Chest Pain Clinical Practice Guidelines (ACC/AHA, 2021)

American College of Cardiology/American Heart Association These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference. December 03, 2021

Clinical guidelines relating to the assessment and diagnosis of chest pain in adults were published in November 2021 by the American Heart Association (AHA), American College of Cardiology (ACC), American Society of Echocardiography (ASE), American College of Chest Physicians (CHEST), Society for Academic Emergency Medicine (SAEM), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR) in the Journal of the American College of Cardiology.[1,2]

Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw is an anginal equivalent, as are shortness of breath and fatigue.

Myocardial injury can be more accurately detected and excluded using high-sensitivity cardiac troponins, making these the preferred standard for biomarker diagnosis of acute myocardial infarction. If a patient has acute chest pain or chest pain–equivalent symptoms, the individual should immediately call 9-1-1 seeking medical care. While in most patients the symptoms will have a noncardiac source, patient evaluations should focus on excluding life-threatening causes or identifying them early. If the patient presenting with chest pain is clinically stable, include the individual in decision making. Facilitate the discussion via information about adverse event risks, radiation exposure, costs, and alternative options. There is no need to perform urgent diagnostic testing for suspected coronary artery disease in low-risk patients with acute or stable chest pain. In the emergency department and outpatient settings, routinely use clinical decision pathways for chest pain.

In men and women ultimately found to have acute coronary syndrome, the dominant, most frequent symptom is chest pain. The likelihood of presenting with accompanying symptoms such as nausea and shortness of breath may be greater in women. Cardiac imaging and testing will most benefit 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." Describe chest pain as "noncardiac" if heart disease is not suspected. The use of the term "atypical" in association with chest pain is discouraged, since "atypical" is considered to be a misleading descriptor. Use evidence-based diagnostic protocols to estimate the risk for coronary artery disease and adverse events in patients presenting with acute or stable chest pain.