AHA unveils first chest pain guidelines

Chest pain is a problem, and not just for patients who have it. From the cardiology office to the emergency department, clinicians must assess whether the pain is likely to be cardiac in origin, figure out which tests are and are not appropriate and determine when to send the patient home, to the cath lab or somewhere else. All the while, you must keep the patient informed and actively involved in decision-making.

“Nonspecific chest pain is the No. 1 reason people present in the emergency room and one of the most common reasons people seek medical care whatever age they are,” said Martha Gulati, MD, MS, FAHA, chair-elect of the American Society for Preventive Cardiology and chair of the American Heart Association/American College of Cardiology/American Society of Echocardiography/Society for Academic Emergency Medicine/ Society of Cardiovascular Computed Tomography/Society for Cardiovascular Magnetic Resonance Chest Pain Guideline Writing Committee.

“The cause isn’t often cardiac when you’re younger, but it’s also not always cardiac when you’re older. And there has never been a guideline of what you should do with chest pain. We have guidelines if they are diagnosed with acute coronary syndrome, or an aortic dissection or a pulmonary embolism. But we’ve never had guidelines that started from the very beginning until now.”

Dr. Gulati will help introduce this first guideline for the assessment of nonspecific chest pain 9:30-10:30 a.m. ET, Monday, Nov. 15, during “Chest Pain Guidelines.” The session will explore 10 key messages to help clinicians evaluate, define and treat nonspecific chest pain.

“The medical community has been clamoring for these guidelines for years,” said co-presenter Phillip D. Levy, MD, MPH, FAHA, Edward S. Thomas Endowed Professor of Emergency Medicine and assistant vice president for translational science and clinical research innovation at Wayne State University and chief innovation officer at Wayne Health.

“Dealing with undifferentiated chest pain has been very challenging prior to the publication of these guidelines. Assessment was done by protocol in a lot of hospitals, which is good, but lacked in standardization. The guidelines have given us the definitive pathways and recommendations as to how we should approach the care of these patients from that initial evaluation to risk stratification and recommendations as to what should happen next. It has very clear-cut algorithms that walk clinicians from that initial interaction with the patient all the way to final disposition.”

Dr. Gulati will present the guidelines as a mnemonic — CHEST PAINS — 10 key messages to help assess the likely cause of emergent chest pain, stratify patients by risk and involve patients in deciding the most appropriate path forward.

“When people say, ‘chest pain,’ they can be describing discomfort in the chest, shoulder, jaw, stomach, neck,” she said. “The guidelines give us an evidence-based assessment to triage which pains are more likely to be cardiac and how to go from there.”

Identifying cardiac-related pain isn’t always simple and distinguishing high-risk pain can be even more difficult. A sharp pain is probably not acute coronary syndrome or ischemia, Dr. Gulati said, in contrast with stress or exertional-related pains. The classic chest discomfort that can be experienced — “elephant on the chest,” feelings of squeezing, pressure, gripping and tightness — are more worrisome, she said.

“The idea that we need to understand chest pain may seem pretty simplistic, but there are still a lot of people in our medical community who need that reminder,” she said. “I deal with it every day as a cardiologist, and I see it missed too often.”

She also pointed to imaging and technology that can help work up the potential causes of chest pain when needed to guide the care of patients.

The new guidelines will likely reinforce much of what is already current practice in many emergency departments, Dr. Levy said.

“A lot of current practice already aligns with the guidelines, which will make it easier to layer on adjustments when they are doing a few things differently,” he said. “And the guidelines will help patients by creating a standard for how they will be treated for chest pain no matter what facility they may go to. Shared decision-making is a big emphasis. We want all patients to be informed participants in their care.”

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