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Chest Pain:

Guidelines for evaluation and diagnosis

Chest Pain:

Guidelines for evaluation and diagnosis

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Chest Pain

A perspective from Prof. Girish Dwivedi, Chief Medical Officer at Artrya

With the publication of robust studies in chest pain subjects, quite deservingly CCTA has been recognised as the modality of choice (class 1 investigation) for investigating not only the intermediate/high risk stable chest pain population with no known CAD but also the intermediate risk acute chest pain population with known non-obstructive CAD as it can evaluate progression of atherosclerotic plaque and also determine any obstructive disease.

Indeed, with the availability of tools like Artrya Salix, we envisage increased utilisation of CCTA for risk stratification in such patients and that is strongly backed by scientific evidence.

Highlights

Visit the ACC guidelines hub for data, tools and reference documents.

Overview

The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently released their clinical guidelines from the ACC and AHA to focus solely on evaluating and diagnosing adult patients with chest pain.

The guidelines provide recommendations and algorithms for conducting initial assessments, general considerations for cardiac testing, choosing the right pathway for patients with acute chest pain, and evaluating patients with stable chest pain.

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain, published Oct. 28 in both the Journal of the American College of Cardiology and Circulation, offers "an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain," while also incorporating cost-value considerations in diagnostic testing and shared decision-making with patients.

The authors Gulati et al. including Vice-Chairs Phillip D. Levy, MD, MPH, FACC, and Debabrata Mukherjee, MD, MS, FACC, note that

Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pretest risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.

The guidelines present CCTA as Class I recommendations and recommend that intermediate-risk patients undergo non-invasive anatomic and stress testing with various modalities preferred according to whether the pain is acute or stable and whether coronary artery disease is known.

BENEFIT >>> RISK
Suggested phrases for writing recommendations:
  • Is recommended
  • Is indicated/useful/effective/beneficial
  • Should be performed/administered/other
  • Comparative-Effectiveness Phrases†:

- Treatment/strategy A is recommended/indicated in
preference to treatment B

- Treatment A should be chosen over treatment B

COR and LOE are determined independently (any COR may be paired with any LOE).

A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).

† For comparative-effectiveness recommendations (COR 1 and 2A; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

‡ The method of assessing quality is evolving, including the application of standardised, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.

COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomised: R, randomised; and RCT, randomised controlled trial.

Clinical Decision Pathways for patients with stable chest pain:

Among patients at intermediate-high risk with stable chest pain and no known CAD, CCTA is useful for diagnosing CAD and for risk stratification; and stress imaging (echocardiography, myocardial perfusion imaging (MPI), or cardiac magnetic resonance (CMR)) is useful for the diagnosis of ischemia and for estimating the risk of Major Adverse Cardiac Event (MACE).

∗Test choice guided by patient’s exercise capacity, resting electrocardiographic abnormalities; CCTA preferable in those <65 years of age and not on optimal preventive therapies; stress testing favored in those ≥65 years of age (with a higher likelihood of ischemia). †High-risk CAD means left main stenosis ≥50%; anatomically significant 3-vessel disease (≥70% stenosis).

Among patients with known non-obstructive CAD and stable chest pain despite Guideline Directed Medical Therapy (GDMT), CCTA or cardiac stress testing is reasonable.

∗Known CAD means prior MI, revascularisation, known obstructive CAD, nonobstructive CAD. †High-risk CAD means left main stenosis ≥50%; or obstructive CAD with FFR-CT ≤0.80. ‡Test choice guided by the patient’s exercise capacity, resting electrocardiographic abnormalities. §Patients with prior CABG or stents >3.0 mm. Follow-up Testing and Intensification of GDMT Guided by Initial Test Results and Persistence / Worsening / Frequency of Symptoms and Shared Decision Making.

Clinical Decision Pathways for patients with acute chest pain:

Among patients with acute chest pain at intermediate risk (patients without high-risk features and not classified as low risk) and no known coronary artery disease (CAD), additional testing can include functional testing (exercise ECG, stress echocardiography, stress nuclear MPI, or stress CMR imaging) or anatomic testing CCTA.

∗Recent negative test: normal CCTA ≤2 years (no plaque/no stenosis) OR negative stress test ≤1 year, given adequate stress. †High-risk CAD means left main stenosis ≥ 50%; anatomically significant 3-vessel disease (≥≥70% stenosis). ‡For FFR-CT, turnaround times may impact prompt clinical care decisions. However, the use of FFR-CT does not require additional testing, as would be the case when adding stress testing.

Among patients with known CAD and acute chest pain at intermediate risk, additional testing can include functional testing or CCTA in the setting of non-obstructive CAD; functional testing in the setting of known obstructive CAD; or invasive coronary angiography (ICA) in the setting of known left main disease, proximal vessel CAD, or multi-vessel CAD.

∗Known CAD is prior MI, revascularisation, known obstructive or nonobstructive CAD on invasive or CCTA. †If extensive plaque is present a high-quality CCTA is unlikely to be achieved, and stress testing is preferred ‡Obstructive CAD includes prior coronary artery bypass graft/percutaneous coronary intervention. §High-risk CAD means left main stenosis ≥50%; anatomically significant 3-vessel disease (≥70% stenosis). ‖FFR-CT turnaround times may impact prompt clinical care decisions.

In an interview with TCTMD, Ron Blankstein, MD (Brigham and Women’s Hospital, Boston, MA), one of the guideline authors, said the recommendations for cardiac testing are “revolutionary” in that they are built on a comprehensive and critical evaluation of high-quality imaging evidence.

CT angiography has certainly moved up in the guidelines, but the concept of one modality moving up at the expense of another modality is not correct.

Other modalities didn’t move down because CT angiography moved up. The reality is that CT now has stronger level of evidence than other modalities. Ultimately, though, the concept is that with imaging, depending on the scenario, there are a lot of options.

Top 10 Takeaways from Updated ACC Guidelines

  1. Chest pain means more than pain in the chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue, should all be considered anginal equivalents.
  2. High-sensitivity troponins are preferred. High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.
  3. Early care for acute symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling an ambulance. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes.
  4. Share the decision-making. Clinically stable patients presenting with chest pain should be included in decision-making; information about the risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.
  5. Testing is not needed routinely for low-risk patients. For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed.
  6. Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.
  7. Accompanying symptoms. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with Acute Coronary Syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath.
  8. Identify patients most likely to benefit from further testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.
  9. Noncardiac is in. Atypical Is Out. “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use is discouraged.
  10. Structured risk assessment should be used. For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols.

Artrya Salix helps clinicians easily assess CAD at the point of care in Medical Imaging practices.

Our artificial intelligence solution detects stenosis, plaque composition, and additional meaningful biomarkers of coronary artery disease (CAD).

The Salix algorithm has been trained on thousands of existing scans. From a single patient scan, each artery is assessed independently and visualised in a precise 3D model.

The report is automatically completed in real-time, at the point of care in medical imaging practices. This reduces the reporting time from days and hours to within 15 minutes.

Salix unlocks the capability to triage patients into risk categories, helping clinicians identify which patients require further clinical assessments.

Detailed assessments of the major arteries (LM, LCX, LAD and RCA) and sub-branches are provided, offering healthcare professionals instant access to critical information.

A structured report to international standards with key coronary findings is presented on a single screen for ease of use.