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2021 Guideline for Chest Pain: Top 10 takeaways

Presented by
Prof. Martha Gulati, University of Arizona, USA
AHA 2021
The top 10 takeaways of the new 2021 Guideline for the Evaluation and Diagnosis of Chest Pain were presented by Prof. Martha Gulati (University of Arizona, AZ, USA) [1]. “Since chest pain accounts for 6.5 million visits to the emergency department (ED) in the US each year, guidelines to manage chest pain are essential,” Prof. Gulati stated. “Although only 5% of the chest pain is cardiac in nature, cardiac chest pain could entail life-threatening underlying disease. Therefore, cardiac chest pain is not to be missed during diagnosis.”
Top 10 takeaways

  1. Chest pain is more than pain in the chest. The shoulder area, jaw, epigastric area, neck, or back are included in the chest pain spectrum. Physicians should perform an initial assessment of chest pain to estimate the likelihood of symptoms being related to myocardial ischaemia (class 1) (see Figure).
Figure: Symptom presentation and probability of ischaemia [1]

  1. High-sensitivity cardiac troponin (hs-cTn) enables swift detection or exclusion of myocardial injury. Thus, hs-cTn is the preferred biomarker in patients presenting with acute chest pain (class 1). In addition, physicians need to be acquainted with the analytical performance and the 99th percentile upper reference limit that defines myocardial injury for the cTn assay at their facility (class 1).


  1. Patients presenting with symptoms of life-threatening causes of acute chest pain need to be transported to the ED with urgency, ideally by emergency medical services (class 1). Patients with stable chest pain should receive an ECG, unless a non-cardiac cause is apparent (class 1).


  1. In patients with acute chest pain and possible acute coronary syndrome (ACS) who have a low-risk profile, shared decision-making facilitates risk communication and increases understanding (class 1). Moreover, shared decision-making does not hamper outcomes.


  1. Patients who present with acute or stable chest pain and have a low-risk profile do not need to be tested routinely (class 1). Prof. Gulati emphasised this recommendation as the most important one in the new guideline.


  1. Patients with acute chest pain and possible ACS should be categorised in low-, intermediate-, and high-risk profiles by means of clinical decision pathways (CDPs) (class 1). Available clinical test results should be incorporated into the CDPs (class 1).


  1. Women with chest pain are at risk for underdiagnosis. Thus, it is recommended to assess for accompanying symptoms that are more prevalent in women with ACS, such as shortness of breath and nausea (class 1).


  1. Patients who are most likely to benefit from (further) testing should be identified. The chest guideline included CDPs to aid clinicians in the decision-making.


  1. The description of chest pain as ‘atypical’ is not helpful. Instead, chest pain should be classified as cardiac, possibly cardiac, or non-cardiac, since these terms are more specific to the underlying diagnosis (class 1).


  1. Finally, evidence-based diagnostic protocols should be used for the assessment of coronary artery disease and adverse events in patients with acute or stable chest pain, establishing a structured risk assessment.


    1. Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. CS.ME.495, AHA 2021 Scientific Sessions, 13­–15 November.


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