AHA and ACC Issue Comprehensive Clinical Practice Guideline on Chest Pain

October 28, 2021—A 2021 guideline for the evaluation and diagnosis of chest pain from the American College of Cardiology (ACC) and the American Heart Association (AHA) offers a new approach to evaluate the source and symptoms of chest pain that can help clinicians improve patient outcomes and reduce health care costs.

The guideline was prepared on behalf of and approved by the ACC and AHA Joint Committee on Clinical Practice Guidelines. Five partnering organizations participated in and approved the guideline: the 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.

According to a press release from ACC, the document is the first comprehensive guideline from the AHA and ACC focused solely on the evaluation and diagnosis of chest pain. Evaluation of chest pain has been covered in previous guidelines. The new guideline recommends medical professionals use standardized risk assessments, clinical pathways, and tools to evaluate and communicate with patients experiencing chest pain.

The document by guideline writing committee Chair Martha Gulati, MD, et al has been published online in the Journal of the American College of Cardiology and the AHA’s Circulation. Phillip D. Levy, MD, and Debabrata Mukherjee, MD, served as Vice Chairs of the writing committee.

The ACC announcement noted that among all adults who come to the emergency department with chest pain, approximately 5% will have acute coronary syndrome (ACS) and more than half of patients will ultimately be diagnosed with a noncardiac reason for the chest pain symptoms, including respiratory, musculoskeletal, gastrointestinal, psychological, and other causes.

As summarized by the ACC, the new guideline advises that to evaluate the severity and the cause of chest pain, clinicians should use standard risk assessments to determine if a patient is at low, intermediate, or high risk for having a cardiac event.

Further, the document noted the following:

• Women are unique when presenting with ACS symptoms. Chest pain is the dominant and most frequent symptom for both men and women. However, women may be more likely to also exhibit accompanying symptoms such as nausea and shortness of breath.
• Emergency department professionals’ initial goals in evaluating patients with chest pain should be to identify if there are life-threatening causes and to determine if there is a need for hospitalization or testing.
• Thorough screening may determine which patients are at high risk versus intermediate or low risk for a cardiac event. Patients at low risk for a cardiac event may be referred for additional evaluation in an outpatient setting rather than being admitted to the hospital.
• Unnecessary or inappropriate testing for some adults with chest pain may be reduced, especially in the emergency department and for those patients screened as low risk for a cardiac event.
• Shared decision making by clinicians can reduce patient fear and concerns as well as reduce extra testing.

A patient-centered process in which clinicians share information and steps with patients as partners to reach a consensus about preferred tests and treatments. Research has shown that shared decision-making allows patients at low risk of serious health issues to participate actively in their care. The approach has also found fewer additional tests are performed with no differences in outcomes among low-risk patients, advised the ACC announcement.

“Everyone should know the symptoms that can indicate a heart attack and that calling 911 is the most important thing to do to save their life or that of their loved one experiencing chest pain,” commented Dr. Gulati in the ACC press release. “This standard approach provides clinicians with the guidance to better evaluate patients with chest pain, identify patients who may be having a cardiac emergency and then select the right test or treatment for the right patient.”

Dr. Gulati continued, “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. 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.”

Finally, Dr. Gulati stated, “While there is no one ‘best test’ for every patient, the guideline emphasizes the tests that may be most appropriate, depending on the individual situation, and which ones won’t provide additional information; therefore, these tests should not be done just for the sake of doing them. Appropriate testing is also dependent upon the technology and screening devices that are available at the hospital or health care center where the patient is receiving care. All imaging modalities highlighted in the guideline have an important role in the assessment of chest pain to help determine the underlying cause, with the goal of preventing a serious cardiac event.”