Chest pain management has been in the spotlight recently both in the medical community and among the public. Of particular interest is chest pain assessment, which has been found to be provider specific and to vary, sometimes widely, according to patients' sex and race.1
Revised guidelines recently published by a joint committee of the American College of Cardiology and the American Heart Association provide recommendations-including algorithms called clinical decision pathways-for risk assessment and management of the various etiologies of chest pain.1
GUIDELINE OVERVIEW
Chest pain that is likely to be a symptom of a major adverse cardiovascular event requires time-sensitive assessment and management, whereas chest pain that is likely noncardiac in origin and doesn't reflect an acute ischemic event doesn't need immediate intervention.1 A detailed and focused triage of patients presenting with chest pain can differentiate symptoms.
Chest pain should be considered acute when it is new or presents in a different pattern from previous chest pain. Pain associated with a certain position or with deep breathing, for example, is likely not cardiac in origin.
Patient history and assessment should include the characteristics of the pain (description, onset and duration, precipitating and relieving factors, location and radiation, and associated symptoms).1 Cardiac risk factors-including diabetes, smoking, hypertension, obesity, elevated cholesterol, older age, sex, and family history-should also be evaluated, as these can identify care priorities and may help eliminate unnecessary diagnostic testing.1
It's important to remember that women with cardiac disease often present with possibly cardiac symptoms-such as nausea and dyspnea1-a factor that contributes to the reported underdiagnosis of ischemic events among women. Treatment disparity is also common among Black and Hispanic populations, as well as uninsured patients or those who have Medicaid.1 Finally, the presence of a major cardiovascular event should be considered in all patients over 75 years of age who present with syncope, dyspnea, or acute confusion.1
Clinicians should assess symptoms by how likely they are to be cardiac in origin, ranging from "very likely" (pressure, squeezing) to "unlikely" (positional, fleeting). See Figure 1.
In addition, patients should be asked to describe their symptoms, since they may not recognize pressure, squeezing, burning, or heaviness as pain that needs to be assessed. Other characteristics, including the duration of the pain, and accompanying features, such as pain that results from a deep breath or a change in position, can also help differentiate cardiac pain.
MAJOR EVIDENCE-BASED RECOMMENDATIONS
* Patients experiencing chest pain should call 911 to be transported to the closest ED. Within 10 minutes of arrival, an electrocardiogram (ECG) should be performed and interpreted and their high-sensitivity cardiac troponin (hs-cTn) level obtained; this will determine if the event is a ST-elevation myocardial infarction (STEMI) that requires time-sensitive coronary reperfusion.1
* Chest pain should not be described as typical or atypical but as cardiac, possibly cardiac, or noncardiac-terms that are "more specific to the potential underlying diagnosis."1
* As the timeliness of an intervention can limit the extent of myocardial damage, a creatine kinase-myocardial band test is no longer recommended.1 A hs-cTn is "the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury and increases diagnostic accuracy."1
* A chest radiograph is indicated in patients presenting with acute chest pain to determine other potential reasons for their symptoms.1
* To achieve the best outcomes for patients with diverse racial and ethnic backgrounds, clinicians should undergo cultural competency training and facilities should offer formal translation services.1
* Clinical decision pathways should be used to stratify patients into low, intermediate, and high risk for subsequent diagnostic evaluation.1
The clinical priorities are to identify and manage the life-threatening causes of chest pain, determine clinical stability, and assess whether the patient needs to be hospitalized or can safely be treated as an outpatient. These concerns involve consideration of all clinically appropriate data. The guidelines categorize chest pain according to ECG results and offer corresponding recommendations. These categories range from the most time-sensitive STEMI, to nondiagnostic or normal ECG, to arrhythmia-related chest pain.
For a review of the evaluation of chest pain as recommended by the guidelines, see Top 10 Take-Home Messages.1
RISK STRATIFICATION AND DIAGNOSTIC EVALUATION
Risk is defined as low, intermediate, or high, and the guidelines contain recommendations for cardiac testing for each category. The goal is to differentiate patients who would benefit from further testing from those who require immediate intervention.1
The guidelines include examples of clinical decision pathways to use to assess risk, and guideline-directed medical therapy (clinical evaluation, diagnostic testing, and pharmacological and procedural treatments1) for each cause of chest pain. Common pathway variables used for risk stratification are history, ECG, age, risk factors, troponin (at 0 and at 2 to 3 hours), and previous acute MI or coronary artery disease (CAD).1
Acute chest pain. Patients with acute chest pain and suspected acute coronary syndrome (ACS) who are deemed low risk by a clinical decision pathway algorithm may benefit from educational resources that improve their understanding of their condition and facilitate communicating with their provider about their risk. For intermediate-risk patients with acute chest pain, transesophageal echocardiography (TEE) is recommended as a "rapid, bedside test to establish baseline ventricular and valvular function, evaluate for wall motion abnormalities, and to assess for pericardial effusion."1 This allows greater differentiation of acuity to determine the type and timeliness of further intervention. Depending on presentation and history, additional testing may include coronary computed tomographic angiography (CCTA), invasive coronary angiography, exercise ECG, stress echocardiography, stress positron emission tomography, single-photon emission computed tomography, myocardial perfusion imaging, and stress cardiovascular magnetic resonance imaging.
For intermediate-risk patients who present with new or worsening acute chest pain, any indicated guideline-directed medical therapy should be maximized prior to initiating further testing.1
For high-risk patients with acute chest pain who are suspected of having ACS, invasive coronary angiography is indicated.1 Those who have had previous coronary artery bypass graft surgery but are not suspected of having ACS can undergo assessment for graft stenosis or occlusion with stress imaging or CCTA.
Stable chest pain. Management of patients with stable chest pain varies, depending on whether these patients have known CAD. With no known CAD, risk stratification should guide any testing and treatment. With known CAD, the priority is to maximize guideline-directed medical therapy.1 If chest pain persists, testing options include anatomical testing (tests that view the status of the coronary arteries, such as coronary angiography), various diagnostic tests such as TEE, and stress testing.
NONISCHEMIC CARDIAC CONDITIONS
Nonischemic cardiac conditions presenting with chest pain include pulmonary embolism, myocarditis, and valvular heart disease. TEE is recommended to diagnose patients with acute chest pain suspected of conditions such as aortic pathology, pericardial effusion, and endocarditis.1 Other recommended tests include ventilation-perfusion scanning to rule out pulmonary embolism, and cardiovascular magnetic resonance imaging and TEE or contrast computed tomographic scanning for suspected endocarditis and ventricular hypertrophic disease. Patients on hemodialysis or with sickle cell disease who develop acute chest pain should be transferred to an acute care setting for more comprehensive management.
To address cost-value considerations and avoid unnecessary diagnostic testing, the guidelines recommend patient education, shared decision-making, and risk stratification.1 Provider-patient communication regarding hospital admission, observation, discharge, or further evaluation in an outpatient setting can also improve patients' understanding and compliance and reduce the frequency of low-value testing.
NURSING IMPLICATIONS
Traditionally, there has been a lag between the release of treatment guidelines and their clinical implementation. If evidence-based management is to succeed, revised recommendations must make their way from publication to implementation in a timely way. As integral health care team members in constant communication with patients, nurses can ensure that care is current and evidence based, and help patients understand their condition by providing information and discussing options.
EVIDENCE GAPS AND FURTHER RESEARCH
Technological improvements that would allow remote acquisition and transmission of assessment data for faster diagnosis of patients with acute symptoms are vital. In addition, the constantly evolving tools for risk stratification and clinical decision-making need to be further studied for efficacy and incorporated into the electronic health record system. Finally, randomized trials are needed to identify unbeneficial diagnostic tests, and patient compliance needs to be better monitored and evaluated.
REFERENCE