In addition to today’s resource, please see and review:
- the outstanding YouTube lecture, The Role of Coronary CTA in the New Guideline Era, from Yale Cardiovascular Medicine Grand Rounds, 1:07:31, Jan 11, 2022, by Todd C. Villenes, MD.
In this post I link to and excerpt from
2021 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 on Clinical Practice Guidelines [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circulation. 2021 Nov 30;144(22):e368-e454. doi: 10.1161/CIR.0000000000001029. Epub 2021 Oct 28.
All that follows is from the above resource.
TOP 10 TAKE-HOME MESSAGES FOR THE EVALUATION AND DIAGNOSIS OF CHEST PAI
N1. Chest Pain Means More Than Pain in the Chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdo-men, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents.
2. High-Sensitivity Troponins Preferred. High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accu-rate 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 9-1-1. 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 risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.
5. Testing 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 evi-dence-based diagnostic protocols.
Figure 1 illustrates the take-home message
1.4.1. Scope of the Problem – Synopsis
After injuries, chest pain is the second most com-mon reason for adults to present to the emergency department (ED) in the United States and accounts for >6.5 million visits, which is 4.7% of all ED visits.1Chest pain also leads to nearly 4 million outpatient vis-its annually in the United States.2 Chest pain remains a diagnostic challenge in the ED and outpatient setting and requires thorough clinical evaluation. Although the cause of chest pain is often noncardiac, coronary artery disease (CAD) affects >18.2 million adults in the United States and remains the leading cause of death for men and women, accounting for >365 000 deaths annually.3 Distinguishing between serious and benign causes of chest pain is imperative. The life-time prevalence of chest pain in the United States is 20% to 40%,4 and women experience this symptom more often than men.5 Of all ED patients with chest pain, only 5.1% will have an acute coronary syndrome (ACS), and more than half will ultimately be found to have a noncardiac cause.6 Nonetheless, chest pain is the most common symptom of CAD in both men and women.
Synopsis
Chest pain is one of the most common reasons that people seek medical care. The term “chest pain” is used by patients and applied by clinicians to describe the many unpleasant or uncomfortable sensations in the anterior chest that prompt concern for a cardiac problem.
Chest pain should be considered acute when it is new onset or involves a change in pattern, intensity, or duration compared with previous episodes in a patient with recurrent symptoms.
Chest pain should be considered stable when symptoms are chronic and associated with consistent precipitants such as exertion or emotional stress.Although the term chest pain is used in clinical practice, patients often report pressure, tightness, squeezing, heaviness, or burning. In this regard, a more appropriate term is “chest discomfort,” because patients may not use the descriptor “pain.” They may also report a location other than the chest, including the shoulder, arm, neck, back, upper abdomen, or jaw. Despite individual variability, the discomfort induced by myocardial ischemia is often char-acteristic and therefore central to the diagnosis. For this reason, features more likely to be associated with ischemia have been described as typical versus atypical; however, the latter can be confusing because it is frequently used to describe symptoms considered nonischemic as well as noncardiac. Although other nonclassic symptoms of ischemia, such as shortness of breath, nausea, radiating discomfort, or numbness, may be present, chest pain or chest discomfort remains the predominant symptom reported in men and women who are ultimately diagnosed with myocardial ischemia.3-7 Pain—described as sharp, fleeting, related to inspiration (pleuritic) or position, or shifting locations—suggests a lower likelihood of ischemia.
Figure 2.Index of Suspicion That Chest “Pain” Is Ischemic in Origin on the Basis of Commonly Used Descriptors
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