Many years of developing and waiting have led us to the latest guidelines published by ACC/AHA together with other societies. This is the first document exclusively dedicated to the assessment and diagnosis of acute chest pain. In this regard, we can safely say this is no mere update of a previous set of guidelines, but an original study written from scratch.
These guidelines incorporate the use of contemporary cardiac images which include coronary computed tomography angiography (CCTA) and coronary artery calcium testing. They also call for selective use of imaging and, of course, detail the factors to take into account when choosing between CCTA and a stress test.
These guidelines also emphasize that chest pain might also be experienced without pressure, tightness, or discomfort, and it might also be felt on shoulders, arms, neck, back, upper abdomen or jaw. Fatigue, shortness of breath and nausea should also be taken into account, particularly in women.
Ultrasensitive troponin are now the standard biomarkers for MI diagnosis. Others such as CK, Mb or total CK should be abandoned.
Patients admitted to the ER with chest pain and suspect acute coronary syndrome should be classified into low, intermediate, and high risk.
For intermediate risk patients with no known CAD, CCTA is recommended, to exclude CAD (class I level A).
If there was evidence of stenosis or the CT scan was not conclusive, functional flow reserve computed tomography (FFR-CT) can be used on a specific vessel, to clear any doubts.
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For intermediate risk patients, it also has a class I recommendation: a stress test with evidence level B.
For high-risk patients, it has a class I recommendation: an invasive angiography.
Patients al low risk, those with a 30-day risk of death or events lower than 1%, can be sent home with guidelines for them to watch for symptoms.
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Another change introduced by this study is removing the word “atypical” from the description and replacing it with “non-cardiac cause” when cardiac causes have been ruled out.
One other additional contribution of these guidelines is minimizing unnecessary studies which will eventually guarantee an event-free period in patients with chest pain. When both regular angiographies and CCTA do not show stenosis or plaque, there is a 2-year guarantee, while a normal stress test offers just one year.
j-jacc-2021-07-053Original Title: 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 of clinical practice guidelines.
Reference: Gulati M et al. Circulation. 2021 Oct 28;CIR0000000000001029. Online ahead of print. doi: 10.1161/CIR.0000000000001029.
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