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man clutching chest in pain

September 17, 2022 - Regardless of age, the majority of patients with chest pain do not have cardiac ischemia. But providers are wary of missing this important diagnosis, so most err on the side of caution when they encounter it. The American Heart Association (AHA) and European Society of Cardiology (ESC) have recently published objective guidance on evaluating chest pain that is applicable in a clinic setting. We've condensed the recommendations into 4 practical steps that provide an evidence- and guideline-based tool for assessing chest pain. Given the litigious and consequential nature of missing cardiac ischemia, many low-risk patients are referred for expensive and unnecessary workups. The steps below can help alleviate the anxiety and excessive testing associated with these patients. The recommendations are intended for people with stable chest pain and no known history of coronary artery disease (CAD).

  • Step 1 - categorize the chest pain - the guidelines recommend that the pain be categorized into 1 of 3 groups: (1) typical angina, (2) atypical angina, or (3) non-anginal pain. The groups are determined by 3 qualities - pain description, relation to exertion, and relief with rest. See Step 1 details for more.
  • Step 2 - obtain a resting ECG - most patients should have a resting ECG. Findings on an ECG that are associated with a higher risk of CAD include left bundle branch block, ST-T wave changes, and pathologic Q waves.
  • Step 3 - assess the pretest probability of obstructive CAD - using a table derived from studies encompassing 15,815 patients with chest pain, the pretest probability of obstructive CAD can be determined based on the patient's sex, age, and pain category. See pretest probability for more.
  • Step 4 - order diagnostic testing
    • Very low-risk patients (pretest probability ≤ 5%) - no testing is indicated unless another compelling reason is present
    • Low-risk patients (pretest probability of 6 - 15%) - consider CAC scoring or exercise stress testing
    • Intermediate-high risk patients (pretest probability > 15%) - coronary CT angiography (CCTA) is recommended in most patients. Stress imaging may also be considered. See Step 4 details for full recommendations.

Cardiologists put their kids through college working up soft chest pain referrals, but it doesn't have to be that way. With the AHA/ESC guidelines, providers can confidently assess these patients, knowing that their decision-making is backed by guidelines and evidence. Even if the patient has obstructive CAD (without left main disease), the ISCHEMIA trial showed that treatment with optimal medical therapy is just as good as PCI or CABG. Instead of shipping your next chest pain patient straight to cardiology, take a walk on the wild side and work them up yourself because you didn't go to school all those years just to fill out referrals.


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