With the endorsement of multiple medical societies, the American College of Cardiology (ACC) and the American Heart Association (AHA) recently published the first clinical guideline devoted to the evaluation and management of adult patients presenting with a complaint of chest pain. The guideline provides contemporary, much-needed clarity for standardizing clinical evaluation, risk stratification, and diagnostic testing to manage the 95% of patients who ultimately do not require an emergent trip to the cardiac cath lab.
The First of Its Kind
With an estimated 6.5 million emergency department (ED) visits attributed to chest pain each year—visits that contribute significantly to the burden on US hospital EDs—it may seem surprising that this is the first clinical guideline aimed at the evaluation and management of chest pain in adult patients. However, it’s important to understand the context of our historical approach.
How Did We Get Here
Driven by a mission to reduce death and disability related to acute cardiac events, EDs in the US have employed “rapid rule out” strategies aimed at identifying and mitigating evolving or imminent myocardial injury events due to acute coronary syndrome (ACS). This mission has been very successful, producing highly effective, integrated STEMI systems of care that have reduced mortality and morbidity related to acute myocardial infarction. However, with tens of millions of ED visits in the rearview mirror, we now know that ACS is not the source of the complaint in the vast majority of the 6.5 million annual ED visits related to chest pain. In fact, more than half of these visits have a noncardiac source.
Toward a New Approach
Advances in cardiac imaging and pharmacology are fueling a contemporary approach to screening, prevention, early identification, and management of coronary artery disease (CAD). Clinical cardiologists armed with tools to evaluate both the anatomic and functional implications of CAD are able to provide patients with a highly individualized plan of care aimed at preventing disease progression and acute cardiac events.
What the Guideline Means for Your Organization
The ACC and AHA have provided the top-10 take-home messages from their guideline. Summarized below, these 10 key points have direct implications for CV programs. As a helpful memory aid, the first letter of each numbered message spells out the words “CHEST PAINS.”
1. Chest Pain Means More Than Pain in the Chest
There should be a continued emphasis on care team education related to anginal equivalents, cultural and ethnic perspectives, disparities in care, and the importance of active listening.
2. High-Sensitivity Troponins Preferred
Although troponin biomarkers have long been the standard of care, your program should implement high-sensitivity troponin testing if it is not already in place.
3. Early Care for Acute Symptoms
Activation of the 911 emergency system should remain a high priority due to the possibility of life-threatening causes of chest pain.
4. Share the Decision-Making—New
The ability to provide a highly individualized plan of care for CV patients creates an imperative for shared decision-making, which will incorporate patients’ values and improve their understanding of risks and benefits.
5. Testing Not Needed Routinely for Low-Risk Patients—New
This guidance has great significance for CV programs and health systems. Patients who previously might have been placed in a bed for observation pending testing may now be discharged for follow-up evaluation. However, added emphasis must be placed on the standard and consistent use of clinical decision pathways, clinical evaluation, and risk stratification in the ED. Clinical decision pathways should be expanded to guide patients’ follow-up referral for further evaluation and testing in the ambulatory setting when required. Community resources and referral processes for prevention and wellness programs should be considered in strategic planning for the CV program if not already in place.
6. Pathways
Evidence-based clinical decision pathways for chest pain should be used in the ED and ambulatory settings. While this guidance is not new, it is important to ensure your program has implemented a multidisciplinary approach to managing and using the pathways, including a process to monitor compliance and clinical outcomes related to use of the pathways.
7. Accompanying Symptoms
There should be continued emphasis on and awareness of gender variations in presentation, as women are more likely to present with symptoms that accompany chest pain, such as nausea and shortness of breath.
8. Identify Patients Most Likely to Benefit from Further Testing—New
New guidance on further testing includes the type and modality of testing, based on risk stratification for obstructive CAD. CV programs should review the recommendations in order to assess community access to traditional and advanced cardiac imaging modalities.
9.“Noncardiac” Is In, “Atypical” Is Out—New
The new guideline points out that “atypical” is a misleading descriptor of chest pain and should be avoided, which may also help programs mitigate coding issues that impact clinical outcome reporting. Educating cardiology and hospital-based providers about this guidance is recommended.
10. Structured Risk Assessment Should Be Used—New
This guidance clarifies the standardization of risk stratification for patients presenting with acute or stable chest pain to estimate the risk of CAD and adverse events. CV programs should incorporate the guideline to ensure evidence-based decision-making is used to sequence diagnostic testing.
The ACC and AHA have provided a CHEST PAINS informatic for ease of keeping these take-home messages front of mind for your care team.
Looking Ahead
The strategies we have historically used to quickly identify potentially life-threatening STEMI events have not changed. However, if the new ACC and AHA clinical guideline is formally implemented and applied to the management of the chest pain population in the ED, organizations may benefit from safely reducing unnecessary observation stays, while ensuring patients can receive follow-up care from the right provider, at the right time, and in the right location.
Published February 2, 2022