Thread by @CianPMcCarthy

⚡️💥BREAKING 💥⚡️
The 2021 ACC/AHA/CHEST/SAEM/SCCT/SCMR Chest Pain guideline was published online today!

Link to paper:
jacc.org/doi/10.1016/j.…

Here are my personal takeaways!
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Thread /

2/ First, huge congratulations to the chair @DrMarthaGulati, vice-chairs Drs. Levy and Mukherjee and the writing committee including @DLBHATTMD, @RonBlankstein @RBP0612 @labunne @ErikHessMD @docHj @lesleejshaw. Incredible work! Not an easy task to put this together..

3/ Let’s start with acute chest pain in the ED. The committee advise against using the term atypical chest pain; instead favoring categorizing as cardiac, possibly cardiac, and non-cardiac chest pain. I like this concept a lot!

4/ Hospitals should use a clinical decision pathway (CDP) when evaluating chest pain - these avoid under or over testing when compared to an unstructured approach. No specific CDP is preferred but very important clinicians familiarize themselves with their pathway.

5/ High-sensitivity troponins preferred to conventional troponin assays as they more efficiently and accurately evaluate for acute myocardial injury.

6/ Clinical decision pathways typically categorize patients as low risk, intermediate risk, or high risk. Examples of low risk would be a patient with a conventional troponin <99th centile with low risk score (e.g HEART <3) or ruling out with ESC 0/1 hs troponin algorithm.

7/ Intermediate risk may be intermediate risk scores (e.g. HEART 4-6 & TIMI 2-4) when combined with conventional troponin or for example classification as intermediate risk per ESC 0/1 high-sensitivity trop pathway. High risk= high risk score or rule in by a hs-troponin pathway

8/ For low risk group, reasonable to discharge without urgent testing/admission. Arguably the most important recommendation IMO and will hopefully reduce over testing.

8/ For intermediate risk group, non-invasive testing generally needed, stratified by known or unknown CAD, unless recent normal stress test <1 year of normal CTCA within 2 years. See these key figures for details.

9/ For those designated high-risk by CDP, ischemic EKGs, new LV dysfunction, or positive testing, invasive coronary angiogram recommended.

10/ Now onto stable CAD… For patients with no known CAD, pre-test probability model such as the CAD consortium model can be helpful to define low versus intermediate/high probability risk of CAD.

11/ If low probability of CAD (estimate is <15%) testing could be deferred. However, it is reasonable (Class IIa) to perform CAC or exercise stress testing without imaging as first line test

12/ For intermediate/high probability of CAD, stress testing and CTCA are Class 1 recs. CCTA is preferable for those <65 y/age and not on preventative therapy while stress imaging may be advantageous in those >65. Patient characteristics and CI should be taken into consideration

13/ There are many more topics covered including 1) evaluation of non-ischemic cardiac pathologies such as aortic syndrome, PE, myopericarditis and noncardiac causes of chest pain, 2) cost-value considerations, 3) gaps and future research areas.

End/ Congratulations again to the guideline writers on this comprehensive document! Looking forward to the discussion!