The U.S. multi-societal chest pain guideline – A quick look into a long-awaited document

Published:October 29, 2021DOI:https://doi.org/10.1016/j.jcct.2021.10.010

      Keywords

      Life is short,and art long,opportunity fleeting,experimentations perilous,and judgment difficult.Vīta brevis,ars longa,occāsiō praeceps,experīmentum perīculōsum,iūdicium difficile.Hippokrates (Aphorismi)
      The long-awaited Guideline for the Evaluation and Diagnosis of Chest Pain from the American Heart Association (AHA), American College of Cardiology (ACC) and subspecialty societies, including the Society of Cardiovascular Computed Tomography (SCCT), is now published and will be widely evaluated.
      • Gulati M.
      • Levy P.D.
      • Mukherjee D.
      • et al.
      AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain.
      As Hippokrates of Kos – the father of modern medicine - noted in his Aphorismi, it takes long to acquire mastery in art (meaning technique, craft) such as in the field in medicine. Similarly, practice guidelines that define the standards of modern medical care require careful thought and incorporation of the best evidence. Indeed, it took more than 4 years to complete extensive work leading to the new Guideline
      • Gulati M.
      • Levy P.D.
      • Mukherjee D.
      • et al.
      AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain.
      and the results are very exciting for the field of cardiovascular computed tomography (CCT). Almost two decades worth of scientific publications, including multiple large clinical trials, have eventually led to the recognition of coronary CT angiography (CTA) as a test with multiple Class 1 Level of Evidence A indications for selected patients with acute and stable chest pain (Table 1, Fig. 1). These guidelines are the attestation to efforts of numerous researchers, clinicians, and patients in the field of CCT who have provided and published the evidence necessary to support these indications.
      Table 1Highlighted indications for cardiovascular computed tomography in patients with acute and stable chest pain.
      CORLOEIndications for CCT
      Acute Chest Pain
      1AFor intermediate-risk patients with acute chest pain and no known CAD eligible for diagnostic testing after a negative or inconclusive evaluation for ACS, CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD.
      2aB-NRFor intermediate-risk patients with acute chest pain and known nonobstructive CAD, CCTA can be useful to determine progression of atherosclerotic plaque and obstructive CAD.
      Stable Chest Pain
      2aB-RFor patients with stable chest pain and no known CAD categorized as low risk, CAC testing is reasonable as a first-line test for excluding calcified plaque and identifying patients with a low likelihood of obstructive CAD.
      1AFor intermediate-high risk patients with stable chest pain and no known CAD, CCTA is effective for diagnosis of CAD, for risk stratification, and for guiding treatment decisions.
      2aB-NRFor intermediate-high risk patients with stable chest pain and no known CAD undergoing stress testing, the addition of CAC testing can be useful.
      2aB-NRFor patients who have stable chest pain with previous coronary revascularization, CCTA is reasonable to evaluate bypass graft or stent patency (for stents ≧3 mm).
      2aB-NRFor symptomatic patients with known nonobstructive CAD who have stable chest pain, CCTA is reasonable for determining atherosclerotic plaque burden and progression to obstructive CAD, and guiding therapeutic decision-making.
      COR - Class of Recommendation.
      LOE – Level of Evidence.
      CCT – cardiovascular computed tomography.
      CCTA – coronary computed tomography angiography.
      CAC – coronary artery calcium.
      The highlights and new approaches of the Guideline are summarized at the beginning of the document in 10 take-home messages represented by the mnemonic CHEST PAINS:
      • 1
        Chest pain means more than pain in the chest and includes other symptoms of coronary artery disease (CAD)
      • 2
        High-sensitivity troponins are preferred in evaluation of acute chest pain
      • 3
        Early care should be sought for acute symptoms
      • 4
        Shared-decision making with inclusion of the patient
      • 5
        Testing is not routinely needed in low-risk patients
      • 6.
        Clinical decision pathways should be used for chest pain patients
      • 7
        Accompanying symptoms (e.g. shortness of breath, nausea) are more common in women
      • 8
        Identify patients who most likely benefit from further testing, mostly patients with intermediate (acute chest pain) or intermediate to high risk of obstructive CAD (stable chest pain)
      • 9
        Non-cardiac chest pain is preferred term and atypical chest pain should not be used
      • 10
        Structured risk assessment should be used
      General Considerations and Test Selection. The authors first present general considerations of cardiac testing in patients with chest pain. In this section, the Guideline introduces a new concept for the term of known CAD. This definition includes all patient with prior anatomic testing with non-obstructive coronary atherosclerosis (defined as <50% stenosis), a group of patients that was not fully recognized and addressed in prior guidelines. The Guideline emphasized that the subgroup of patients with non-obstructive CAD will benefit from optimized preventive therapies. Another concept emphasized in this section is that the testing choice is influenced by site expertise and availability. This sentence is critical for the CCT community. It is the aim of the SCCT to assure that all patients in the US will have access to high quality CCT as recommended by the recent US ACC/multi-society CCTA summit.
      • Poon M.
      • Lesser J.R.
      • Biga C.
      • et al.
      Current evidence and recommendations for coronary CTA first in evaluation of stable coronary artery disease.
      In the period following the publication of the Guideline, SCCT will take the lead in working to provide the very high quality resources for training, assessment of competence, and advocacy for fair reimbursement. Indeed, SCCT has planned on-line webinars accompanying the publication of the guideline to help both our members and clinicians using CCT services (e.g. emergency medicine, internal medicine, hospital medicine). To better educate those performing CCT, SCCT has an on-line level I training course and soon will be launching a level II training course. These efforts are complemented by a vast array of educational opportunities available on-line and in-person (https://scct.org/page/EducationandMeetings), as well as guidelines outlining specifics on the performance, interpretation and appropriate utilization of CCT.
      • Narula J.
      • Chandrashekhar Y.
      • Ahmadi A.
      • et al.
      SCCT 2021 expert consensus document on coronary computed tomographic angiography: a report of the society of cardiovascular computed tomography.
      • Shaw L.J.
      • Blankstein R.
      • Bax J.J.
      • et al.
      Society of cardiovascular computed tomography/North American society of cardiovascular imaging - expert consensus document on coronary CT imaging of atherosclerotic plaque.
      • Hecht H.S.
      • Blaha M.J.
      • Kazerooni E.A.
      • et al.
      CAC-DRS: coronary artery calcium data and reporting system. An expert consensus document of the society of cardiovascular computed tomography (SCCT).
      • Hecht H.S.
      • Cronin P.
      • Blaha M.J.
      • et al.
      SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology.
      • Abbara S.
      • Blanke P.
      • Maroules C.D.
      • et al.
      SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: a report of the society of cardiovascular computed tomography guidelines committee: endorsed by the North American society for cardiovascular imaging (NASCI).
      • Cury R.C.
      • Abbara S.
      • Achenbach S.
      • et al.
      CAD-RADS(TM) coronary artery disease - reporting and data system. An expert consensus document of the society of cardiovascular computed tomography (SCCT), the American College of Radiology (ACR) and the North American society for cardiovascular imaging (NASCI). Endorsed by the American College of Cardiology.
      • Leipsic J.
      • Abbara S.
      • Achenbach S.
      • et al.
      SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee.
      • Raff G.L.
      • Chinnaiyan K.M.
      • Cury R.C.
      • et al.
      SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: a Report of the Society of Cardiovascular Computed Tomography Guidelines Committee.
      • Halliburton S.S.
      • Abbara S.
      • Chen M.Y.
      • et al.
      SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT.
      A few factors and questions should be considered when deciding on test selection for the evaluation of patients with chest pain. The first is whether to rule out obstructive CAD and detect non-obstructive CAD (CCTA is preferred) vs. planned ischemia guided management (stress imaging is preferred). This is an important new approach, which emphasized the importance of non-obstructive CAD that can be detected by CCTA. It highlights the importance of baseline coronary artery disease status, if known, to guide test selection. Throughout the document, the authors highlight the role of preventive therapies following the initial evaluation for symptoms of chest pain. The guideline uses the age cut-off of 65 years, which is based on the pre-test likelihood of obstructive CAD, as a criterium which may favor CCTA vs. stress imaging. Thus, when both tests are available, older patients (≧65 years) can be considered for stress imaging while younger patients for CCTA. However, these recommendations are not absolute and the decision on the best test for an individual patient should be also guided by other information, such as cardiovascular risk profile, prior imaging with evidence and extent of coronary atherosclerosis measured by vascular calcium on a non-cardiac CT. For example, women over the age of 65 typically have significantly lower amounts of calcified atherosclerosis as compared to men, with coronary CTA shown to be more effective than functional testing in women of all ages.
      • Pagidipati N.J.
      • Hemal K.
      • Coles A.
      • et al.
      Sex differences in functional and CT angiography testing in patients with suspected coronary artery disease.
      Acute Chest Pain. The section on the evaluation of acute chest pain provides guidance for the work-up of patients in the emergency department. Two main recommendations include the use of clinical decision pathways (CDP) for the stratification of risk, which in turn guide the use of subsequent testing (low risk – no need for testing, intermediate risk – further diagnostic testing may be indicated, high risk – invasive coronary angiography and/or management based on acute coronary syndrome guidelines). The major change as compared to prior guidelines is that patients with low risk (i.e. <1% 30-day risk of death or major adverse cardiovascular events - MACE) should be discharged without the need for outpatient testing, particularly when high-sensitivity troponin assays are utilized; prior guidelines recommended outpatient testing within 72 hours of discharge.
      • Anderson J.L.
      • Adams C.D.
      • Antman E.M.
      • et al.
      ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable Angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines.
      However, it is recommended that low-risk patients have their atherosclerotic cardiovascular (ASCVD) risk assessed as outpatients. One option for doing so is to perform an outpatient coronary artery calcium (CAC) scan for long-term risk stratification. This is a new concept taking information from outpatient guidelines to the population of patients with acute chest pain.
      • Grundy S.M.
      • Stone N.J.
      • Bailey A.L.
      • et al.
      AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
      The recommendation acknowledges a unique and important opportunity for the introduction of preventive measures following the acute presentation and encounter with health care system.
      With regard to diagnostic testing in patients classified as intermediate risk based on CDP and/or high-sensitivity troponin in whom additional testing is indicated, CCTA has class 1 (level of evidence A) indication as a useful tool to exclude atherosclerotic plaque and obstructive CAD in patients with no known CAD. In patients with no known CAD and prior inconclusive or mildly abnormal stress testing results, CCTA is the preferred non-invasive test (class 2a, level of evidence C-EO (expert opinion)), highlighting its role as an effective gatekeeper to the catheterization lab. The recommendation also emphasizes the importance of identifying non-obstructive CAD to guide risk factor modification following the initial encounter for acute chest pain. Stress testing has class 1 (level of evidence B-NR - non-randomized data) indication in the population of patients classified as intermediate risk and no known CAD. The new Guideline also addresses the issue of FFR-CT and gives this technique a 2a (level of evidence B-NR) indication in patients with 40–90% stenosis in the proximal or middle coronary artery segments on CCTA.
      A new concept of warranty period (2 years for normal invasive coronary angiography or CCTA and 1 year for normal stress testing) for obstructive CAD and/or ischemia is introduced. Patients with prior testing and negative electrocardiogram and cardiac troponin (high-sensitivity troponin is preferred) may be discharged from the emergency department without additional testing if they had prior normal test within the warranty period. The difference in the time interval from previous testing reflects the very low number of incident events among patients with normal CCTA vs. patients with normal stress testing who may still have significant plaque and higher event rate. The concept of warranty period is important to consider in order to reduce unnecessary testing in patients frequently presenting to the emergency department.
      In patients with known CAD and acute chest pain who are classified as intermediate risk based of CDP, the Guideline stratifies by known non-obstructive and obstructive CAD. In patients with known high-risk obstructive CAD (defined as left main stenosis ≧50%, or anatomically significant 3-vessel disease with ≧70% stenosis) the Guideline recommends optimization of guideline directed therapies (class 1A) and invasive coronary angiography (class 1A). Stress testing has 2a B-NR indication in patients with known obstructive CAD (≧50% stenosis), prior coronary bypass surgery, or percutaneous coronary intervention, who have new onset or worsening symptoms. For patients with non-obstructive CAD on prior imaging, CCTA can be useful to determine progression of atherosclerotic plaque and obstructive CAD (class 2a B-NR). For patients with non-obstructive CAD on prior imaging, stress testing is preferred if extensive plaque is present or high-quality CCTA is unlikely (class 2a B-NR).
      Stable Chest Pain. In patients with stable chest pain, the Guideline highlights the role of formal assessment of pretest probability (PTP) of obstructive CAD with one of the available tools (class 1 B-NR).
      • Winther S.
      • Schmidt S.E.
      • Mayrhofer T.
      • et al.
      Incorporating coronary calcification into pre-test assessment of the likelihood of coronary artery disease.
      • Juarez Orozco L.E.
      • Saraste A.
      • Capodanno D.
      • et al.
      Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease.
      • Genders T.S.S.
      • Coles A.
      • Hoffmann U.
      • et al.
      The external validity of prediction models for the diagnosis of obstructive coronary artery disease in patients with stable chest pain: insights from the PROMISE trial.
      • Fordyce C.B.
      • Douglas P.S.
      • Roberts R.S.
      • et al.
      Identification of patients with stable chest pain deriving minimal value from noninvasive testing: the PROMISE minimal-risk tool, A secondary analysis of a randomized clinical trial.
      • Genders T.S.S.
      • Steyerberg E.W.
      • Hunink M.G.M.
      • et al.
      Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts.
      • Genders T.S.S.
      • Steyerberg E.W.
      • Alkadhi H.
      • et al.
      A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension.
      However, the document does not provide a clear preference as to the recommend method to assess pre-test probability of significant CAD with the recently-published ESC guideline-approach endorsed in the supportive text and in a figure.
      • Juarez Orozco L.E.
      • Saraste A.
      • Capodanno D.
      • et al.
      Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease.
      ,
      • Knuuti J.
      • Wijns W.
      • Saraste A.
      • et al.
      ESC Guidelines for the diagnosis and management of chronic coronary syndromes.
      The presence of CAC (on CAC score scan or on non-cardiac chest CT) should be included in the assessment of pre-test probability of obstructive CAD. It will be important to implement the pretest probability assessment in each individual health system, ideally as part of standardized pathways embedded in the electronic medical records.
      Stable Chest Pain and No Known CAD. Low-risk patients based on PTP assessment can opt for no testing after shared decision making; although, the Guideline gives class 2a, level of evidence B-R indication for CAC scoring to exclude calcified plaque and identify patients with low likelihood of obstructive CAD to identify calcified plaque and class 2a, level of evidence B-NR recommendation for stress test without imaging to exclude ischemia and determine functional capacity. This is consistent with the recommendation for acute chest pain patients and emphasizes the importance of long-term preventive measures following the initial health care encounter.
      Intermediate and high-risk patients with stable chest pain are both placed into a single category of patients who should undergo non-invasive anatomic (CCTA) or stress testing first. There is a class 1, level of evidence A indication for CCTA for the diagnosis of CAD, risk stratification, and guiding treatment decision-making. Similar to the acute chest pain setting, FFR-CT can be useful (class 2a B-NR) for diagnosis of vessel specific ischemia and to guide decision-making regarding the use of coronary revascularization. Stress imaging has class 1, level of evidence B-R (randomized data) indication as an effective tool to diagnose ischemia and estimate risk of MACE. The supporting text further specifies that CCTA may be preferable for patients <65 years of age and not on optimal preventive therapies. Stress testing may be advantageous in those ≧65 years of age, because they have a higher likelihood of obstructive CAD and ischemia. CCTA can add information on the presence and extent of non-obstructive CAD, which may lead to intensification of preventive therapies, and thereby improved outcomes as demonstrated in the SCOT-HEART trial and a pre-specified sub-analysis of patients with diabetes in the PROMISE trial.
      • Newby D.E.
      • Adamson P.D.
      • et al.
      SCOT-HEART investigators
      Coronary CT angiography and 5-year risk of myocardial infarction.
      • Douglas P.S.
      • Hoffmann U.
      • Patel M.R.
      • et al.
      Outcomes of anatomical versus functional testing for coronary artery disease.
      • Mortensen M.B.
      • Dzaye O.
      • Steffensen F.H.
      • et al.
      Impact of plaque burden versus stenosis on ischemic events in patients with coronary atherosclerosis.
      • Bittencourt M.S.
      • Hulten E.A.
      • Murthy V.L.
      • et al.
      Clinical outcomes after evaluation of stable chest pain by coronary computed tomographic angiography versus usual care: a meta-analysis.
      The Guideline also recommends the addition of CAC score in patients undergoing stress testing (class 2a B-NR). CAC can detect atherosclerotic plaque burden, improve risk assessment, and guide preventive management. These recommendations highlight the role of coronary plaque detection and quantification in the accurate prediction of future MACE, which has been recently confirmed in the analysis from ISCHEMIA trial.
      • Reynolds H.R.
      • Shaw L.J.
      • Min J.K.
      • et al.
      Outcomes in the ISCHEMIA trial based on coronary artery disease and ischemia severity.
      In many ways, this Guideline, more than any in history, emphasizes the clinical importance of coronary atherosclerosis evaluation for the assessment of cardiovascular risk, test selection, and preventive management.
      Stable Chest Pain and Known CAD. The Guideline now differentiates between patients with known obstructive CAD and those with non-obstructive CAD. The role of CCTA in patients with known obstructive CAD who present with recurrent or worsening chest pain is limited. CCTA may be appropriate in patients with prior CABG or prior stents with ≧3mm in diameter to assess the patency of grafts or stents (class 2a B-NR), respectively. The guideline emphasizes the role of guideline-directed medical therapy and invasive coronary angiography in patients with high-risk coronary anatomy and symptoms despite medical therapy. Stress testing can assess whether symptoms are consistent with angina pectoris (exercise treadmill testing, class 2a B-NR) and quantify the amount of ischemia to guide decision making and estimation of MACE risk (class 1 B-NR).
      In patients with known non-obstructive CAD, CCTA is reasonable to determine atherosclerotic plaque burden and guide therapeutic decision making and can be combined with FFR-CT in those with 40–90% stenosis (class 2a B-NR). In patients with known extensive non-obstructive CAD, stress testing with imaging is reasonable for the diagnosis of myocardial ischemia (class 2a C-LD - Limited Data), especially in those in whom microvascular angina is suspected (where PET myocardial perfusion imaging and stress MRI are the preferred tests). The Guideline emphasizes the progressive nature of coronary atherosclerosis and importance of additional compositional assessment of plaque for detecting high-risk plaque features and amount of low CT attenuation plaque.
      • Ferencik M.
      • Mayrhofer T.
      • Bittner D.O.
      • et al.
      Use of high-risk coronary atherosclerotic plaque detection for risk stratification of patients with stable chest pain: a secondary analysis of the PROMISE randomized clinical trial.
      • Williams M.C.
      • Kwiecinski J.
      • Doris M.
      • et al.
      Low-attenuation noncalcified plaque on coronary computed tomography angiography predicts myocardial infarction: results from the multicenter SCOT-HEART trial (scottish computed tomography of the HEART).
      • Williams M.C.
      • Moss A.J.
      • Dweck M.
      • et al.
      Coronary artery plaque characteristics associated with adverse outcomes in the SCOT-HEART study.
      Summary. The new Guideline for the Evaluation and Diagnosis of Chest Pain significantly strengthens the role of CCT, providing class 1 indications in a large portion of patients presenting in acute or stable setting. Coronary CTA is now the preferred non-invasive test for many patients without known CAD presenting with acute or chronic symptoms. Hence, the new Guideline is now aligned with the European Society of Cardiology and National Institute for Health and Care Excellence recommendations for the appropriate use of CCT.
      • Knuuti J.
      • Wijns W.
      • Saraste A.
      • et al.
      ESC Guidelines for the diagnosis and management of chronic coronary syndromes.
      ,
      • Roffi M.
      • Patrono C.
      • Collet J.-P.
      • et al.
      ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European society of Cardiology (ESC).
      ,
      National Institute for Health and Care Excellence (Great Britain)
      Chest-Pain of Recent Onset.
      The Guideline authors are to be commended on the herculean effort of summarizing the available and emerging evidence over the 4 years of development. The committee presented recommendations for both acute and chronic chest pain scenarios that will significantly change current practice. Our Society, the SCCT, has an important task to disseminate and implement the Guideline while assuring the availability and growth of high quality CCT. This approach will hopefully lead to better and cost-effective care of patients presenting with one of the most common clinical symptoms – chest pain. Further research work will continue to define the role of CCT in guiding preventive, novel lipid-lowering, and anti-inflammatory therapies as well as the importance of coronary atherosclerosis quantification and characterization. The monitoring of the Guideline implementation, collection of data on health care resource utilization will be critical for the success and will also inform next guidelines. The growing international SCCT community will be excited and ready to participate in those processes.

      Disclosures

      Maros Ferencik – Grants NIH and AHA , consulting Biograph, Inc.
      Andrew Choi – Grant support – GW Heart and Vascular Institute ; Equity , Cleerly .
      Kelley Branch – Bayer, Locke Foundation, Novartis, Astra Zeneca, Janssen Pharmaceuticals, Novartis, Sanofi-Aventis, Consultant Bayer, Janssen Pharmaceuticals.
      Ron Blankstein – Research funding Amgen , Astellas Pharma , Gilead Sciences , Sanofi-Aventis , Consultant Amgen , Astellas Inc , EKOS Corp .
      Leslee Shaw – Scientific Advisory Board Covanos Inc.
      Armin Arbab-Zadeh – Research Grant Canon Medical Systems .
      Todd Villines – Grant support – U.S. Center for Disease Control and Prevention (CDC) .

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