substitution policies can lead to patients receiving the wrong test, unnecessary testing, and care delays. Insurers’ push to use a single first-line test in all patients with chest pain is not supported by evidence and may undermine a patient’s confidence in, and adherence to, their treatment plan.”

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