Guideline sources The following summarized guidelines for the evaluation and management of chest pain are prepared by our editorial team based on guidelines from the Society of Cardiovascular Computed Tomography (SCCT/SCMR/AHA/SAEM/ASE/ACC/ACCP 2021). 1 Calculator Calculator Calculator Emergency Department Assess HEART score for chest pain INTERCHE Guidelines 1. Diagnostic investigations History and physical examination: elicit a focused history including characteristics and duration of symptoms relative to presentation as well as associated features and assess cardiovascular risk factors in patients presenting with chest pain. B Show 7 more https://web.pathway.md/diseases/recMS5xLCcTSYKMde 1/5 6/29/23, 3:51 AM Chest pain Pathway Electrocardiogram: obtain an ECG in patients seen in the office setting with stable chest pain unless a non-cardiac cause is evident. Refer patients to the emergency department for an ECG if it is unavailable in the office setting. B Show 3 more Troponin levels: obtain cardiac troponin as soon as possible after presentation in all patients presenting to the emergency department with acute chest pain and suspected acute coronary syndrome. B Show 4 more Transthoracic echocardiography: obtain TTE in patients with acute chest pain with suspected other potentially life-threatening non-ischemic cardiac conditions (such as aortic pathology, pericardial effusion, endocarditis). B Chest radiography: consider obtaining CXR to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms in patients presenting with acute chest pain. B Evaluation for acute coronary syndrome (general principles): treat patients with chest pain and initial ECG consistent with acute coronary syndrome according to STEMI and non-ST-elevation acute coronary syndrome guidelines. B Show 7 more Evaluation for acute coronary syndrome (low risk): View patients with acute chest pain and a 30-day risk of death or major adverse cardiovascular events < 1% as being at low risk. B Consider discharging patients with acute chest pain and suspected acute coronary syndrome deemed low risk (< 1% 30-day risk of death or major adverse cardiovascular events) home without admission or urgent cardiac testing. C Evaluation for acute coronary syndrome (intermediate risk): obtain transthoracic echocardiography to establish baseline ventricular and valvular function, evaluate for wall motion abnormalities, and to assess for pericardial effusion in intermediate-risk patients with acute chest pain. B Show 13 more Evaluation for acute coronary syndrome (high risk): View patients with acute chest pain and suspected acute coronary syndrome having any of the following as being at high risk for short- term major adverse cardiovascular events: new ischemic changes on ECG troponin-confirmed acute myocardial injury new-onset LV systolic dysfunction (ejection fraction < 40%) newly diagnosed moderate-to-severe ischemia on stress testing hemodynamic instability high clinical decision pathway risk score. B Show 2 more Evaluation for non-ischemic cardiac causes (acute aortic syndrome): https://web.pathway.md/diseases/recMS5xLCcTSYKMde 2/5 6/29/23, 3:51 AM Chest pain Pathway Obtain CT angiography of the chest, abdomen, and pelvis for the diagnosis and treatment planning in patients with acute chest pain, if there is a clinical concern for aortic dissection. B Obtain TEE or cardiac MRI, if CT is contraindicated or unavailable. B Evaluation for non-ischemic cardiac causes (myopericarditis): consider obtaining cardiac MRI with gadolinium contrast to distinguish myopericarditis from other causes, including myocardial infarction and nonobstructive coronary arteries, in patients with acute chest pain and myocardial injury having nonobstructive coronary arteries on anatomic testing. B Show 3 more Evaluation for non-ischemic cardiac causes (valvular heart disease): Consider obtaining TTE for determining the presence, severity and cause of VHD in patients presenting with acute chest pain with suspected or known history of VHD. B Consider obtaining TTE (with 3D imaging if available) for determining the severity and cause of VHD in patients presenting with acute chest pain with suspected or known VHD, if TTE diagnostic quality is inadequate. B Evaluation for non-ischemic cardiac causes (pulmonary embolism): Obtain CT angiography using a PE protocol in stable patients with acute chest pain with high clinical suspicion for PE. B Decide on further testing in patients with acute chest pain and possible PE based on pretest probability. B Evaluation for non-cardiac causes: evaluate for non-cardiac causes in patients with acute chest pain with persistent or recurring symptoms despite a negative stress test or anatomic cardiac evaluation, or a low-risk designation by a clinical decision pathway. B Show 3 more Evaluation of stable chest pain (low risk): consider using a model to estimate pretest probability of obstructive coronary artery disease in patients with stable chest pain and no known coronary artery disease presenting to the outpatient clinic, to identify patients at low risk for obstructive coronary artery disease and favorable prognosis in whom additional diagnostic testing can be deferred. B Show 2 more Evaluation of stable chest pain (intermediate-high risk): consider obtaining coronary CT angiography for diagnosis of coronary artery disease, for risk stratification and guiding treatment decisions in intermediate-high risk patients with stable chest pain and no known coronary artery disease. B Show 10 more Updated evidence: DISCHARGE In patients with stable chest pain who had an intermediate pretest probability of obstructive coronary artery disease and were referred for invasive coronary angiography, CT was not superior to invasive coronary angiography with respect to the rate of composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke over 3.5 years. https://web.pathway.md/diseases/recMS5xLCcTSYKMde 3/5 6/29/23, 3:51 AM Chest pain Pathway DISCHARGE Trial Group et al. N Engl J Med. 2022 Apr 28. Evaluation of stable chest pain (known obstructive CAD): optimize guideline-directed medical therapy in patients with obstructive coronary artery disease and stable chest pain. A Show 8 more Evaluation of stable chest pain (known nonobstructive CAD): optimize preventive therapies in patients with known nonobstructive coronary artery disease and stable chest pain. B Show 3 more Evaluation of stable chest pain (INOCA): consider obtaining invasive coronary function testing to improve the diagnosis of coronary microvascular dysfunction and to enhance risk stratification in patients with persistent stable chest pain and nonobstructive coronary artery disease and at least mild myocardial ischemia on imaging. C Show 3 more 2. Specific circumstances Post-CABG patients (acute chest pain): Consider obtaining stress imaging to evaluate for myocardial ischemia or coronary CT angiography for graft stenosis or occlusion in patients with a history of CABG surgery presenting with acute chest pain not having acute coronary syndrome. B Consider obtaining invasive coronary angiography in patients with a history of CABG surgery presenting with acute chest pain not having acute coronary syndrome or having an indeterminate/nondiagnostic stress test. B Post-CABG patients (stable chest pain): Obtain invasive coronary angiography for guiding therapeutic decision-making in patients with a history of CABG surgery presenting with stable chest pain, if noninvasive stress test results show moderate-to-severe ischemia, or suspected to have myocardial ischemia with indeterminate/nondiagnostic stress test. B Consider obtaining stress imaging or coronary CT angiography to evaluate for myocardial ischemia or graft stenosis or occlusion in patients with a history of CABG surgery presenting with stable chest pain suspected to have myocardial ischemia. C 3. Follow-up and surveillance Transfer to emergency department: transport patients with clinical evidence of acute coronary syndrome or other life-threatening causes of acute chest pain seen in the office setting to the emergency department urgently, ideally by emergency medical services. B Show 4 more https://web.pathway.md/diseases/recMS5xLCcTSYKMde 4/5 6/29/23, 3:51 AM Chest pain Pathway 4. Quality improvement Cultural competency training: Implement cultural competency training to help achieve the best outcomes in patients of diverse racial and ethnic backgrounds presenting with chest pain. B Address language barriers with the use of formal translation services among patients of diverse race and ethnicity presenting with chest pain, if English is not their primary language. B Studies 2022 DISCHARGE In patients with stable chest pain who had an intermediate pretest probability of obstructive coronary artery disease and were referred for invasive coronary angiography, CT was not superior to invasive coronary angiography with respect to the rate of composite outcome of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke over 3.5 years. DISCHARGE Trial Group et al. N Engl J Med. 2022 Apr 28. References 1. Martha Gulati, Phillip D Levy, Debabrata Mukherjee et al. 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. 2021 Nov 30;144 22):e368-e454. Open 2. Simon A Mahler, Robert F Riley, Brian C Hiestand et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8 2 195 203. Open 3. Martin Than, Sally Aldous, Sarah Jane Lord et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014 Jan;174 1 51 8. Open 4. Mohammad Jalili, Zia Hejripour, Amir Reza Honarmand et al. Validation of the Vancouver Chest Pain Rule: a prospective cohort study. Acad Emerg Med. 2012 Jul;19 7 837 42. Open 5. DISCHARGE Trial Group, P l Maurovich-Horvat, Maria Bosserdt et al. CT or Invasive Coronary Angiography in Stable Chest Pain. N Engl J Med. 2022 Apr 28;386 17 1591 1602. Open 6. A J Six, B E Backus, J C Kelder. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008 Jun;16 6 191 6. Open 7. Martin Than, Dylan Flaws, Sharon Sanders et al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014 Feb;26 1 34 44. Open https://web.pathway.md/diseases/recMS5xLCcTSYKMde 5/5