The American Heart Association/American College of Cardiology (AHA/ACC) have jointly released the first clinical practice guideline on evaluation of chest pain.¹

A heart attack classically presents as chest pain in both men and women. But a heart attack may also present as pain in the shoulders, arms, jaw, neck, back and upper abdomen. Women in particular are more likely to have accompanying symptoms such as nausea and shortness of breath, which must be enquired about when eliciting history. Patients with chest pain must seek immediate medical attention as it could mean a heart attack.

The guideline reiterates that not all chest pain is due to a heart disease. Chest pain may also have “non-cardiac” causes and may be a symptom of respiratory, musculoskeletal, gastrointestinal, and psychological conditions.

The guideline recommends using the term “non-cardiac” in place of “atypical” as it may be misleading and implies that it is not cardiac. “Chest pain should not be described as atypical, because 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”. Look for noncardiac causes if the symptoms persist and cardiac evaluation is negative, says the guideline.

Patients who present to the ER with chest pain should be evaluated for life-threatening causes and risk stratification done using a clinical decision pathway to determine the need for hospitalization or diagnostic evaluation. A focused cardiovascular examination will help identify the potentially fatal causes of chest pain such as pulmonary embolism, aortic dissection etc.

High sensitivity cardiac troponin is the standard test used to quickly diagnose an acute heart attack. Regarding testing, the experts say, “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 wont provide additional information; therefore, these tests should not be done just for the sake of doing them.” Shared decision-making is recommended as it allays patient fear and concerns and reduces extra testing.

The guideline has 10 key messages for physicians that must be considered when evaluating a patient with chest pain.

1. “Chest pain means more than pain in the chest.
2. High-sensitivity troponins preferred.
3. Early care for acute symptoms.
4. Share the decision-making.
5. Testing not needed routinely for low-risk patients.
6. Pathways.
7. Accompanying symptoms
8. Identify patients most likely to benefit from further testing.
9. Noncardiac is in. atypical is out.
10. Structured risk assessment should be used.”

The guideline has been published simultaneously in the journal “Circulation” and “Journal of the American College of Cardiology”.

Reference

1. Gulati M, et al. 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.