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Guideline for the Evaluation and Diagnosis of Chest Pain PowerPoint Presentation

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This medical PowerPoint presentation lists Guideline for the Evaluation and Diagnosis of Chest Pain adapted from 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline.
The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain emphasizes the importance of a comprehensive, stepwise approach to evaluating patients with chest pain, with careful consideration of individual patient characteristics and risk factors.

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Slide 1-

Endorsed by the American Society of Echocardiography, American College of Chest Physicians, Society for Academic Emergency Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain
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Citation This slide set is adapted from the 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain. Published online ahead of print October 29, 2021, available at: Circulation. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029 and Journal of the American College of Cardiology published online ahead of print October 29, 2021. J Am Coll Cardiol. https://doi.org/10.1016/j.jacc.2021.07.053
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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† Martha Gulati, MD, MS, FACC, FAHA, Chair† Phillip D. Levy, MD, MPH, FACC, FAHA, Vice Chair † Debabrata Mukherjee, MD, MS, FACC, FAHA, Vice Chair† 2021 Writing Committee Members* *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡ ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. §Society of Cardiovascular Computed Tomography Representative. ║ Lay Patient Representative. ¶Society for Academic Emergency Medicine Representative. #Former ACC/AHA Joint Committee member; current member during the writing effort. **Society for Cardiovascular Magnetic Resonance Representative. ††American College of Chest Physicians Representative. ‡‡American Society of Echocardiography Representative. §§Task Force on Performance Measures, Liaison.
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Top 10 Take-Home Messages 4 2021 Evaluation and Diagnosis of Chest Pain
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1. 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. Top 10 Take Home Messages 5
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2. 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. Top 10 Take Home Messages 6
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3. 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. Top 10 Take Home Messages 7
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4. 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. Top 10 Take Home Messages 8
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5. 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. Top 10 Take Home Messages 9
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6. Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely. Top 10 Take Home Messages 10
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7. 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. Top 10 Take Home Messages 11
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8. 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. Top 10 Take Home Messages 12
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9. 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. Top 10 Take Home Messages 13
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10. 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. Top 10 Take Home Messages 14
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Figure 1. Take-Home Messages for the Evaluation and Diagnosis of Chest Pain 15
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Table 1. ACC/AHA Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019) 16
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17 Defining Chest Pain
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Defining Chest Pain 18
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Figure 2. Index of Suspicion That Chest “Pain” Is Ischemic in Origin on the Basis of Commonly Used Descriptors. 19
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20 Initial Evaluation
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History 21
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Figure 3. Top 10 Causes of Chest Pain in the ED Based on Age (Weighted Percentage). 22 Created using data from Hsia RY, et al. (3).
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Table 3. Chest Pain Characteristics and Corresponding Causes 23
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Table 3. Chest Pain Characteristics and Corresponding Causes (con’t.) 24 ACS indicates acute coronary syndrome.
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A Focus on the Uniqueness of Chest Pain in Women 25
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Considerations for Older Patients With Chest Pain 26
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Considerations for Diverse Patient Populations With Chest Pain 27
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Patient-Centric Considerations 28
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Physical Examination 29
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Table 4. Physical Examination in Patients With Chest Pain 30 ACS indicates acute coronary syndrome; AR, aortic regurgitation; AS, aortic stenosis; CXR, chest x-ray; LR, likelihood ratio; HCM, hypertrophic cardiomyopathy; MR, mitral regurgitation; PE, pulmonary embolism; and PUD, peptic ulcer disease.
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Table 4. Physical Examination in Patients With Chest Pain (con’t.) 31 ACS indicates acute coronary syndrome; AR, aortic regurgitation; AS, aortic stenosis; CXR, chest x-ray; LR, likelihood ratio; HCM, hypertrophic cardiomyopathy; MR, mitral regurgitation; PE, pulmonary embolism; and PUD, peptic ulcer disease.
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Setting Considerations 32
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Setting Considerations (con’t.) 33
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34 Electrocardiogram
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35 Figure 4. Electrocardiographic-Directed Management of Chest Pain. Colors correspond to the Class of Recommendation in Table 1. ECG indicates electrocardiogram; NSTE-ACS, non–ST-segment–elevation acute coronary syndrome; MI, myocardial infarction; and STEMI, ST-segment elevation myocardial infarction.
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36 Chest Radiography
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37 Biomarkers
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38 Biomarkers (con’t.)
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39 Cardiac Testing General Considerations
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40 Figure 5. Chest Pain and Cardiac Testing Considerations. The choice of imaging depends on the clinical question of importance, to either a) ascertain the diagnosis of CAD and define coronary anatomy or b) assess ischemia severity among patients with an expected higher likelihood of ischemia with an abnormal resting ECG or those incapable of performing maximal exercise. ACS indicates acute coronary syndrome; CAC, coronary artery calcium; CAD, coronary artery disease; and ECG, electrocardiogram. Please refer to Section 4.1. For risk assessment in acute chest pain: See Figure 9. For risk assessment in stable chest pain: See Figure 11.
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41 Figure 6. Choosing the Right Diagnostic Test. ASCVD indicates atherosclerotic cardiovascular disease; CAD, coronary artery disease; CAC, coronary artery calcium; CCTA, coronary computed tomography angiography; CMR, cardiovascular magnetic resonance; LV, left ventricular; MPI, myocardial perfusion imaging; and PET, positron emission tomography.
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42 Table 5. Contraindication by Type of Imaging Modality and Stress Protocol
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43 ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; AS, aortic stenosis; CCTA, cardiac computed tomography angiography; CMR, cardiovascular magnetic resonance imaging; COPD, chronic obstructive pulmonary disease; GFR, glomerular filtration rate; LV, left ventricular; MET, metabolic equivalent; MRI, magnetic resonance imaging; PE, pulmonary embolism; SBP, systolic blood pressure; and VT, ventricular tachycardia. Readers should also review each imaging society’s guidelines for more details on test contraindications. *Screening for potential pregnancy by history and/or pregnancy testing should be performed according to the local imaging facilities policies for undertaking radiological examinations that involve ionizing radiation in women of child-bearing age. †Low-dose dobutamine may be useful for assessing for low-gradient AS. Table 5. Contraindication by Type of Imaging Modality and Stress Protocol (cont..)
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44 Choosing the Right Pathway With Patient-Centric Algorithms for Acute Chest Pain
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45 Figure 7. Patient-Centric Algorithms for Acute Chest Pain. ECG indicates electrocardiogram; and STEMI, ST-segment–elevation myocardial infarction. Colors correspond to the Class of Recommendation in Table 1.
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46 Patients With Acute Chest Pain and Suspected ACS (Not Including STEMI)
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47 Patients With Acute Chest Pain and Suspected ACS (Not Including STEMI) (cont..)
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48 Figure 8. General Approach to Risk Stratification of Patients With Suspected ACS. ACS indicates acute coronary syndrome; CDP, clinical decision pathway; and ECG, electrocardiogram Colors correspond to the Class of Recommendation in Table 1.
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49 Table 6. Sample Clinical Decision Pathways Used to Define Risk
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50 Table 6. Sample Clinical Decision Pathways Used to Define Risk (cont..)
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51 Table 6. Sample Clinical Decision Pathways Used to Define Risk (cont..)
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52 Table 6. Sample Clinical Decision Pathways Used to Define Risk (con’t.)
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53 *The terms “very low,” “low,” “high,” “1 h ∆,” and “2 h ∆” refer to hs-cTn assay-specific thresholds published in the ESC guideline (46, 47). ACS indicates acute coronary syndrome; ADAPT, Accelerated Diagnostic protocol to Assess chest Pain using Troponins; AMI, acute myocardial infarction; CP, chest pain or equivalent; Cr, creatinine; cTn, cardiac troponin; hs-cTn, high-sensitivity cardiac troponin; ECG, electrocardiogram; ED, emergency department; EDACS, emergency department ACS; ESC, European Society of Cardiology; GRACE, Global Registry of Acute Coronary Events; HEART, history, ECG, age, risk factors, troponin; HR, heart rate; hs, high sensitivity; MACE, major adverse cardiac events; mADAPT, modified (including TIMI scores of 1) ADAPT; N.A., not applicable; neg, negative; NICE, National Institute for Health and Clinical Excellence; NOTR, No Objective Testing Rule; SBP, systolic blood pressure; SSACS, symptoms suggestive of ACS; Sx, symptoms; and ULN, upper limit of normal. Table 6. Sample Clinical Decision Pathways Used to Define Risk (con’t.)
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54 Table 7. Warranty Period for Prior Cardiac Testing CCTA indicates coronary computed tomographic angiography.
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55 Low-Risk Patients With Acute Chest Pain
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56 Table 8. Definition Used for Low-Risk Patients With Chest Pain
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57 Table 8. Definition Used for Low-Risk Patients With Chest Pain (con’t.) ADAPT indicates 2-hour Accelerated Diagnostic Protocol to Access Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarkers; cTn, cardiac troponin; EDACS, Emergency Department Acute Coronary Syndrome; HEART Pathway, History, ECG, Age, Risk Factors, Troponin; hs-cTn, high-sensitivity cardiac troponin; MACE, major adverse cardiac events; mADAPT, modified 2-hour Accelerated Diagnostic Protocol to Access Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarkers; NOTR, No Objective Testing Rule; NPV, negative predictive value; and TIMI, Thrombolysis in Myocardial Infarction.
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58 Intermediate-Risk Patients With Acute Chest Pain
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59 Intermediate-Risk Patients With Acute Chest Pain and No Known CAD
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60 Intermediate-Risk Patients With Acute Chest Pain and No Known CAD (con’t.)
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61 Intermediate-Risk Patients With Acute Chest Pain and No Known CAD (con’t.)
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62 Figure 9. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With No Known CAD. Colors correspond to the Class of Recommendation in Table 1.
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63 Test choice should be guided by local availability and expertise. *Recent negative test: normal CCTA ≤2 years (no plaque/no stenosis) OR negative stress test ≤1 year, given adequate stress. †High-risk CAD means left main stenosis ≥ 50%; anatomically significant 3-vessel disease (≥70% stenosis). ‡For FFR-CT, turnaround times may impact prompt clinical care decisions. However, the use of FFR-CT does not require additional testing, as would be the case when adding stress testing. CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed management and therapy; ICA, invasive coronary angiography; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission computed tomography. Figure 9. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With No Known CAD.
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64 Intermediate-Risk Patients With Acute Chest Pain and Known CAD
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65 Intermediate-Risk Patients With Acute Chest Pain and Known CAD (con’t.)
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66 Intermediate-Risk Patients With Acute Chest Pain and Known CAD (con’t.)
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67 Colors correspond to the Class of Recommendation in Table 1. Figure 10. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With Known CAD.
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68 Figure 10. Evaluation Algorithm for Patients With Suspected ACS at Intermediate Risk With Known CAD (con’t). Test choice should be guided by local availability and expertise. *Known CAD is prior MI, revascularization, known obstructive or nonobstructive CAD on invasive or CCTA. †If extensive plaque is present a high-quality CCTA is unlikely to be achieved, and stress testing is preferred ‡Obstructive CAD includes prior coronary artery bypass graft/percutaneous coronary intervention. §High-risk CAD means left main stenosis ≥ 50%; anatomically significant 3-vessel disease (≥70% stenosis). ║FFR-CT turnaround times may impact prompt clinical care decisions. CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed management and therapy; ICA, invasive coronary angiography; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission CT.
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69 High-Risk Patients With Acute Chest Pain
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70 High-Risk Patients With Acute Chest Pain (con’t.)
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71 Acute Chest Pain in Patients With Prior Coronary Artery Bypass Graft (CABG) Surgery
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72 Evaluation of Patients With Acute Chest Pain Receiving Dialysis
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73 Evaluation of Acute Chest Pain in Patients With Cocaine and Methamphetamine Use
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74 Shared Decision-Making in Patients With Acute Chest Pain
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75 Evaluation of Acute Chest Pain With Nonischemic Cardiac Pathologies
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76 Acute Chest Pain With Suspected Acute Aortic Syndrome
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77 Acute Chest Pain With Suspected PE
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78 Acute Chest Pain With Suspected Myopericarditis
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79 Acute Chest Pain With Suspected Myopericarditis (con’t.)
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80 Acute Chest Pain With Valvular Heart Disease
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81 Acute Chest Pain With Valvular Heart Disease (con’t.)
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82 Evaluation of Acute Chest Pain With Suspected Noncardiac Causes
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83 Table 9. Differential Diagnosis of Noncardiac Chest Pain
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84 Table 9. Differential Diagnosis of Noncardiac Chest Pain (con’t.)
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85 Table 9. Differential Diagnosis of Noncardiac Chest Pain (con’t.)
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86 Evaluation of Acute Chest Pain With Suspected Gastrointestinal Syndromes
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87 Evaluation of Acute Chest Pain With Suspected Anxiety and Other Psychosomatic Considerations
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88 Evaluation of Acute Chest Pain in Patients With Sickle Cell Disease
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89 Evaluation of Patients With Stable Chest Pain
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90 Figure 11. Pretest Probabilities of Obstructive CAD in Symptomatic Patients According to Age, Sex, and Symptoms. Colors correspond to the Class of Recommendation in Table 1. CAC indicates coronary artery calcium; and CAD, coronary artery disease.
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91 Low-Risk Patients With Stable Chest Pain and No Known CAD
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92 Low-Risk Patients With Stable Chest Pain and No Known CAD (con’t.)
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93 Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD
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94 Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD (con’t.)
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95 Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD (con’t.)
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96 Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD (con’t.)
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97 Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD (con’t.)
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98 Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD (con’t.)
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99 Figure 12. Clinical Decision Pathway for Patients With Stable Chest Pain and No Known CAD Colors correspond to the Class of Recommendation in Table 1.
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100 Test choice should be guided by local availability and expertise. *Test choice guided by patient’s exercise capacity, resting electrocardiographic abnormalities; CCTA preferable in those <65 years of age and not on optimal preventive therapies; stress testing favored in those ≥65 years of age (with a higher likelihood of ischemia). †High-risk CAD means left main stenosis ≥ 50%; anatomically significant 3-vessel disease (≥70% stenosis). CAD indicates coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed management and therapy; INOCA, ischemia and no obstructive coronary artery disease; PET, positron emission tomography; and SPECT, single-photon emission CT. Figure 12. Clinical Decision Pathway for Patients With Stable Chest Pain and No Known CAD (con’t.)
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101 Patients With Known CAD Presenting With Stable Chest Pain
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102 Patients With Obstructive CAD Who Present With Stable Chest Pain
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103 Patients With Obstructive CAD Who Present With Stable Chest Pain (con’t.)
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104 Patients With Obstructive CAD Who Present With Stable Chest Pain (con’t.)
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105 Patients With Obstructive CAD Who Present With Stable Chest Pain (con’t.)
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106 Figure 13. Clinical Decision Pathway for Patients With Stable Chest Pain (or Equivalent) Symptoms With Prior MI, Prior Revascularization, or Known CAD on Invasive Coronary Angiography or CCTA, Including Those With Nonobstructive CAD. Colors correspond to the Class of Recommendation in Table 1.
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107 Figure 13. Clinical Decision Pathway for Patients With Stable Chest Pain (or Equivalent) Symptoms With Prior MI, Prior Revascularization, or Known CAD on Invasive Coronary Angiography or CCTA, Including Those With Nonobstructive CAD (con’t.) Test choice should be guided by local availability and expertise. *Known CAD means prior MI, revascularization, known obstructive CAD, nonobstructive CAD. †High-risk CAD means left main stenosis ≥50%; or obstructive CAD with FFR-CT ≤0.80. ‡Test choice guided by the patient’s exercise capacity, resting electrocardiographic abnormalities. §Patients with prior CABG or stents >3.0 mm. Follow-up Testing and Intensification of GDMT Guided by Initial Test Results and Persistence / Worsening / Frequency of Symptoms and Shared Decision Making CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCTA, coronary CT angiography; CMR, cardiovascular magnetic resonance imaging; CT, computed tomography; ECG, electrocardiogram; FFR-CT, fractional flow reserve with CT; GDMT, guideline-directed management and therapy; ICA, invasive coronary angiography; iFR, instant wave-free ratio; INOCA, ischemia and no obstructive coronary artery disease; MI, myocardial infarction; MPI, myocardial perfusion imaging; PET, positron emission tomography; SIHD, stable ischemic heart disease; and SPECT, single-photon emission CT.
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108 Patients With Prior Coronary Artery Bypass Surgery With Stable Chest Pain
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109 Patients With Known Nonobstructive CAD Presenting With Stable Chest Pain
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110 Patients With Known Nonobstructive CAD Presenting With Stable Chest Pain (con’t.)
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111 Patients With Suspected Ischemia and No Obstructive CAD (INOCA)
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112 Patients With Suspected Ischemia and No Obstructive CAD (INOCA) (con’t.)
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113 Figure 14. Clinical Decision Pathway for INOCA. Colors correspond to the Class of Recommendation in Table 1.
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114 Test choice should be guided by local availability and expertise. *Ford T, et al. (16). †Cannot exclude microvascular vasospasm. ACh indicates acetylcholine; CFR, coronary flow reserve; CMD, coronary microvascular dysfunction; CFVR, coronary flow velocity reserve; CV, cardiovascular; FFR, fractional flow reserve; IMR, index of microcirculatory restriction; INOCA, ischemia and nonobstructive CAD; MACE, major adverse cardiovascular events; and MBFR, myocardial blood flow reserve. Figure 14. Clinical Decision Pathway for INOCA (con’t.).
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115 Abbreviations used in this Guideline
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116 Abbreviations used in this Guideline
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117 Abbreviations used in this Guideline
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118 Abbreviations used in this Guideline