Martha Gulati, MD, MS, FACC, FAHA, FASPC, FESC, discusses 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain.
But I'm gonna be talking to you today about the chest pain guidelines that were released late in 2021. I have no disclosures And let's start with just a little bit of history. The first documented description of chest pain or Angina was by her burden in 1772. And he describes it quite dramatically. And of course in that time they didn't have many treatments for this. So, understandably, it was a bit dramatic, but those who are afflicted with it are seized while they're walking or especially if it be uphill or soon after eating with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life if it were to increase or to continue. But the moment they stand still, all this uneasiness spanish is and he goes on to describe it further talking about that if for no accident interferes, but the disease goes on to its height, the patients all suddenly fall down and perish almost immediately. Well, these descriptions have, you know, to some degree haven't changed that much in terms of our description of Angina. The difference is, though, is that we have not until 2021 actually had guidelines that have helped us understand the work up for patients who present with chest pain. We certainly have guidelines when there's a diagnosis, but not symptom based guidelines. So, these were the first symptom based guidelines from the American College of Cardiology and the american heart association and chest pain is obviously incredibly common. It's one of the most common reasons patients seek care. There's 6.5 million emergency department visits and about four million office visits and of course, what we're trying to determine is if it's a life threatening cause first and foremost and then determining how we will deal with acute chest pain versus stable chest pain. But the reality of the situation remains that the most of the people end up having a diagnosis of non specific chest pain regardless of age group. And of course, with greater age, there's more coronary atherosclerosis or myocardial infarction notice, but again, non specific chest pain is the most common diagnosis that they leave with in our emergency rooms. Now the priorities is, as I said, when someone presents with chest pain to the emergency department is to find out if it's a life threatening cause. And of course, using a good history will be an important part of working up chest pain because there's characteristics of the chest pain that help us determine what is the most likely cause. And as a cardiology community, of course, we are looking for cardiac characteristics in the chest pain that we are well established in the literature. But of course we care about other things beyond acute coronary syndrome or even aortic dissection. We have to rule out the risk of a pulmonary embolism or other non vascular emergent causes. And so the differential is wide and varied even with acute chest pain. Again, the emergent causes have some classical symptoms and signs that might help us determine one of these is present over the other, but also to not mistake it with other other causes that may not be as serious. So, we made our story about the chest pain guidelines are top 10 messages if you will, but using the acronym chest pains, um, and it may be a little too cutesy, but if we really did take into account our top messages that we wanted to get out, so I'm going to go through these. So the first one is is that chest pain means more than pain in the chest. And when we were assigned with the chest pain guidelines, some people weren't that happy with the title of them because they were like saying, you know, chest pain isn't always what we hear and it isn't just chest pain. Of course, it can be pain in the shoulder, the jaw, the epic gastric or neck or back. But what we also knew is there's not just one symptom that tells us whether it's cardiac or non cardiac and are in it assessment of chest pain is to triage the patient effectively on the basis of the likelihood of the symptoms being related to ischemia. And we described what we thought were the high probability of ischemia symptoms versus the lower probability symptoms of ischemia. And of course, there's not just one specific word that a patient will use, that guarantees that this is a schematic or non ischemic, but we have to still really lie on our history taking and that's why that will never be removed from an evaluation of a patient of chest pain. Now it is true. Sometimes people have a clear and glaring non cardiac cause, but we don't all take care of vampires. We also focused in the guidelines about special populations and populations that we have ignored in the past. These include women, but I'm going to talk about women a little bit later, but the elderly and people who are ethnically diverse. All three groups have we know we have data that have shown that people are under diagnosed and undertreated for elderly patients. We want people to remember that patients who present with symptoms such as shortness of breath or sink copy or even when they present with an unexplained fall. We should think about acute coronary syndromes in that population. We have a class one recommendation that cultural competency training is recommended. This will help us achieve the best outcomes in our patients. And of course when patients don't speak english, when it's not their first language. We should address barriers in care by using formal translation services with our patients to really get the nuance of what symptoms they're experiencing and not to rely on the use of family members at the bedside that will never really help us make a diagnosis. Our next letter, stand, the H stands for high sensitivity troponin. It's here with high sensitivity components are preferred. But proponents in general are what are preferred. That's a class one recommendation. Most hospitals in the United States have transition to high sensitivity troponin and we have more data about its specificity and its ability to help us with rapid detection or exclusion of myocardial Action. It increases the diagnostic accuracy. That is why we give it a class one recommendation. Now, we can't say that from one hospital to another hospital, even if they're across the street from each other, what their 99th%ile upper reference will be. You need to be aware of your own institutions essay and use that for cutoffs. And some hospitals we use sex specific cutoffs and some will not. But it is a Class 33 recommendation that there is no benefit anymore using CK MB or myoglobin when we're trying to diagnose acute myocardial ischemia. Our next letter is the E. And it stands for seek seek care early for acute symptoms. So it's a class one recommendation that patients with evidence of acute coronary syndrome should be seen quickly and be transported to the emergency department even when they're seen in an office setting. And unless a non cardiac causes evidence, an E K G should be performed in the office setting. But if an E K G is unavailable, patient should be referred to the emergency department where one could be obtained very quickly. Those are Class one recommendations we should not harm a patient by delaying the care waiting for cardiac proponents in an office setting if you suspect acute coronary syndrome. The point is is to get them into the emergency department as soon as possible and again you know when they we also were asked to address timing of the E. K. G. And we have data showing that especially for S. T. Elevation, myocardial infarction. We want to rule that out quickly and that's why the K. G. Should be done within 10 minutes of arrival. In terms of how quickly proponents should be done. It is impossible for us to give a time. They should be done as soon as possible when you suspect acute coronary syndrome. But the timing of that is not entirely clear by our modern literature. So of course after history physical exam in E. K. G. Is the next part of the work up. Class One recommendation. It helps us rule out S. T. Elevation. Myocardial infarction of course. And then it also helps with other diagnosis is like if you diagnose pericarditis, you might treat that if the S. T. Or T. Wave inversions, you follow the non S. T. Elevation A. CS guidelines. If it's non diagnostic you might repeat it or you might do a reverse lady K. G. And of course you might diagnose a new arrhythmia with an E. K. G. And of course then you would follow the treatment for that and of course a chest X ray has not been somehow disappeared with our newer technologies. We still think a chest X ray can be useful to help evaluate for other potential cardiac causes but also pulmonary and thoracic causes of someone's symptoms. And so it still remains a class one recommendation. The next letter stands for share the decision making and our class one recommendation is that when patients present with acute chest pain and suspected a CS and when they're deemed low risk by clinical decision pathway patient decision aids will be beneficial to improve understanding for the patient and effectively facilitate risk communication. We are actually one of the few guidelines that actually has research randomized control trial data on shared decision making and Dr ERic Hess who was one of the co authors on these guidelines has led a lot of this research where they showed that patients who are low risk when you use the clinical decision aid with the patient to help them understand their risk. They actually improve the patient's understanding and the patient would often choose not to do any additional testing Because when they were gamed low risk they understood the risk. And they also chose not to have additional testing. And that group of people did not do worse despite them not undergoing additional testing. That's always the concern in our emergency department. Right. The reason that they want to do tests is to not harm any patients. So again, when we know a patient's low risk, we can actually help communicate this information effectively to them. And this is was from dr Hesse's work using these tools, they shared decision making tools, communicating effectively with a patient, a patient doesn't understand percentages. What they understand is if you're showing them some figure like this, that out of all these people to people will ultimately have a problem and this can help them better understand their own personal risk and put it in a meaningful way that they understand. So if our emergency room started using this tool, I think more effectively patients who are low risk, who we know don't need additional testing will ultimately choose not to get additional testing. And that's why our other recommendations that testing is not routinely needed In low risk patients. Again, low risk is defined as people who have a 30 day risk of death or major adverse cardiovascular events. That is less than 1%. Those are the people that we call low risk and that's a class one recommendation from our guidelines. So once you know that, you know, using clinical decision pathways will help us, it will help us stratify patients to low risk to high risk and intermediate risk and again, the low risk patients, we may choose not to do any additional testing, especially with shared decision making, high risk patients would go for invasive angiography, but intermediate risk. And if we all know what we're talking about, that can be very valuable because that's usually when they call cardiology. So it's a class one recommendation to use these clinical decision pathways to categorize adequately our patients and when you have previous testing available, you should make use of it. If they've already undergone some testing to help you choose perhaps the next test. Clinical decision pathways have a lot of different names. They've been called accelerated diagnostic protocols or disposition pathways. We wanted to unify the terminology. So we now call them clinical decision pathways. And again, if you know what your emergency room uses and in the United States, most emergency rooms use the heart but they may use any of these pathways and we just need to know what the emergency room uses so that we can effectively communicate with them so that we know are they stratify ng from low risk intermediate risk or high risk or they just saying we can identify low risk and everyone else is in the other category, whatever their use. So we, I think the emergency room and the cardiologists are talking the same language will always understand when they're calling us for additional assistance. And again, identifying those low risk patients specifically will help the emergency room not have a burden of patients there and not even need to call cardiology to make those decisions. Now, I promised to come back a little to talk a little bit about women and one of our recommendations is talking about the accompanying symptoms that occur frequently in women. First of all, it's important to point out that women who present with chest pain are at risk for many years. We've known this at risk of under diagnosis and ultimately potential cardiac causes should be considered because it's the leading cause of death in women as it is in men. So that's a class one recommendation. But when we take a history and a woman it's important to understand that a woman might present with chest pain but they also might present with three or more additional symptoms. And we have a significant body of contemporary data showing that the accompanying symptoms often are there with the chest pain. And we should be thinking about acute coronary syndrome even when chest pain is only a minor or a very small component of what they're reporting. The next letter stands for identifying patients most likely to benefit from further testing and this is really for intermediate risk patients when they present with acute chest pain. Making a decision about what type of tests they need and if they've had prior testing incorporating that into your evaluation. Now, as you can see, we give a class one recommendation to C. C. T. A. Or an atomic testing. And we also gave a class one recommendation to functional testing any of the stress testing modalities. Again, you will always use what's available in your emergency room or available in your setting when you're about evaluating acute chest pain. You will also rely on the expertise in your hospital or your institution. So, and you also want to rely, know what they've had done in the past to make decisions about what is the next test. And whether we're talking about acute chest pain or hear stable chest pain, same thing goes now. It's important to know that we downgraded exercise E K. G. Because we know that we're again we get more information from stress testing with imaging than we do with exercise E K. G um in these intermediate risk patients. And I think that with exercise E K. G alone often we don't fully get our answers. But again, understanding these pathways is important. And here's just a summary of what those figures say again, for acute chest pain on the left and stable chest pain on the right. And again, we don't recommend that people who are asymptomatic have any tests. And that's why again, these guidelines are specific for people experiencing chest pain or chest discomfort. So the question that we often get is does my patient need further testing. You know, this is in our clinical setting and also can be in the emergency room, but again, in our in our stable chest pain, we know with the United States, we are doing testing in very low risk patients in our contemporary literature compared to older literature. And so you can see really the only high risk group or intermediate to high risk group is patients over the age of 70 who are male and then their intermediate risk group is some of the older ages and include men and women. But again the younger you are the lower the risk you are. So there is options for different type of testing and with stable chest pain and no known coronary disease. Again as I told you you can use an atomic testing or stress functional testing or stress testing. Now we gave a class one a recommendation for an atomic testing because there's so much contemporary literature right now showing that C. C. T. A. Is effective for the diagnosis of coronary artery disease also for risk stratification and for guiding our treatment decisions. But that isn't to belittle functional testing. Certainly functional testing is highly effective for diagnosing myocardial ischemia. And so we should be using that if that is what is used in your setting. But we should obviously our questions might lead us to choose one over the other. So that's just what I have shown you earlier before. But again you you might want to use C. C. T. A. Because you're trying to rule out obstructive disease. Maybe if they're younger population where you can younger people are less likely to have coronary disease. And obviously if you've had a prior functional test that was inconclusive then you would choose C. C. T. A. Versus stress testing. If you're doing a skeptic guided management then you might choose that if they're older or if they've had a prior C. C. T. A. That's inconclusive or you suspect scar or you suspect microvascular dysfunction. There may be reasons that you use functional testing and again local availability, expertise, patient characteristics, shared decision making with our patients. If you need exercise information you're going to use stress testing and again other reasons you would choose specific test. Again we did make a recommendation that if you have pet it's actually preferred over respect. We know its quality of image imaging is superior. And again this is just a summary of that table of which test to use when you're using a different type of stress test. We were also asked to try to address cost. It was very challenging and we were not able to say conclusively that one type of test is more cost effective than another because not every testing modality has been compared to each other. We summarize what we knew. For example for C. C. T. A. For example when you compare just two angiography obviously it proves to be cost effective exercise. E. K. G. Again compared to other types of testing has been proven to be cost effective but you can say this for really anything any imaging modality depending on what they compared themselves to. We have some cost effective information but not a way to say that one test is superior to all in when you're talking about costs. Other decisions about what test choice you would use, especially for women of childbearing age is obviously for everyone. We want to use the lowest effective dose of radiation, but for pregnant women, specifically, the only reason you should use something with radiation is really if the benefit outweighs the risk. And you should probably think about alternative test if you can get your answer from there, like cardiac MRI or echocardiogram, because it's obviously a safer alternative. Now, back to women a little bit, you know, although this is really not only to women, but we gave a recommendation that non cardiac is in and atypical is out. Atypical chest pain is a word that or words that have been used in the medical community for way too long. In my opinion. When people say typical, they don't mean it's a different presentation than normal. What they mean is they don't think it's cardiac. And we see that often communicated when women present whether they have the symptoms that you would expect or not. So we really want to get rid of these words because we actually know from contemporary literature that 90% of men and women both have quote unquote typical symptoms if you think the chest pain is cardiac, say it. If you think it's non cardiac, say it, and if you think it's possibly cardiac say it, those are Class one recommendations for how you should describe chest pain, but certainly class one recommendation is also to not describe chest pain as a typical because it's not helpful and can be misinterpreted as benign. Just to quickly show you some of that literature from the Virgo study of young men and young women under the age of 65. We are 55. Sorry, we did not know a lot about them until the Virgo study really collected that data and showed that 90% of men and women reported chest pain in these young population. The difference between women compared to men was that women had more accompanying symptoms. And even in Virgo we saw that women who sought care prior to the M. I. Were more likely to be told it was not cardiac. Now from all age group, the high stakes group from the U. K. They also looked at the And for those who went on to have a myocardial infarction, they actually showed that more women than men had what you would call typical symptoms. And the air may study that used cardio linguistic technology. It listened in used artificial intelligence in the communication between the patient and the physician. And they also found that 90% of men and 90% of women reported chest pain. So we really need to get away from this idea that women don't say chest pain. It's just that women are more likely to report accompanying symptoms and usually three or more accompanying symptoms. So we need to be listening to what a woman says to all her words. Certainly the last of our top 10 is that structured risk assessment should be used and that's what we hope we've laid out for you for both acute chest pain and stable chest pain so that using this evidence-based diagnostic protocol should improve the care of the patients that present every day with chest pain. Now some new concepts in our guidelines is that we define coronary artery disease to include both obstructive and non obstructive coronary disease. And then also we have hidden in the guidelines a little bit about prevention. First of all, when people have known coronary disease, we should always focus on guideline director medical therapy and optimizing their therapy when they present with chest pain. We also talk about the role of coronary calcium and exercise treadmill testing when assessing a. S. CVD risk in a person who presents with chest pain but is deemed to be low risk that they still need risk stratification. And again, another part of our guidelines is focused on non obstructive coronary disease which is part of coronary artery disease. So when you know it's obstructive, I think we've all been dealing with that for a while but we really needed in the guidelines something to tell what to do with the patients who have ischemia with no obstructive coronary arteries. So we provided that pathway. You can do invasive testing in the cath lab if you do this in your hospital. We know not every hospital does though invasive coronary function testing. So you can also use cardiac imaging as well. But for patients with Anoka having a diagnosis made can improve their outcomes and improve their symptoms. As it has been shown by core Michael, which is where we took specifically the invasive coronary function testing, which was a randomized trial and that patients who underwent coronary functional testing actually did better than those who did not undergo that procedure. So hopefully now in the future anoka evaluations will occur. So our guidelines, what did they provide provided updated randomized trials. It provides new terminology. We want you to eliminate the word a typical we've redefined coronary artery disease. We also hope we've provided a way for people to avoid unnecessary testing because I think that that has been a big concern in our emergency department and by our emergency department colleagues. But even in our clinical setting and of course we recommend and emphasize guideline directed medical therapy when you know somebody has coronary disease. Now there is some gaps in some areas that we need to work on for the future. Certainly we want to close gaps in care like delays from symptoms to onset and those studies are ongoing. Certainly when you make a diagnosis of Anoka Anoka, we still need to know how to optimally treat these patients. And so that's ongoing work in terms of symptom classification. I think machine learning may help us like the Army study has shown us but we need to replicate that and we also need to see if our clinical stratification tools actually improve outcomes and if they streamline care. We also have questions about high sensitivity proponents that have not been used that long in the United States for us to know their entire utility or if we're over diagnosing in our specific population. So with that I would just like to acknowledge my entire writing group that is listed here. This was a team sport and couldn't have done it without all my great colleagues that are on this including my two co chairs dr Phil levy and dr Deb Mukherjee as well as the joint committee and the staff as well as our endorsing societies. And if you need any resource, I just guide you to either the chest pain hub at the sec website or at the age a heart dot org. That has a lot of these um slides and and different templates for you to use and also our apps. We have three different apps that are available at A C. C. And on the appstore as well. Free for use and of course patient information from cardio smart that you can use as well. So again thank you for allowing me to be here today and I hope I'll get some time for questions