section name header

Information

Population: Adults presenting with complaint of chest pain.

Organizations

ImagesACC/AHA/ASE/CHEST/SAEM/SCCT/SCMR 2021

Recommendations

–Classify chest pain as cardiac, possibly cardiac, or noncardiac based on suspicion (not: “typical” or “atypical”).1

–Obtain resting ECG within 10 min in all symptoms of chest pain (cardiac or noncardiac in nature). Send to emergency department for serial ECGs + troponin if high clinical suspicion.

–In the emergency department, if suspected ACS obtain a cardiac troponin (preferably high-sensitivity) as soon as possible, then measure serially.

–Consider chest X-ray to evaluate for nonischemic causes of pain.

–Consider transthoracic echocardiogram in intermediate-risk patients.

–After initial evaluation to rule out STEMI, perform a diagnostic test depending on the likelihood of CAD:

• Low risk: no testing needed.

• Intermediate risk: stress testing (preferred age 65 y or suspected obstructive CAD) or CT coronary angiography (CCTA).

• High risk (generally: higher risk patient, rising troponin, ongoing cardiac chest pain; high-risk findings on stress test or CCTA): invasive coronary angiography.

–If known CAD, consider deferring testing and intensifying guideline-directed medical therapies vs. stress testing (if 50% stenosis) or CCTA (if <50% stenosis).

–If diagnosis is made of noncardiac chest pain, consider a broad differential diagnosis:

• Respiratory: pulmonary embolism, pneumothorax, pneumomediastinum, pneumonia, bronchitis, pleural irritation, malignancy.

• Gastrointestinal: cholecystitis, pancreatitis, hiatal hernia, GERD/gastritis/esophagitis, peptic ulcer disease, esophageal spasm, dyspepsia.

Chest wall: costochondritis, chest wall trauma/inflammation, herpes zoster, cervical radiculopathy, breast disease, rib fracture, musculoskeletal injury or spasm.

• Psychological: panic disorder, anxiety, clinical depression, somatization disorder, hypochondria.

• Other: hyperventilation syndrome, carbon monoxide poisoning, sarcoidosis, lead poisoning, prolapsed intervertebral disc, thoracic outlet syndrome, adverse effect of certain medications (eg, 5-FU), sickle cell crisis.

Source

JACC. 2021;78(22):e187-e285.