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New Guidelines for Evaluating, Diagnosing, and Treating Chest Pain in Adults

CardioSmart Contributors

By Sal Esposito; Arielle Abovich, MD, MPH; Roger S. Blumenthal, MD; Martha Gulati, MD

After injuries, chest pain is the primary reason for emergency department (ED) visits for adults in the United States, accounting for 1 in every 20 visits to the ED. Approximately 6.5 million visits to the ED and 4 million outpatient visits occur annually in the United States for chest pain.  Although the majority of chest pain is not cardiac, it is imperative that the cause of the patient’s chest pain is accurately determined.

For the first time, the American Heart Association (AHA) and the American College of Cardiology (ACC) have released a comprehensive guideline for the evaluation of chest pain. The AHA/ACC Chest Pain Guideline is a “clinical practice guideline for the evaluation and diagnosis of chest pain that provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.” 

National guidelines are revised as new information is obtained regarding various methods of diagnosis and treatment. Importantly, this is the first symptom-based guideline ever to be released by the ACC and AHA.

The term “chest pain” is a wide-ranging description of a sensation of discomfort or pain in the general anterior chest area, sometimes stretching also to the neck, arms, shoulders, back, upper abdomen, and even jaw. It is vital that the clinician and the patient are communicating clearly with each other and that the necessary time is taken to obtain a detailed history and physical exam to make the most accurate diagnosis.

When chest pain is caused by ischemia, or inadequate blood supply to the heart arteries, this is also labelled as ”angina.” Identifying angina is one of the chief concerns when discussing chest pain. Any chest pain that correlates with acute angina needs to be diagnosed and treated with urgency, as it may be an indication of an acute coronary syndrome (ACS) or heart attack, also called a myocardial infarction (MI).

Because differentiating between different types of chest pain can be nuanced, it is paramount for patients to share any associated symptoms and to describe their chest discomfort with as much detail as possible. Likewise, for clinicians, using the proper terminology to describe what a patient has explained is also important.

Vague terms such as “atypical” to describe chest pain can make it more difficult to obtain a clear diagnosis. Atypical chest pain is often used to describe symptoms that are noncardiac. To avoid confusion, further clarity is provided by terms such as “cardiac,” “possible cardiac,” and “noncardiac” to describe the suspected cause of chest pain and the authors recommended moving away from describing chest pain as “atypical.”

In their lifetimes, 20%-40% of Americans will experience prolonged chest pain, and women are more likely to experience this symptom than men. Women are less likely to “have timely and appropriate care” compared with men. This may be because women present with accompanying symptoms more often than men, or because women are more likely than men to experience and realize early signs of an issue before the major signs of a problem occur (prodromal symptoms).

It is of great importance that the associated symptoms more commonly experienced by women, including palpitations, jaw, neck, and back pain, in addition to underlying factors such as high blood pressure, high cholesterol, and family history, are taken into an evaluation and diagnosis.

Finally, the differentiation between the care of a patient with acute versus chronic, or stable, conditions is based on the risk of greater cardiac episodes. Stable chest pain is when symptoms have been present for an extended period of time and are exacerbated by exertion, both emotional and/or physical. Acute chest pain is new onset and varies in intensity, pattern, and duration.

Both acute and stable chest pain need to be evaluated by a clinician, and based on their findings, further testing may be pursued. The proper testing for a patient presenting with acute or stable chest pain is based on their risk of major coronary artery disease (CAD) events. Conducting the appropriate testing based on patient risk not only allows for faster identification of an accurate diagnosis, but it also prevents unnecessary testing, leading to more effective care.

Clear communication of chest pain descriptors and any associated symptoms by both patients and clinicians using the new AHA/ACC Chest Pain Guideline will likely lead to better utilization of testing, more accurate diagnoses, and quicker treatments, ultimately saving lives while decreasing health care costs.

Sal Esposito is a premedical student based out of Huntington Station, NY. Arielle Abovich, MD, MPH is an internal medicine resident at Johns Hopkins Hospital. Roger S. Blumenthal, MD, FACC, is Director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. Martha Gulati, MD, FACC, is the former Editor-in-Chief of CardioSmart.

Read the original article: “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,” Journal of the American College of Cardiology, Oct. 28, 2021.

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