Chest pain diagnostic study of choice
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Risk calculators and risk factors for Chest pain diagnostic study of choice |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Nuha Al-Howthi, MD[3]
Overview
Chest pain or chest pain equivalent may be referred as chest pain. Diagnosis of nontraumatic chest pain is frequent challenge for physicians. Initial evaluation is considered for life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism , as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax). So, therapy for those with less critical illnesses is reasonable. Although there are several life-threatening causes, chest pain usually reflects a more benign condition. The initial work-up is taking ECG, but exact history, physical examination, biomarkers, and other tests are necessary. There is no association between the intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history with all characteristics of chest pain including nature; 2) onset and duration, 3) location and radiation, 4) precipitating factors, 5) relieving factors, and 6) associated symptoms should be obtained to identify the underlying causes of chest pain.
Diagnostic Study of Choice
- Chest pain or chest pain equivalent may be referred as chest pain.
- The diagnosis of nontraumatic chest pain is a frequent challenge for clinicians in emergency department.
- Initial evaluation for work-up of chest pain is considered for life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism , as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax).
- Therapy for those with less critical illnesses is reasonable.
- Although there are several life-threatening causes, chest pain usually reflects a more benign condition.
- The initial ECG is important to the evaluation, but history, physical examination, biomarkers, and other tests are necessary.
- There is no direct association between the intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain.
- A comprehensive history that collects all the characteristics of chest pain including:
Approach to patients with acute chest pain
- Patients with acute chest pain and suspected ACS should be categorized into low- versus intermediate- or high-risk groups once STEMI has been excluded.
- This risk stratification is important to guide subsequent management.
- Although most high-risk patients should undergo cardiac catheterization, these patients still require a clinical assessment to determine if invasive evaluation is appropriate.
- ECG, symptoms, risk factors of coronary artery disease (CAD), and cTn are used to estimate a patient’s probability of ACS or risk of 30-day major adverse cardiovascular events (MACE).
- The high sensivity cardiac troponin (hs-cTn) result may be more predictive than other clinical components of the risk score.
- If a single level of hs-cTn is below the limit of detection and chest pain symptoms initiated at least 3 hours before ED arrival, the patient is categorized to low risk group ( the probability of MACE within 30 days is ≤1%).
- If the patient is clinically still suspicious for ACS or diagnostic uncertainty remains after serial cTn measurement, repeating cTn assay later (beyond 3 hours for high-sensitivity and beyond 6 hours for conventional assays) is recommended.
- Intermediate risk group should be tested by cardiac imaging or undergoing cardiac catheterization.
- There is no need for additional tests for low risk patients.
| Patient with acute chest pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History, physical exam | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Consider non cardiac cause | Consider nonischemic cardiac cause | Possible ACS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| NO cardiac testing needed | Other cardiac testing as required | Obtain troponin | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Risk stratification by clinical condition evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Low risk | Intermediate risk | High risk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| NO testing required, discharge | Further diagnostic test may be needed | Invasive coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 AHA/ACC/ASE Guideline[1] |
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| Recommendations for diagnostic tests of chest pain |
| ECG (class 1 ) |
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❑ ECG is recommended in patients presenting with stable chest pain, unless in the evidence of noncardiac causes |
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
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Diagnostic algorythm based on the ECG
| Chest pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History, physical exam | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| STEMI | Diffuse ST elevation consistent with pericarditis | ST-depression,New T-wave inversion | Non diagnostic or normal ECG | New arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Approach to STEMI | Management of pericarditis | Approach to NSTE-ACS | *Repeat ECG in the presence of persistent symptoms or change or elevated troponin level
| Approach to arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 AHA/ACC/ASE Guideline[1] |
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- After initial evaluation, the next step is determining whether further diagnostic testing is required to establish the diagnosis.
- The initial assessment of patients presenting with acute chest pain is identification of patients with immediately life-threatening conditions such as ACS, acute aortic syndromes, and pulmonary embolism.
- Myopericarditis can be manifested as fulminant myocarditis with high mortality rate.
- Noncardiovascular syndromes whether identified life-threatening, including esophageal rupture, tension pneumothorax, and sickle cell chest crisis.
- Nonemergency causes of chest pain include costochondritis and other musculoskeletal, or gastrointestinal causes.
Algorithm for evaluation of suspected ACS with intermediate risk and NO history of coronary artery disease
Abbreviations: Recent negative test: Normal CCTA ≤ 2 years (no plaque, no stenosis) or negative stress test≤ 1 year ; High risk CAD: Left main stenosis ≥ 50%; significant three vessel disease (stenosis ≥ 70%) CAD: Coronary artery disease ; CCTA: Coronary CT angiography; FFR-CT: Fractional flow reserve with CT; PET: Positron emission tomography; SPECT: Single-photon emission CT; INOCA: schemia and no obstructive coronary artery disease; CMR: Cardiovascular magnetic resonance imaging; CT:Computed tomography
| Acute chest pain, intermediate risk, No known CAD | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Perior testing | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stress testing
| Coronary CT angiography | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Recent negative test | Perior inconclusive or mildly abnormal stress test ≤ 1 year | Moderate severely abnormal test ≤ 1 year | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discharge | Coronary CT angiography (2a) | Invasive coronary angiography | Non obstructive CAD (stenosis<50%)= Discharge | Inconclusive stenosis | Obstructive CAD (stenosis)≥ 50% | High risk CAD or frequent angina=Coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non obstructive CAD (stenosis<50%) | Inconclusive result | Obstructive CAD (stenosis ≥ 50%) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT, or stress testing | Medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discharge | FFR-CT or stress test (2a) | *High risk CAD, frequent angina= Coronary angiography
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| FFR-CT≤0.8, moderate to severe ischemia=Coronary angiography | FFR-CT>0.8, mild ischemia= medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT ≤ 0.8 , moderate severely ischemia=Coronary angiography | FFR-CT>0.8, mild ischemia=Medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Negative or mildly abnormal=discharge | Moderately severe ischemia= Coronary angiography | Inconclusive=Coronary CT angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 AHA/ACC/ASE Guideline[1] |
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- Among patients with recent normal prior testing , no further testing is recommended.
- The intervals (1 year for stress testing, 2 years for CCTA without plaque or stenosis) are reasonable due to lack of atherosclerosis progression and low likelihood of cardiac events in patients with normal CCTA.
- When stress test is inconclusive or mildly abnormal in the past year, CCTA is recommended.
- It is recommended to test another study to rule-out of obstructive CAD when the previous result is inconclusive.
- For patients with presentation of acute chest pain and moderate-severe abnormalities on previous testing, without anatomic testing, invasive coronary angiography may be helpful for diagnosis of obstructive CAD.
- CCTA or stress test are the initial tests in patients without a previous diagnostic evaluation and no known CAD.
- When the initial stress test is inconclusive, second-line testing may be helpful.
- In patients with intermediate-risk who have intermediate stenosis on CCTA, FFR-CT, or stress testing may be indicated.
- Coronary angiography is recommended for high risk patients. However, patients with an intermediate-risk score may be recommended for CCTA or invasive coronary angiography in the context of moderate-severe ischemia or significant left ventricular dysfunction on diagnostic testing.
- Patients with coronary artery stenosis of 40% to 90% in a proximal or middle coronary segment on CCTA may benefit from measurement of FFR-CT.
- CCTA is highly effective at ruling out the presence of plaque or stenosis and may be helpful to risk assessment and management in patients with no known CAD with inconclusive stress test results.
- Stress test with imaging may be indicated in patients with acute chest pain who have indeterminate stenosis on CCTA for evaluation of myocardial ischemia.
- Symptomatic patients with inconclusive or mildly abnormal stress tests often have an increased risk of MACE.
- Patients with previous stress testing often have atherosclerotic plaque and obstructive CAD lesion.
Recommendation for intermediate to high risk patients with stable chest pain and NO known CAD
| Recommendation for intermediate to high risk patients with stable chest pain and NO known CAD |
| Anatomic test: |
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❑CCTA is reasonable for diagnosis, risk stratification, and guide therapy for intermediate to high risk patients and NO known CAD with stable chest pain (Class I, Level of Evidence A): |
| Stress test: |
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❑ For intermediate to high risk stable chest pain, use of stress imaging such as stress echocardiography, PET, SPECT /MPI,or CMR is effective to diagnosis of myocardial ischemia and determination the risk of MACE. (Class I, Level of Evidence B) |
| Assessment of left ventricular function: |
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❑ Transthoracic echocardiography is reasonable in intermediate-high risk stable chest pain and evidence of Q waves on ECG, heart failure signs and symptoms, complex ventricular arrhythmia, heart murmur (Class I, Level of Evidence B) |
| Add-on testing: |
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❑FFR-CCTA is recommended in intermediate-high risk patients with known CAD and stenosis 40%-90% in coronary CT angiography for determination of ischemia territory and decision making for revascularization (Class IIa, Level of Evidence B) |
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
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- Among patients with recent normal prior testing , no further testing is recommended.
- The intervals (1 year for stress testing, 2 years for CCTA without plaque or stenosis) are reasonable due to lack of atherosclerosis progression and low likelihood of cardiac events in patients with normal CCTA.
- When a stress test is inconclusive or mildly abnormal in the past year, CCTA is recommended.
- It is recommended to test another study to rule-out of obstructive CAD when the previous result is inconclusive.
- For patients with the presentation of acute chest pain and moderate-severe abnormalities on the previous testing, without anatomic testing, invasive coronary angiography may be helpful for diagnosis of obstructive CAD.
- CCTA or stress test are the initial tests in patients without a previous diagnostic evaluation and no known CAD.
- When the initial stress test is inconclusive, second-line testing may be helpful.
- In patients with intermediate-risk who have intermediate stenosis on CCTA, FFR-CT, or stress testing may be indicated.
- Coronary angiography is recommended for high risk patients. However, patients with an intermediate-risk score may be recommended for CCTA or invasive coronary angiography in the context of moderate-severe ischemia or significant left ventricular dysfunction on diagnostic testing.
- Patients with coronary artery stenosis of 40% to 90% in a proximal or middle coronary segment on CCTA may benefit from measurement of FFR-CT.
- CCTA is highly effective at ruling out the presence of plaque or stenosis and may be helpful to risk assessment and management in patients with no known CAD with inconclusive stress test results.
- Stress test with imaging may be indicated in patients with acute chest pain who have indeterminate stenosis on CCTA for evaluation of myocardial ischemia.
- Symptomatic patients with inconclusive or mildly abnormal stress tests often have an increased risk of MACE.
- Patients with previous stress testing often have atherosclerotic plaque and obstructive CAD lesion.
Approach to stable chest pain and ischemia and no obstructive CAD (INOCA)
| Stable chest pain suspected INOCA | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Non-invasive test more prevalent
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| Invasive coronary functional testing | Stress PET, Stress CMR, Stress echocardiography | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CFR( coronary flow reserve)≥2
| Epicardial artery spasm > 90% with acetylcholine
| IMR (index of microcirculatory restriction)≥25
| NO ischemia and normal myocardial blood flow reserve | Ischemia and normal myocardial blood flow reserve | Ischemia , reduced myocardial blood flow reserve | Reduced myocardial blood flow reserve, No Ischemia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Noncardiac | Vasospasm | Coronary microvascular dysfunction | Low risk for cardiovascular event | INOCA, NO CMD (coronary microvascular dysfunction) | CMD (Coronary microvascular dysfunction), Ischemia | CMD | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 AHA/ACC/ASE Guideline[1] |
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References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "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". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check
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