Written by Clay Smith
Using the acrostic CHEST PAINS, the AHA has issued outstanding new guidelines on the chest pain workup.
Why does this matter?
Chest pain is one of the most common problems we see in the ED, and the stakes are high if we get this wrong. That said, we can’t image or cath everyone who walks in. So, what’s the latest, best thinking on the chest pain workup?
CHEST PAINS from the AHA
This is an exhaustive guideline on the evaluation and diagnosis of chest pain. It’s a beast. Even the executive summary is a beast. However, the AHA has gone above and beyond to summarize this info, and in such a clever way. They came up with an acrostic – CHEST PAINS, and it’s actually not a tortured acrostic! I am going to give you the AHA bullet points for CHEST PAINS and point out a few relevant specifics that were in the fine print and make a few comments. This summary is longer than our usual, but keep in mind, the document is 87 pages long; even the executive summary is 30 pages. But I will keep it as brief as possible.
C – “Chest Pain Means More Than Pain in the Chest. 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. “
Comment: Beware asking elderly patients about chest “pain.” They might think pressure, discomfort, squeezing, heaviness, or the fact they can’t breathe doesn’t constitute “pain” per se. Use different adjectives for pain.
H – “High-Sensitivity Troponins Preferred. 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.”
Comment: So, it’s a bummer some of us don’t have hs-Tn. If you do use hs-Tn, know your local cutoffs and 99th percentile upper reference limit for your specific assay. There is significant discordance among various hs-Tn assays. You could use COMPASS-MI to run estimates based on assay and cut-offs.
E – “Early Care for Acute Symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1. 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.”
Comment: EMS can start aspirin, +/- nitrates, +/- O2, obtain a 12-lead and transmit it, potentially reducing door-to-balloon time in some patients with STEMI.
S – “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.”
Comment: Yes! For many patients who are low risk, a frank discussion is both reassuring and results in a desire to complete the workup as an outpatient. The chest/breast radiation dose of most cardiac tests is not trivial. Be mindful in patients who have had or may need repeat CCTA or nuclear tests.
T – “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.”
Comment: Again, yes! Risk stratification can safely identify patients at low risk. This is both patient-centered and improves ED flow to not have patients awaiting testing in the ED.
P – “Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.”
Comment: We have written so much on the HEART score and HEART pathway. The HEART score has some issues you should consider. Also, the AHA affirms if you use HEART pathway that ≤3 is considered low risk. There is some talk about discharging intermediate risk patients with scores 4-6. I’d say – be careful about that.
A – “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.”
Comment: It was thought that women were more likely to have atypical chest pain symptoms. Turns out, women have chest pain as often as men but may have greater prodromal symptoms and more often have associated symptoms which could distract the clinician away from the chest pain.
I – “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.”
Comment: This is where the pathways mentioned above really help. We don’t need imaging in the ED in most low risk patients.
N – “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.”
Comment: Rationale for using noncardiac vs atypical is, “it is not helpful in determining the cause and can be misinterpreted as benign in nature. Instead, chest pain should be described as cardiac, possibly cardiac, or noncardiac because these terms are more specific to the potential underlying diagnosis.” Remember, “noncardiac” causes can still be bad: PE, PTX, pneumonia, cancer, and many more bad actors.
S – “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.”
Comment: Apparently pathways beat out gestalt when it comes to chest pain. “Compared with an unstructured clinical assessment, CDPs [clinical decision pathways] have been shown to decrease unnecessary testing and reduce admissions while maintaining high sensitivity for detection of acute myocardial injury and 30-day MACE.” Also, they specifically call out the “warranty period” after a normal coronary CTA (no stenosis or plaque) – 2 years; and a normal stress test (assuming adequate stress) – 1 year.
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Oct 28;CIR0000000000001029. doi: 10.1161/CIR.0000000000001029. Online ahead of print.
2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR 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. Circulation. 2021 Oct 28;CIR0000000000001030. doi: 10.1161/CIR.0000000000001030. Online ahead of print.