Heart

New chest pain guidelines to improve ER heart attack diagnoses

Chest pain should be treated like a medical emergency. Call 911 immediately or go to the nearest hospital for emergency care.

Chest pain is often the first sign of a heart attack. However, crushing or radiating pain in the chest, shoulder, or jaw also can indicate non-cardiac medical emergencies, such as a pulmonary embolism or other thoracic pathologies.

According to the Centers for Disease Control and Prevention (CDC), chest pain is the most common reason for trips to the ER, resulting in more than 7 million annual visits. Before October 2021, emergency care professionals had to determine the cause of chest pain by ordering several tests and imaging studies that cost patients time and money.

Now, hospitals around the world have a new set of guidelines regarding how best to diagnose the cause of chest pain – faster, more precisely, and with fewer unnecessary tests.

Published simultaneously on Oct. 28 in Circulation and the Journals of the American College of Cardiology, the new chest pain guidelines were spearheaded by the American Heart Association (AHA) and American College of Cardiology (ACC) Joint Committee on Clinical Practice Guidelines.

Deborah Diercks, M.D.

My colleague, Deborah Diercks, M.D., Chair of the UT Southwestern Department of Emergency Medicine, and I were members of the multidisciplinary team that wrote and refined the guidelines over two years.

The recommendations are infused with cutting-edge clinical data, targeted protocols, and recommendations on the use of an advanced blood test – high-sensitivity troponin – that can determine quickly whether someone is having a heart attack. That test, developed in part at UT Southwestern, has been a valuable tool that the Emergency Department teams at UTSW’s Clements University Hospital and Parkland have used for several years.

Specifically, the AHA/ACC guidelines were designed to clearly and rapidly narrow the diagnostic possibilities and develop advanced testing standards. The guidelines emphasize three distinct facets of patient care:

  • Defining precise, patient-centered terminology
  • Reducing unnecessary tests and interventions
  • Debunking myths around women’s chest pain

Defining precise, patient-centered terminology

Chest pain used to be classified as typical (consistent with heart attack) or atypical (not consistent with heart attack), and acute or stable. However, these vague terms don’t address the full range of heart attack symptoms, consider the patient’s overall risk profile, or provide clear next steps for evaluation and management, especially when the pain is not clearly heart-related.

The AHA/ACC Joint Committee writing team employed more precise terms that create a higher level of urgency and identify clear next steps for obvious and less-obvious symptoms. Following the new guidelines, chest pain should be categorized as:

  • Cardiac: The heart or a blocked blood vessel is the clear cause of the patient’s symptoms. This category could include heart attack symptoms or angina, an indicator of coronary artery disease.
  • Possible cardiac: It’s unclear whether the pain is heart-related. This could include severe, persistent, or come-and-go pain, or other worrisome symptoms that can’t immediately be identified as heart-related pain.
  • Non-cardiac: The pain is clearly not of cardiac ischemic origin. It could be a mild problem, such as inflammation of the pectoral tissue or an anxiety attack, or a life-threatening condition such as a pulmonary embolism or ruptured aorta.

Under the new guidelines, providers can use these more accurate, patient-centered definitions – along with a specific, high-tech blood test – to reduce unnecessary imaging or procedure-based tests.

Related reading: How PCI stenting can reduce chest pain and heart attack damage – without surgery

Chest pain guidelines

"The new chest pain guidelines sunset the case-by-case diagnostic process of ordering myriad tests and invasive procedures that cost patients time and money.”

– Jose Joglar, M.D.

Reducing unnecessary tests and interventions

The new guidelines recommend that all patients with chest pain get a specific blood test to diagnose or rule out a heart attack.

Developed in part at UT Southwestern, the high-sensitive serial assessment of cardiac troponin (cTn) blood test can detect troponin T in the blood. This protein shows whether the patient is having a heart attack, had one recently, or has incurred heart muscle damage.

Providers can then order appropriate tests by combining information from the patient’s cTn results, category of chest pain, and personal heart disease risk factors, such as:

  • Age, since cardiovascular risk increases over time
  • History of coronary artery disease, a major risk factor for heart disease
  • Overall health
  • Persistent chest pain despite previous medical treatment
  • Symptom severity

The blood test results are typically available in about an hour, so this personalized approach can reduce wait times in the ER, overall saving hours of wait time. Patients quickly receive customized care, saving time and money.

Related reading: Medication as effective as stents, bypass for treating blocked arteries

Debunking myths around women’s chest pain

Medical publications have suggested that women’s heart attack symptoms are vastly different from men’s. The most persistent myth is that women’s chest pain is less likely than men’s to be heart-related.

The new guidelines debunk this myth. AHA and ACC Joint Committee research shows that approximately 70% of women and men experience chest pain during heart attacks. Women, however, also feel more associated symptoms than men, such as radiating pain in the shoulder, arm, and jaw.

Chest pain should always be treated as an emergency. These guidelines explicitly state that patients and providers should never assume chest pain is not heart-related simply because the patient is a woman.

According to the guidelines: “Chest pain is the most common symptom among both men and women diagnosed with acute coronary syndrome (ACS). However, women more commonly have accompanying symptoms including nausea, palpitations, and shortness of breath.”

The bottom line

If you or a loved one experience chest pain, radiating torso pain, or sudden symptoms such as nausea, vomiting, or sweating, call 911 or immediately go to your closest hospital.

Emergency care teams are trained to stabilize you and quickly determine the best next steps – such as transferring you to a specialized heart center.

The new chest pain guidelines, which were developed with the expertise of the AHA, ACC, and care teams at specialized centers such as UT Southwestern, will standardize and streamline the level of patient care – and help providers make timely decisions when patients need advanced treatment

For non-emergency questions or to talk with a doctor about your personal heart disease risk factors, call 214-645-8300 or request an appointment online.