New chest pain guideline: Takeaways & Concerns

A new guideline on chest pain evaluation and diagnosis – touted as the first of its kind – is now out, reaping both praises and dissent from experts.

The guideline is the first under the purview of the American Heart Association and American College of Cardiology, in collaboration with other societies. “A lot of people seemed to mistake us for the stable ischaemic heart disease guideline, but we’re not,” said Dr Martha Gulati, chair of the guideline writing committee, and president-elect of the American Society of Preventive Cardiology. “We’re actually a new guideline.”

“Chest pain” is defined in the guideline as more than just a pain in the chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, and jaw, as well as fatigue, shortness of breath, and nausea, particularly in women, should all be considered anginal equivalents. [J Am Coll Cardiol 2021;78(22)e187–e285]

‘Atypical’ is no longer in

The guideline cautions against using “atypical” to describe chest pain. Instead, the term “noncardiac” or “possibly cardiac” is encouraged if heart disease is not suspected.

“Atypical, by definition, means presenting a little bit differently. The problem is it’s been misinterpreted,” explained Gulati. “It is thus more useful to describe the probability of the pain as being cardiac or noncardiac to avoid confusion.”

Other than preventive therapies, which were given much emphasis in the guideline, early care for acute symptoms is recommended. Evaluation of patients should focus on the early identification or exclusion of life-threatening causes.

Inclusion of stable patients with chest pain in the decision-making process is encouraged, so is the need for informed choices on alternative options, the risk for adverse events, radiation exposure, and costs.

Women are overlooked

Chest pain is the most frequent symptom of acute coronary syndrome, but women may be more likely to present with concomitant symptoms, including nausea and shortness of breath. “Women are often overlooked when they present with symptoms suggestive of ischaemia. We hope the current evidence will change how we talk about chest pain and how we care for our patients,” Gulati said.

Physicians are also advised to follow structured risk assessments, using evidence-based diagnostic protocols when evaluating chest pain, both in the emergency and outpatient settings.

High-sensitivity cardiac troponin is preferred over conventional troponin assays for the biomarker diagnosis of acute myocardial infarction.

In patients who present with chest pain but are identified as low risk, urgent diagnostic testing for coronary artery disease (CAD) is not required. “Low-risk patients often do not need additional testing. If we communicate this effectively with our patients, we can reduce unnecessary testing in these patients,” Gulati emphasized.

Patients who are at intermediate- or intermediate- to high-risk with suspected acute coronary syndrome (ACS) may benefit the most from cardiac imaging and stress testing.

Big endorsement for CCTA

The guideline also urges more selective use of imaging and offers advice on how to decide between coronary CT angiography (CCTA) and stress testing. CCTA, to check for plaque buildup in the coronary arteries, grabbed class I recommendations. Fractional flow reserve CT (FFR-CT) got a class IIa recommendation for add-on testing in some cases.

“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 pointed out. “This is the guideline that we felt strongly needed to be done right.”

Experts’ perspective

“Revolutionary” was how Dr Ron Blankstein from the Brigham and Women’s Hospital in Boston, Massachusetts, US, described the recommendations for cardiac testing, noting that those are built upon high-quality imaging evidence.

“CT angiography has certainly moved up, but the concept of one modality moving up at the expense of another modality is incorrect,” he added. “Other modalities didn’t move down because CT angiography moved up. The concept is that there are lot of options with imaging.”

Another member of the writing committee, Dr Deepak Bhatt from the Brigham and Women’s Hospital, Boston, Massachusetts, US, agreed with Blankstein, saying there are circumstances that will favour CT angiography, whereas stress imaging might be more appropriate in some settings.

“Our goal wasn’t to focus on a procedure, or an imaging modality, or a testing modality, per se, but rather to approach it from the patient’s perspective,” he explained. “When someone presents with a symptom, how do we deal with that patient?”

The guideline is not also meant to replace other guidelines “but to integrate knowledge from a variety of different data streams … to figure out how to provide the best care for patients with chest pain,” Bhatt clarified. 

The guideline is endorsed by the American Society of Echocardiography (ASE), American College of Chest Physicians (CHEST), Society for Academic Emergency Medicine (SAEM), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR), but not the American Society of Nuclear Cardiology (ASNC).

Differing opinion

The ASNC felt the guideline is not balanced, and that the FFR-CT  has been given the prominence it does not deserve.

“A major concern was the oversized role given to FFR-CT, especially given the limited availability, efficacy, level of adoption, substantial cost, and inconsistent insurance coverage,” said ASNC president Dr Randall Thompson, a cardiologist at Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, US.  “There’s also a fair amount of dispute about exactly how useful it is in patients with lesions in the 40–70 percent stenosis range.” 

Nonetheless, the guideline provides a basis for standardization of care that will help improve patient outcomes and resource utilization, commented guideline co-chair Dr Phillip Levy from Wayne State University in Detroit, Michigan, US.

 

10 Takeaways for Clinicians

1. Chest pain means more than pain in the chest.

2. High-sensitivity troponins are preferred.

3. Seek early care for acute symptoms.

4. Share the decision-making with patients.

5. Testing is not needed routinely in low-risk patients.

6. Use clinical decision pathways.

7. Women may be more likely to present with accompanying symptoms (nausea, shortness of breath).

8. Identify patients most likely to benefit from further testing.

9. Noncardiac is in, atypical is out.

10. Use structured risk assessment.