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CME / ABIM MOC / CE

What Is New in the Updated Chest Pain Guidelines?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 12/23/2021
  • Valid for credit through: 12/23/2022
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, critical care clinicians, emergency medicine clinicians, family medicine/primary care clinicians, internists, nurses, pharmacists, and other members of the health care team who treat and manage patients with chest pain.

The goal of this activity is to describe updated recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients, based on a new joint clinical practice guideline released by the American Heart Association and American College of Cardiology.

Upon completion of this activity, participants will:

  • Assess the first 5 of the top 10 take-home messages for chest pain evaluation and diagnosis, based on the new American Heart Association and American College of Cardiology joint clinical practice guideline
  • Evaluate 5 additional take-home messages from the top 10 take-home messages for chest pain evaluation and diagnosis, based on the new American Heart Association and American College of Cardiology joint clinical practice guideline
  • Outline implications for the healthcare team


Disclosures

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Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Editor/CME Reviewer/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

CE Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

None of the nonfaculty planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.


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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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CME / ABIM MOC / CE

What Is New in the Updated Chest Pain Guidelines?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 12/23/2021

Valid for credit through: 12/23/2022

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Clinical Context

In the US, more than 6.5 million adults present to the emergency department (ED) each year with chest pain, whereas more than 4 million present to outpatient clinics. However, only 5% of these patients seen in the ED have acute coronary syndrome (ACS); more than 50% have a noncardiac cause of chest pain.

Study Synopsis and Perspective

Clinicians should use standardized risk assessments, clinical pathways, and tools to evaluate and communicate with patients who present with chest pain (angina), advises a joint clinical practice guideline released October 28 by American Heart Association (AHA) and American College of Cardiology (ACC).

Although evaluation of chest pain has been covered in previous guidelines, this is the first comprehensive guideline from the AHA and ACC focused exclusively on the evaluation and diagnosis of chest pain.

"As our imaging technologies have evolved, we needed a contemporary approach to which patients need further testing and which do not, in addition to what testing is effective," Martha Gulati, MD, from the University of Arizona, chair of the guideline writing group, told theheart.org | Medscape Cardiology.

"Our hope is that we have provided an evidence-based approach to evaluating patients that will assist all of us who manage, diagnose, and treat patients who experience chest pain," said Dr Gulati, who is also president-elect of the American Society for Preventive Cardiology.

The guideline was simultaneously published online October 28 in Circulation and the Journal of the American College of Cardiology.[1,2]

"Atypical" Is Out, "Noncardiac" Is In

Each year, chest pain sends more than 6.5 million adults to the ED and more than 4 million to outpatient clinics in the United States.

Yet among all patients who come to the ED, only 5% will have ACS. More than half will ultimately have a noncardiac reason for their chest pain, including respiratory, musculoskeletal, gastrointestinal, psychological, or other causes.

The guideline says evaluating the severity and the cause of chest pain is essential and advises using standard risk assessments to determine whether a patient is at low, intermediate, or high risk of having a cardiac event.

"I hope clinicians take from our guidelines the understanding that low-risk patients often do not need additional testing. And if we communicate this effectively with our patients, incorporating shared-decision making into our practice, we can reduce 'overtesting' in low-risk patients," Dr Gulati told theheart.org | Medscape Cardiology.

The guideline notes that women are unique when presenting with ACS symptoms. Although chest pain is the dominant and most common symptom for both men and women, women may be more likely to also have symptoms such as nausea and shortness of breath.

The guideline also encourages using the term "noncardiac" if heart disease is not suspected in a patient with angina and says the term "atypical" is a "misleading" descriptor of chest pain and should not be used.

"Words matter, and we need to move away from describing chest pain as 'atypical' because it has resulted in confusion when these words are used," Dr Gulati stressed.

"Rather than meaning a different way of presenting, it has taken on a meaning to imply it is not cardiac. It is more useful to talk about the probability of the pain being cardiac vs noncardiac," Dr Gulati explained.

No One Best Test for Everyone

There is also a focus on evaluation of patients with chest pain who present to the ED. The initial goals of ED physicians should be to identify whether there are life-threatening causes and to determine whether there is a need for hospital admission or testing, the guideline states.

Thorough screening in the ED may help determine who is at high risk vs intermediate or low risk for a cardiac event. An individual deemed to be at low risk may be referred for additional evaluation in an outpatient setting rather than being admitted to the hospital, the authors write.

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, they add.

"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 won't provide additional information; therefore, these tests should not be done just for the sake of doing them," Dr Gulati said in a news release.

"Appropriate testing is also dependent upon the technology and screening devices that are available at the hospital or healthcare center where the patient is receiving care. All imaging modalities highlighted in the guideline have an important role in the assessment of chest pain to help determine the underlying cause, with the goal of preventing a serious cardiac event," Dr Gulati added.

The guideline was prepared on behalf of and approved by the AHA and ACC Joint Committee on Clinical Practice Guidelines.

Five other partnering organizations participated in and approved the guideline: the American Society of Echocardiography, the American College of Chest Physicians, the Society for Academic Emergency Medicine, the Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance.

The writing group included representatives from each of the partnering organizations and experts in the field (cardiac intensivists, cardiac interventionalists, cardiac surgeons, cardiologists, emergency physicians, and epidemiologists), as well as a lay/patient representative.

This research had no commercial funding. A complete list of disclosures for the writing group is available with the original articles.

Circulation. Published online October 28, 2021. 

J Am Coll Cardiol. Published online October 28, 2021.

Study Highlights

  • The guidelines include top 10 take-home messages for chest pain evaluation and diagnosis.
  • Chest pain includes pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, but shortness of breath and fatigue should also be considered anginal equivalents.
  • High-sensitivity cardiac troponins are the preferred biomarker standard to diagnose acute myocardial infarction, allowing more accurate detection and exclusion of myocardial injury, and should be measured as soon as possible.
  • Patients with acute chest pain or anginal equivalent should seek immediate medical care by calling 911.
  • Most patients will not have a cardiac cause, but assessment of all patients should focus on early identification or exclusion of life-threatening causes.
  • Decision-making regarding testing should be shared with clinically stable patients presenting with chest pain.
  • To facilitate discussion, clinicians should provide information regarding risk for adverse events, radiation exposure, costs, and alternative options.
  • Cultural competency training should help achieve best outcomes in patients of diverse racial and ethnic backgrounds, and formal translation services may benefit those for whom English is not their primary language.
  • As there is no one "best test" for every patient, the guideline emphasizes which tests may be most appropriate, based on individual patient factors, and which tests are unlikely to give additional information and therefore should not be done.
  • Appropriate testing also depends on technology and screening devices available at the facility where the patient is receiving care.
  • All imaging tests described in the guideline are important in evaluating chest pain to help determine the underlying cause and thereby prevent a serious cardiac event.
  • Patients with acute or stable chest pain who are determined to be low risk do not routinely need urgent diagnostic testing for suspected CAD.
  • ECG should be performed for patients seen in the office setting with stable chest pain unless a noncardiac cause is evident.
  • All patients with acute chest pain in any setting should undergo ECG to be reviewed for ST-segment–elevation myocardial infarction within 10 minutes of arrival.
  • In the ED and outpatient settings, clinical decision pathways for chest pain should be used routinely.
  • Although chest pain is the dominant and leading symptom for men and women ultimately diagnosed with ACS, women may be more likely to present with accompanying symptoms such as nausea and shortness of breath and are therefore more at risk for underdiagnosis unless history taking enquires about these symptoms.
  • Similarly, in patients older than 75 years, ACS should be considered when accompanying symptoms include shortness of breath, syncope, acute delirium, or unexplained fall.
  • Clinicians should identify patients most likely to benefit from further testing.
  • Cardiac imaging and testing are most likely to benefit patients with acute or stable chest pain who are at intermediate or intermediate-to-high pretest risk for obstructive coronary artery disease.
  • The term "noncardiac" should be used if heart disease is not suspected (eg, from respiratory, musculoskeletal, gastrointestinal, psychological, or other causes); "atypical" is a misleading descriptor of chest pain and its use is discouraged.
  • Structured risk assessment should be used for patients presenting with acute or stable chest pain, using evidence-based diagnostic protocols to estimate risk for coronary artery disease and adverse events.

Clinical Implications

  • High-sensitivity cardiac troponins are the preferred biomarker standard to diagnose acute myocardial infarction.
  • Clinicians should identify patients most likely to benefit from further testing.
  • Implications for the Health Care Team: While chest pain can present in as more typical pain, pressure, and other similar symptoms, members of the healthcare team should consider shortness of breath and fatigue as anginal equivalents.

 

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