Chest pain diagnostic study of choice: Difference between revisions
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Revision as of 13:41, 19 December 2021
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Chest pain Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Chest pain diagnostic study of choice On the Web |
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Risk calculators and risk factors for Chest pain diagnostic study of choice |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Nuha Al-Howthi, MD[3]
Overview
Chest pain or chest pain equivalent nay be referred as chest pain. Diagnosis of nontraumatic chest pain is frequent challenge for physicians. Initial evaluation is considered for life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism , as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax). So, therapy for those with less critical illnesses is reasonable. Although there are several life-threatening causes, chest pain usually reflects a more benign condition. The initial work-up is taking ECG, but exact history, physical examination, biomarkers, and other tests are necessary. There is no association between the intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history with all characteristics of chest pain including nature; 2) onset and duration, 3) location and radiation, 4) precipitating factors, 5) relieving factors, and 6) associated symptoms should be obtained from all patients to identify the underlying causes of chest pain.
Diagnostic Study of Choice
- Chest pain or chest pain equivalent may be referred as chest pain.
- The diagnosis of nontraumatic chest pain is a frequent challenge for clinicians in ED.
- Initial evaluation for work-up of chest pain is considered for life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism , as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax).
- Therapy for those with less critical illnesses is reasonable.
- Although there are several life-threatening causes, chest pain usually reflects a more benign condition.
- The initial ECG is important to the evaluation, but history, physical examination, biomarkers, and other tests are necessary.
- There is no direct association between the intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain.
- A comprehensive history that collects all the characteristics of chest pain including:
| Recommendations for diagnostic tests of chest pain |
| ECG (class 1 ) |
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❑ ECG is recommended in patients presenting with stable chest pain, unless in the evidence of noncardiac causes |
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
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Diagnostic algorythm based on the ECG
| Chest pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History, physical exam | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| STEMI | Diffuse ST elevation consistent with pericarditis | ST-depression,New T-wave inversion | Non diagnostic or normal ECG | New arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Approach to STEMI | Management of pericarditis | Approach to NSTE-ACS | *Repear ECG in the presence of persistent symptoms or change or elevated troponin level
| Approach to arrhythmia | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
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Algorithm for evaluation of suspected ACS with intermediate risk and NO history of coronary artery disease
Abbreviations: Recent negative test: Normal CCTA ≤ 2 years (no plaque, no stenosis) or negative stress test≤ 1 year ; High risk CAD: Left main stenosis ≥ 50%; significant three vessel disease (stenosis ≥ 70%) CAD: Coronary artery disease ; CCTA: Coronary CT angiography; FFR-CT: Fractional flow reserve with CT; PET: Positron emission tomography; SPECT: Single-photon emission CT; INOCA: schemia and no obstructive coronary artery disease; CMR: Cardiovascular magnetic resonance imaging; CT:Computed tomography
| Acute chest pain, intermediate risk, No known CAD | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Perior testing | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes | NO | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stress testing
| Coronary CT angiography | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Recent negative test | Perior inconclusive or mildly abnormal stress test ≤ 1 year | Moderate severely abnormal test ≤ 1 year | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discharge | Coronary CT angiography (2a) | Invasive coronary angiography | Non obstructive CAD (stenosis<50%)= Discharge | Inconclusive stenosis | Obstructive CAD (stenosis)≥ 50% | High risk CAD or frequent angina=Coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Non obstructive CAD (stenosis<50%) | Inconclusive result | Obstructive CAD (stenosis ≥ 50%) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT, or stress testing | Medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Discharge | FFR-CT or stress test (2a) | *High risk CAD, frequent angina= Coronary angiography
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| FFR-CT≤0.8, moderate to severe ischemia=Coronary angiography | FFR-CT>0.8, mild ischemia= medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| FFR-CT ≤ 0.8 , moderate severely ischemia=Coronary angiography | FFR-CT>0.8, mild ischemia=Medical therapy, discharge | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Negative or mildly abnormal=discharge | Moderately severe ischemia= Coronary angiography | Inconclusive=Coronary CT angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
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Approach to patients with acute chest pain
| Patient with acute chest pain | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| History, physical exam | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ECG | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Consider non cardiac cause | Consider nonischemic cardiac cause | Possible ACS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| NO cardiac testing needed | Other cardiac testing as required | Obtain troponin | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Risk stratification by clinical condition evaluation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Low risk | Intermediate risk | High risk | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| NO testing required, discharge | Further diagnostic test may be needed | Invasive coronary angiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 AHA/ACC/ASE Guideline[1] |
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References
- ↑ 1.0 1.1 1.2 1.3 Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ (November 2021). "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. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check
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