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Circulation
AHA/ACC CLINICAL PRACTICE GUIDELINE
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
Writing Committee Members*
Martha Gulati, MD, MS, FACC, FAHA, Chair†; Phillip D. Levy, MD, MPH, FACC, FAHA, Vice Chair†;
Debabrata Mukherjee, MD, MS, FACC, FAHA, Vice Chair†; Ezra Amsterdam, MD, FACC†; Deepak L. Bhatt, MD, MPH, FACC, FAHA†; Kim K. Birtcher, MS, PharmD, AACC‡; Ron Blankstein, MD, FACC, MSCC†§; Jack Boyd, MD†;
Renee P. Bullock-Palmer, MD, FACC, FAHA, FASE, FSCCT†; Theresa Conejo, RN, BSN, FAHA||; Deborah B. Diercks, MD, MSc, FACC¶; Federico Gentile, MD, FACC#; John P. Greenwood, MBChB, PhD, FSCMR, FACC**; Erik P. Hess, MD, MSc†;
Steven M. Hollenberg, MD, FACC, FAHA, FCCP††; Wael A. Jaber, MD, FACC, FASE‡‡; Hani Jneid, MD, FACC, FAHA§§;
José A. Joglar, MD, FAHA, FACC‡; David A. Morrow, MD, MPH, FACC, FAHA†; Robert E. O'Connor, MD, MPH, FAHA†;
Michael A. Ross, MD, FACC†; Leslee J. Shaw, PhD, FACC, FAHA, MSCCCT†
AIM: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.
METHODS: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.
STRUCTURE: Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Key Words: AHA Scientific Statements ■ chest pain ■ angina ■ coronary artery disease ■ acute coronary syndrome ■ myocardial ischemia
■ myocardial infarction ■ myocardial injury ■ noncardiac ■ accelerated diagnostic pathway ■ clinical decision pathway ■ sex differences
■ troponins ■ chest pain syndromes ■ biomarkers ■ shared decision-making ■ noncardiac chest pain ■ cardiac imaging
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. †ACC/AHA Representative. ‡ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison. §Society of Cardiovascular Computed Tomography Representative. ||Lay Patient Representative. ¶Society for Academic Emergency Medicine Representative. #Former ACC/AHA Joint Committee member; current member during the writing effort. **Society for Cardiovascular Magnetic Resonance Representative. ††American College of Chest Physicians Representative. ‡‡American Society of Echocardiography Representative. §§Task Force on Performance Measures, Liaison.
ACC/AHA Joint Committee on Clinical Practice Guidelines Members, see page e420.
The American Heart Association requests that this document be cited as follows: 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. 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. 2021;144:e368–e454. doi: 10.1161/CIR.00000000000010029
© 2021 by the American Heart Association, Inc., and the American College of Cardiology Foundation.
Circulation is available at www.ahajournals.org/journal/circ
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CONTENTS
Abstract. e368
Top 10 Take-Home Messages for the
Evaluation and Diagnosis of Chest Pain .....e370
Preamble ....e370
1. Introduction ....e372
1.1. Methodology and Evidence Review ..... e372
1.2. Organization of the Writing Committee....e373
1.3. Document Review and Approval....e374
1.4. Scope of the Guideline .....e374
1.4.1. Scope of the Problem.....e374
1.4.2. Defining Chest Pain ..... e375
1.5. Abbreviations ....e376
2. Initial Evaluation ....e377
2.1. History ....e377
2.1.1. A Focus on the Uniqueness of Chest Pain in Women ....e378
2.1.2. Considerations for Older Patients With Chest Pain....e379
2.1.3. Considerations for Diverse Patient Populations With Chest Pain .....e379
2.1.4. Patient-Centric Considerations ... e380
2.2. Physical Examination....e380
2.3. Diagnostic Testing....e381
2.3.1. Setting Considerations.....e381
2.3.2. Electrocardiogram....e382
2.3.3. Chest Radiography ....e382
2.3.4. Biomarkers ....e383
3. Cardiac Testing General Considerations ..... e384
3.1. Anatomic Testing....e385
3.1.1. Coronary Computed Tomography Angiography ..... e385
3.1.2. Invasive Coronary Angiography... e385
3.2. Diagnostic Testing....e386
3.2.1. Exercise ECG....e386
3.2.2. Echocardiography/Stress Echocardiography....e387
3.2.3. Stress Nuclear (PET or SPECT)
Myocardial Perfusion Imaging.....e387
3.2.4. Cardiovascular Magnetic Resonance Imaging .... e387
3.3. Cardiac Testing Considerations for Women Who Are Pregnant, Postpartum, or of Child-Bearing Age .... e387
4. Choosing the Right Pathway With Patient-Centric Algorithms for Acute Chest Pain .....e387
4.1. Patients With Acute Chest Pain and Suspected ACS (Not Including STEMI).....e389
4.1.1. Low-Risk Patients With Acute Chest Pain....e392
4.1.1.1. Cost-Value Considerations
in the Evaluation of
Low-Risk Patients ..... e393
4.1.2. Intermediate-Risk Patients
With Acute Chest Pain ..... e393
4.1.2.1. Intermediate-Risk Patients With Acute Chest Pain and No Known CAD.....e394
4.1.2.1.1. Cost-Value Considerations... e395
4.1.2.2. Intermediate-Risk Patients With Acute Chest Pain and Known CAD... e395
4.1.3. High-Risk Patients With Acute Chest Pain....e398
4.1.4. Acute Chest Pain in Patients With Prior Coronary Artery Bypass Graft (CABG) Surgery ..... e398
4.1.5. Evaluation of Patients With Acute Chest Pain Receiving Dialysis ....e399
4.1.6. Evaluation of Acute Chest Pain in Patients With Cocaine and Methamphetamine Use ..... e400
4.1.7. Shared Decision-Making in Patients With Acute Chest Pain ... e400
4.2. Evaluation of Acute Chest Pain With Nonischemic Cardiac Pathologies..... e401
4.2.1. Acute Chest Pain With Suspected Acute Aortic Syndrome ..... e401
4.2.2. Acute Chest Pain With Suspected PE....e402
4.2.3. Acute Chest Pain With Suspected Myopericarditis ..... e402
4.2.4. Acute Chest Pain With Valvular Heart Disease....e403
4.3. Evaluation of Acute Chest Pain With Suspected Noncardiac Causes ..... e404
4.3.1. Evaluation of Acute Chest Pain With Suspected Gastrointestinal Syndromes ..... e405
4.3.2. Evaluation of Acute Chest Pain With Suspected Anxiety and Other Psychosomatic Considerations ..... e405
4.3.3. Evaluation of Acute Chest Pain in Patients With Sickle Cell Disease ..... e406
5. Evaluation of Patients With Stable Chest Pain .....e406
5.1. Patients With No Known CAD Presenting With Stable Chest Pain ..... e406
5.1.1. Pretest Risk Probability to Guide Need for Stress and Anatomic Tests....e406
5.1.2. Low-Risk Patients With Stable Chest Pain and No Known CAD.....e407
5.1.3. Intermediate-High Risk Patients With Stable Chest Pain and No Known CAD ..... e408
5.2. Patients With Known CAD Presenting With Stable Chest Pain....e411
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5.2.1. Patients With Obstructive CAD Who Present With Stable Chest Pain.....e412
5.2.1.1. Patients With Prior Coronary Artery Bypass Surgery With Stable Chest Pain..... e414
5.2.2. Patients With Known Nonobstructive CAD Presenting With Stable Chest Pain .... e415
5.2.3. Patients With Suspected Ischemia and No Obstructive CAD (INOCA) ... e416
5.3. Cost-Value Considerations in Diagnostic Testing.... e418
5.3.1. CCTA and CAC Scanning Cost-Value Considerations .... e418
5.3.2. Exercise Electrocardiographic Cost-Value Considerations ..... e418
5.3.3. Stress Echocardiographic Cost-Value Considerations ..... e418
5.3.4. Stress Nuclear MPI Cost-Value Considerations ..... e419
5.3.5. Stress CMR Cost-Value Considerations ..... e419
6. Evidence Gaps and Future Research ..... e419
References.... e421
Appendix 1
Author Relationships With Industry and Other Entities (Relevant).... e445
Appendix 2
Reviewer Relationships With Industry and Other Entities (Comprehensive).... e448
TOP 10 TAKE-HOME MESSAGES FOR THE EVALUATION AND DIAGNOSIS OF CHEST PAIN
1. Chest Pain Means More Than Pain in the Chest. Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents.
2. High-Sensitivity Troponins Preferred. High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.
3. Early Care for Acute Symptoms. Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes.
4. Share the Decision-Making. Clinically stable patients presenting with chest pain should be included in decision-making; information about risk
of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.
5. Testing Not Needed Routinely for Low-Risk Patients. For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed.
6. Pathways. Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.
7. Accompanying Symptoms. Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath.
8. Identify Patients Most Likely to Benefit From Further Testing. Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.
9. Noncardiac Is In. Atypical Is Out. “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use is discouraged.
10. Structured Risk Assessment Should Be Used. For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols.
Figure 1 illustrates the take-home messages.
PREAMBLE
Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a foundation for the delivery of quality cardiovascular care. The ACC and AHA sponsor the development and publication of clinical practice guidelines without commercial support, and members volunteer their time to the writing and review efforts. Guidelines are official policy of the ACC and AHA. For some guidelines, the ACC and AHA partner with other organizations.
Intended Use
Clinical practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice
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Figure 1. Take-Home Messages for the Evaluation and Diagnosis of Chest Pain
in the United States, but these guidelines are relevant to patients throughout the world. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients' interests. Guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances and should not replace clinical judgment.
Clinical Implementation
Management, in accordance with guideline recommendations, is effective only when followed by both practitioners and patients. Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities.
Methodology and Modernization
The ACC/AHA Joint Committee on Clinical Practice Guidelines (Joint Committee) continuously reviews, updates, and modifies guideline methodology on the basis of published standards from organizations, including the Institute of Medicine, \( ^{12} \) and on the basis of internal re-evaluation. Similarly, presentation and delivery of guidelines are reevaluated and modified in response to evolving technologies and other factors to optimally facilitate dissemination of information to healthcare professionals at the point of care.
Numerous modifications to the guidelines have been implemented to make them shorter and enhance “user friendliness.” Guidelines are written and presented in a modular, “knowledge chunk” format, in which each chunk includes a table of recommendations, a brief synopsis, recommendation-specific supportive text and, when
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appropriate, flow diagrams or additional tables. Hyper-linked references are provided for each modular knowledge chunk to facilitate quick access and review.
In recognition of the importance of cost-value considerations, in certain guidelines, when appropriate and feasible, an analysis of value for a drug, device, or intervention may be performed in accordance with the ACC/AHA methodology. \( ^{3} \)
To ensure that guideline recommendations remain current, new data will be reviewed on an ongoing basis by the writing committee and staff. Going forward, targeted sections/knowledge chunks will be revised dynamically after publication and timely peer review of potentially practice-changing science. The previous designations of “full revision” and “focused update” will be phased out. For additional information and policies on guideline development, readers may consult the ACC/AHA guideline methodology manual \( ^{4} \) and other methodology articles. \( ^{5-7} \) The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1). \( ^{4} \)
Selection of Writing Committee Members
The Joint Committee strives to ensure that the guideline writing committee contains requisite content expertise and is representative of the broader cardiovascular community by selection of experts across a spectrum of backgrounds, representing different geographic regions, sexes, races, ethnicities, intellectual perspectives/biases, and clinical practice settings. Organizations and professional societies with related interests and expertise are invited to participate as partners or collaborators.
Relationships With Industry and Other Entities
The ACC and AHA have rigorous policies and methods to ensure that documents are developed without bias or improper influence. The complete policy on relationships with industry and other entities (RWI) can be found online. Appendix 1 of the guideline lists writing committee members' relevant RWI; for the purposes of full transparency, their comprehensive disclosure information is available in the Supplemental Appendix. Comprehensive disclosure information for the Joint Committee is also available online.
Evidence Review and Evidence Review Committees
In developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data. \( ^{4,5} \) Literature searches focus on randomized
controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinions. Only key references are cited.
An independent evidence review committee is commissioned when there are \( \geq \) 1 questions deemed of utmost clinical importance and merit formal systematic review to determine which patients are most likely to benefit from a drug, device, or treatment strategy, and to what degree. Criteria for commissioning an evidence review committee and formal systematic review include absence of a current authoritative systematic review, feasibility of defining the benefit and risk in a time frame consistent with the writing of a guideline, relevance to a substantial number of patients, and likelihood that the findings can be translated into actionable recommendations. Evidence review committee members may include methodologists, epidemiologists, clinicians, and biostatisticians. Recommendations developed by the writing committee on the basis of the systematic review are marked “SR.”
Guideline-Directed Management and Therapy
The term guideline-directed medical therapy (GDMT) encompasses clinical evaluation, diagnostic testing, and both pharmacological and procedural treatments. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and evaluate for contraindications and interactions. Recommendations are limited to drugs, devices, and treatments approved for clinical use in the United States.
Patrick T. O'Gara, MD, MACC, FAHA
Chair, ACC/AHA Joint Committee on
Clinical Practice Guidelines
1. INTRODUCTION
1.1. Methodology and Evidence Review
The recommendations listed in this guideline are, whenever possible, evidence based. An initial extensive evidence review, which included literature derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline, was conducted from November 11, 2017, to May 1, 2020. Key search words included but were not limited to the following: acute coronary syndrome, angina, angina pectoris, aortic valve stenosis, biomarker, biomarkers, brain natriuretic peptide, cardiac-gated single photon emission computer-assisted tomography, cardiovascular magnetic resonance, chest pain, CKMB, coronary angiography, coronary arteriosclerosis, coronary artery disease, creatine kinase, creatine kinase MB, echocardiography, electrocardiography, heart valve disease, hypertrophic
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Table 1. Applying ACC/AHA Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)*
<table><tr><td colspan="2">CLASS (STRENGTH) OF RECOMMENDATION</td></tr><tr><td>CLASS 1 (STRONG)</td><td>Benefit &gt;&gt;&gt; Risk</td></tr><tr><td colspan="2">Suggested phrases for writing recommendations:Is recommendedIs indicated/useful/effective/beneficialShould be performed/administered/otherComparative-Effectiveness Phrases↑:- Treatment/strategy A is recommended/indicated in preference to treatment B-Treatment A should be chosen over treatment B</td></tr><tr><td>CLASS 2a (MODERATE)</td><td>Benefit &gt;&gt; Risk</td></tr><tr><td colspan="2">Suggested phrases for writing recommendations:Is reasonableCan be useful/effective/beneficialComparative-Effectiveness Phrases↑:- Treatment/strategy A is probably recommended/indicated in preference to treatment B- It is reasonable to choose treatment A over treatment B</td></tr><tr><td>CLASS 2b (WEAK)</td><td>Benefit ≥ Risk</td></tr><tr><td colspan="2">Suggested phrases for writing recommendations:May/might be reasonableMay/might be consideredUsefulness/effectiveness is unknown/unclear/uncertain or not well-established</td></tr><tr><td>CLASS 3: No Benefit (MODERATE)(Generally, LOE A or B use only)</td><td>Benefit = Risk</td></tr><tr><td colspan="2">Suggested phrases for writing recommendations:Is not recommendedIs not indicated/useful/effective/beneficialShould not be performed/administered/other</td></tr><tr><td>Class 3: Harm (STRONG)</td><td>Risk &gt; Benefit</td></tr><tr><td colspan="2">Suggested phrases for writing recommendations:Potentially harmfulCauses harmAssociated with excess morbidity/mortalityShould not be performed/administered/other</td></tr></table>
cardiomyopathy, magnetic resonance imaging, mitral valve stenosis, multidetector computed tomography, myocardial infarction, myocardial ischemia, myocardium, NT-proBNP, perfusion imaging, positron-emission tomography, pulmonary hypertension, stable angina, troponin I, troponin T, unstable angina, x-ray computed tomography. Additional relevant studies, published through November 2020 during the guideline writing process, were also considered by the writing committee and added to the evidence tables when appropriate. The final evidence tables are included in the Online Data Supplement and summarize the evidence used by the writing committee to formulate recommendations. References selected and published in the present document are representative and not all-inclusive.
LEVEL (QUALITY) OF EVIDENCE‡
<table><tr><td>LEVEL A</td></tr><tr><td>High-quality evidence‡ from more than 1 RCTMeta-analyses of high-quality RCTsOne or more RCTs corroborated by high-quality registry studies</td></tr><tr><td>LEVEL B-R(Randomized)</td></tr><tr><td>Moderate-quality evidence‡ from 1 or more RCTsMeta-analyses of moderate-quality RCTs</td></tr><tr><td>LEVEL B-NR(Nonrandomized)</td></tr><tr><td>Moderate-quality evidence‡ from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studiesMeta-analyses of such studies</td></tr><tr><td>LEVEL C-LD(Limited Data)</td></tr><tr><td>Randomized or nonrandomized observational or registry studies with limitations of design or executionMeta-analyses of such studiesPhysiological or mechanistic studies in human subjects</td></tr><tr><td>LEVEL C-E0(Expert Opinion)</td></tr><tr><td>Consensus of expert opinion based on clinical experience</td></tr></table>
COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
† For comparative-effectiveness recommendations (COR 1 and 2a; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
± The method of assessing quality is evolving, including the application of standardized, widely-used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.
COR indicates Class of Recommendation; E0, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; and RCT, randomized controlled trial.
1.2. Organization of the Writing Committee
The writing committee consisted of cardiac intensivists, cardiac interventionalists, cardiac surgeons, cardiologists, emergency physicians, epidemiologists, and a lay/patient representative. The writing committee included representatives from the ACC, AHA, American Society of Echocardiography (ASE), American College of Chest Physicians (CHEST), Society for Academic Emergency Medicine (SAEM), Society of Cardiovascular Computed Tomography (SCCT), and Society for Cardiovascular Magnetic Resonance (SCMR). Appendix 1 lists writing committee members' relevant RWI. For the purposes of full transparency, the writing committee members' comprehensive disclosure information is available in the Supplemental Appendix.
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Table 2. Associated Guidelines and Statements
<table><tr><td>Title</td><td>Organization</td><td>Publication Year (Reference)</td></tr><tr><td colspan="3">Guidelines</td></tr><tr><td>Stable ischemic heart disease</td><td>ACC/AHA/AATS/PCNA/SCAI/STS</td><td>\( 2014^{1*} \)\( 2012^2 \)</td></tr><tr><td>Atrial fibrillation</td><td>AHA/ACC/HRS</td><td>\( 2014^{3*} \)\( 2019^4 \)</td></tr><tr><td>Non-ST elevation ACS</td><td>AHA/ACC</td><td>\( 2014^5 \)</td></tr><tr><td>Blood cholesterol</td><td>AHA/ACC/AACVP/R/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA</td><td>\( 2018^6 \)</td></tr><tr><td>Heart failure</td><td>ACC/AHA</td><td>\( 2013^{7*} \)\( 2017^8 \)</td></tr><tr><td>Primary prevention of cardiovascular disease</td><td>ACC/AHA</td><td>\( 2019^9 \)</td></tr><tr><td>Management of overweight and obesity in adults</td><td>AHA/ACC/TOS</td><td>\( 2014^{10} \)</td></tr><tr><td>ST-elevation myocardial infarction</td><td>ACC/AHA</td><td>\( 2013^{11} \)</td></tr><tr><td>Ventricular arrhythmias and the prevention of sudden cardiac death</td><td>AHA/ACC/HRS</td><td>\( 2017^{12} \)</td></tr><tr><td>Coronary artery bypass graft surgery</td><td>ACC/AHA</td><td>\( 2011^{13} \)</td></tr><tr><td>Hypertrophic cardiomyopathy</td><td>ACC/AHA</td><td>\( 2020^{14} \)</td></tr><tr><td>Percutaneous coronary intervention</td><td>ACC/AHA/SCAI</td><td>\( 2011^{15*} \)\( 2015^{16} \)</td></tr><tr><td>Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease</td><td>AHA/ACC</td><td>\( 2011^{17} \)</td></tr><tr><td>Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care-part 9: postcardiac arrest care</td><td>AHA</td><td>\( 2010^{18*} \)\( 2019^{19} \)</td></tr><tr><td>Prevention, detection, evaluation, and management of high blood pressure in adults</td><td>ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA</td><td>\( 2017^{20} \)</td></tr><tr><td colspan="3">Statements</td></tr><tr><td>Testing of low-risk patients presenting to the emergency department with chest pain</td><td>AHA</td><td>\( 2010^{21} \)</td></tr><tr><td>Prevention of cardiovascular disease in adults with type 2 diabetes mellitus</td><td>AHA/ADA</td><td>\( 2015^{22} \)</td></tr><tr><td>Prevention and control of seasonal influenza with vaccines</td><td>CDC</td><td>\( 2018^{23} \)</td></tr></table>
AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AAPA, American Academy of Physician Assistants; AATS, American Association for Thoracic Surgery; ABC, Association of Black Cardiologists; ACC, American College of Cardiology; ACPM, American College of Preventive Medicine; ADA, American Diabetes Association; AGS, American Geriatrics Society; AHA, American Heart Association; APhA, American Pharmacists Association; ASH, American Society of Hypertension; ASPC, American Society for Preventive Cardiology; CDC, Centers for Disease Control and Prevention; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; NHLBI, National Heart, Lung, and Blood Institute; NLA, National Lipid Association; NMA, National Medical Association; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and TOS, The Obesity Society.
*The full-text guideline and focused update references are provided.
1.3. Document Review and Approval
This document was reviewed by 16 official reviewers nominated by the ACC, the American College of Emergency Physicians, AHA, ASE, American Society of Nuclear Cardiology, CHEST, SAEM, SCCT, and SCMR, and 39 individual content reviewers. Reviewers' RWI information was distributed to the writing committee and is published in this document (Appendix 2).
This document was approved for publication by the governing bodies of the ACC and the AHA and was endorsed by the ASE, CHEST, SAEM, SCCT, and SCMR.
1.4. Scope of the Guideline
The charge of the writing committee was to develop a guideline for the evaluation of acute or stable chest pain or other anginal equivalents, in various clinical settings, with an
emphasis on the diagnosis on ischemic causes. This guideline will not provide recommendations on whether revascularization is appropriate or what modality is indicated. Such recommendations can be found in the forthcoming ACC/AHA coronary artery revascularization guideline. In developing the “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain,” the writing committee first reviewed previous published guidelines and related statements. Table 2 contains a list of these publications deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations.
1.4.1. Scope of the Problem Synopsis
After injuries, chest pain is the second most common reason for adults to present to the emergency
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department (ED) in the United States and accounts for >6.5 million visits, which is 4.7% of all ED visits. \( ^{1} \) Chest pain also leads to nearly 4 million outpatient visits annually in the United States. \( ^{2} \) Chest pain remains a diagnostic challenge in the ED and outpatient setting and requires thorough clinical evaluation. Although the cause of chest pain is often noncardiac, coronary artery disease (CAD) affects >18.2 million adults in the United States and remains the leading cause of death for men and women, accounting for >365 000 deaths annually. \( ^{3} \) Distinguishing between serious and benign causes of chest pain is imperative. The lifetime prevalence of chest pain in the United States is 20% to 40%, \( ^{4} \) and women experience this symptom more often than men. \( ^{5} \) Of all ED patients with chest pain, only 5.1% will have an acute coronary syndrome (ACS), and more than half will ultimately be found to have a noncardiac cause. \( ^{6} \) Nonetheless, chest pain is the most common symptom of CAD in both men and women.
1.4.2. Defining Chest Pain
<table><tr><td colspan="3">Recommendations for Defining Chest PainReferenced studies that support the recommendations are summarized in Online Data Supplements 1, 2, 3</td></tr><tr><td>COR</td><td>LOE</td><td>Recommendations</td></tr><tr><td>1</td><td>B-NR</td><td>1. An initial assessment of chest pain is recommended to triage patients effectively on the basis of the likelihood that symptoms may be attributable to myocardial ischemia.1-7</td></tr><tr><td>1</td><td>C-LD</td><td>2. Chest pain should not be described as atypical, because it is not helpful in determining the cause and can be misinterpreted as benign in nature. Instead, chest pain should be described as cardiac, possibly cardiac, or noncardiac because these terms are more specific to the potential underlying diagnosis.</td></tr></table>
Synopsis
Chest pain is one of the most common reasons that people seek medical care. The term “chest pain” is used by patients and applied by clinicians to describe the many unpleasant or uncomfortable sensations in the anterior chest that prompt concern for a cardiac problem. Chest pain should be considered acute when it is new onset or involves a change in pattern, intensity, or duration compared with previous episodes in a patient with recurrent symptoms. Chest pain should be considered stable when symptoms are chronic and associated with consistent precipitants such as exertion or emotional stress.
Although the term chest pain is used in clinical practice, patients often report pressure, tightness, squeezing, heaviness, or burning. In this regard, a more appropriate term is “chest discomfort,” because patients may not use the descriptor “pain.” They may also report a location other than the chest, including the shoulder, arm, neck, back, upper abdomen, or jaw. Despite individual variability, the discomfort induced by myocardial ischemia is often characteristic and therefore central to the diagnosis. For this reason, features more likely to be associated with ischemia have been described as typical versus atypical; however, the latter can be confusing because it is frequently used to describe symptoms considered nonischemic as well as noncardiac. Although other nonclassic symptoms of ischemia, such as shortness of breath, nausea, radiating discomfort, or numbness, may be present, chest pain or chest discomfort remains the predominant symptom reported in men and women who are ultimately diagnosed with myocardial ischemia. \( ^{3-7} \) Pain—described as sharp, fleeting, related to inspiration (pleuritic) or position, or shifting locations—suggests a lower likelihood of ischemia.

Figure 2. Index of Suspicion That Chest “Pain” Is Ischemic in Origin on the Basis of Commonly Used Descriptors
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Recommendation-Specific Supportive Text
1. Like most visceral discomfort, the sensation produced by myocardial ischemia is characteristically deep, difficult to localize, and usually diffuse. Point tenderness renders ischemia less likely. Reported symptoms lie somewhere on a continuum of higher or lower probability of ischemia based on the presence or absence of specific characteristics (Figure 2). Other clinical elements (eg, duration, provoking and relieving factors, patient age, cardiac risk factors) provide further focus toward or away from ischemia in the diagnostic process. It is essential to ascertain the characteristics of the chest pain directly from the patient for optimal interpretation. \( ^{1-7} \) A patient's history is the most important basis for considering presence or absence of myocardial ischemia, but the source of cardiac symptoms is complex, and their expression is variable. The diagnosis of ischemia may require data beyond history alone. In some patients, what appears to be noncardiac chest pain may be ischemic in origin.
2. Chest pain has been traditionally stratified into “typical” and “atypical” types. Chest pain that is more likely associated with ischemia consists of substernal chest discomfort provoked by exertion or emotional stress and relieved by rest or nitroglycerin. The more classic the chest discomfort is based on quality, location, radiation, and provoking and relieving factors, the more likely it is to be of cardiac ischemic origin. Atypical chest pain is a problematic term. Although it was intended to indicate angina without typical chest symptoms, it is more often used to state that the symptom is noncardiac in origin. As such, we discourage the use of atypical chest pain. Emphasis is more constructively placed on specific aspects of symptoms that suggest their origin in terms of probable ischemia. Of note, chest pain is broadly defined to also include referred pain in the shoulders, arms, jaw, neck, and upper abdomen. To diminish ambiguity, use “cardiac,” “possible cardiac,” and “noncardiac” to describe the suspected cause of chest pain is encouraged.
1.5. Abbreviations
<table><tr><td>Abbreviation</td><td>Meaning/Phrase</td></tr><tr><td>ACS</td><td>acute coronary syndrome</td></tr><tr><td>AMI</td><td>acute myocardial infarction</td></tr><tr><td>CABG</td><td>coronary artery bypass graft</td></tr><tr><td>CAC</td><td>coronary artery calcium</td></tr><tr><td>CAD</td><td>coronary artery disease</td></tr><tr><td>CCTA</td><td>coronary computed tomographic angiography</td></tr><tr><td>CDP</td><td>clinical decision pathway</td></tr><tr><td>CMR</td><td>cardiovascular magnetic resonance</td></tr><tr><td>cTn</td><td>cardiac troponin</td></tr><tr><td>ECG</td><td>electrocardiogram</td></tr><tr><td>ED</td><td>emergency department</td></tr><tr><td>EMS</td><td>emergency medical services</td></tr><tr><td>FFR-CT</td><td>fractional flow reserve with computed tomography</td></tr><tr><td>GDMT</td><td>guideline-directed medical therapy</td></tr><tr><td>hs-cTn</td><td>high-sensitivity cardiac troponin</td></tr><tr><td>ICA</td><td>invasive coronary angiography</td></tr><tr><td>INOCA</td><td>ischemia and no obstructive coronary artery disease</td></tr><tr><td>MACE</td><td>major adverse cardiovascular events</td></tr><tr><td>MBFR</td><td>myocardial blood flow reserve</td></tr><tr><td>METs</td><td>metabolic equivalents</td></tr><tr><td>MINOCA</td><td>myocardial infarction and nonobstructive coronary arteries</td></tr><tr><td>MPI</td><td>myocardial perfusion imaging</td></tr><tr><td>NSTE-ACS</td><td>non-ST-segment-elevation acute coronary syndrome</td></tr><tr><td>PCI</td><td>percutaneous coronary intervention</td></tr><tr><td>PE</td><td>pulmonary embolism</td></tr><tr><td>PET</td><td>positron emission tomography</td></tr><tr><td>SIHD</td><td>stable ischemic heart disease</td></tr><tr><td>SPECT</td><td>single-photon emission computed tomography</td></tr><tr><td>STEMI</td><td>ST-segment-elevation myocardial infarction</td></tr><tr><td>TEE</td><td>transesophageal echocardiography</td></tr><tr><td>TTE</td><td>transthoracic echocardiography</td></tr><tr><td>VF</td><td>ventricular fibrillation</td></tr><tr><td>VHD</td><td>valvular heart disease</td></tr><tr><td>VT</td><td>ventricular tachycardia</td></tr></table>
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Figure 3. Top 10 Causes of Chest Pain in the ED Based on Age (Weighted Percentage)
Created using data from Hsia RY et al. \( ^{3} \) ED indicates emergency department.
2. INITIAL EVALUATION
2.1. History
<table><tr><td colspan="3">Recommendation for History</td></tr><tr><td>COR</td><td>LOE</td><td>Recommendation</td></tr><tr><td>1</td><td>C-LD</td><td>1. In patients with chest pain, a focused history that includes characteristics and duration of symptoms relative to presentation as well as associated features, and cardiovascular risk factor assessment should be obtained.</td></tr></table>
Synopsis
Chest pain or chest pain equivalent will be referred to in these guidelines as “chest pain.” Patients presenting to the ED with nontraumatic chest pain are a frequent diagnostic challenge. \( ^{1} \) The priorities are: 1) rapid initiation of optimal management in patients with life-threatening conditions such as ACS, aortic dissection, and pulmonary embolism (PE), as well as nonvascular syndromes (eg, esophageal rupture, tension pneumothorax); and 2) deliberate therapy for those with less critical illness. Although there are several life-threatening causes, chest pain usually reflects a more benign condition (Figure 3). \( ^{2-4} \) The initial ECG is important to the evaluation, but history, examination, biomarkers, and other aids remain essential. There is frequently a lack of correlation between intensity of symptoms and seriousness of disease and general similarity of symptoms among different causes of chest pain. A comprehensive history that captures all the characteristics of chest pain (Table 3), including
but not limited to its: 1) nature; 2) onset and duration; 3) location and radiation; 4) precipitating factors; 5) relieving factors; and 6) associated symptoms can help better identify potential cardiac causes and should be obtained from all patients.
Recommendation-Specific Supportive Text
1. Angina pectoris is perceived as a retrosternal chest discomfort that builds gradually in intensity (over several minutes), is usually precipitated by stress (physical or emotional) or occurring at rest (as in the case of an ACS) with characteristic radiation (eg, left arm, neck, jaw) and its associated symptoms (eg, dyspnea, nausea, lightheadedness). When actively treated or spontaneously resolving, it dissipates over a few minutes. Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion, especially because other entities demonstrate comparable response (eg, esophageal spasm). \( ^{1,5} \) Associated symptoms such as shortness of breath, nausea or vomiting, lightheadedness, confusion, presyncope or syncope, or vague abdominal symptoms are more frequent among patients with diabetes, women, and the elderly. A detailed assessment of cardiovascular risk factors, review of systems, past medical history, and family and social history should complement the assessment of presenting symptoms.
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2.1.1. A Focus on the Uniqueness of Chest Pain in Women
<table><tr><td colspan="3">Recommendations for a Focus on the Uniqueness of Chest Pain in Women</td></tr><tr><td colspan="3">Referenced studies that support the recommendations are summarized in Online Data Supplements 6 and 4.</td></tr><tr><td>COR</td><td>LOE</td><td>Recommendations</td></tr><tr><td>1</td><td>B-NR</td><td>1. Women who present with chest pain are at risk for underdiagnosis, and potential cardiac causes should always be considered.\( ^{1-7} \)</td></tr><tr><td>1</td><td>B-NR</td><td>2. In women presenting with chest pain, it is recommended to obtain a history that emphasizes accompanying symptoms that are more common in women with ACS.\( ^{1-7} \)</td></tr></table>
Table 3. Chest Pain Characteristics and Corresponding Causes
<table><tr><td>Nature</td></tr><tr><td>Anginal symptoms are perceived as retrosternal chest discomfort (eg, pain, discomfort, heaviness, tightness, pressure, constriction, squeezing) (Section 1.4.2, Defining Chest Pain).</td></tr><tr><td>Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (eg, these symptoms usually occur with acute pericarditis).</td></tr><tr><td>Onset and duration</td></tr><tr><td>Anginal symptoms gradually build in intensity over a few minutes.</td></tr><tr><td>Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome.</td></tr><tr><td>Fleeting chest pain–of few seconds&#x27; duration–is unlikely to be related to ischemic heart disease.</td></tr><tr><td>Location and radiation</td></tr><tr><td>Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia.</td></tr><tr><td>Severity</td></tr><tr><td>Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (eg, aortic dissection).</td></tr><tr><td>Precipitating factors</td></tr><tr><td>Physical exercise or emotional stress are common triggers of anginal symptoms.</td></tr><tr><td>Occurrence at rest or with minimal exertion associated with anginal symptoms usually indicates ACS.</td></tr><tr><td>Positional chest pain is usually nonischemic (eg, musculoskeletal).</td></tr><tr><td>Relieving factors</td></tr><tr><td>Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion.</td></tr><tr><td>Associated symptoms</td></tr><tr><td>Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, pressup-cope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting.</td></tr><tr><td>Symptoms on the left or right side of the chest, stabbing, sharp pain, or discomfort in the throat or abdomen may occur in patients with diabetes, women, and elderly patients.</td></tr></table>
ACS indicates acute coronary syndrome.
Synopsis
Most patients who present to the ED with chest pain are women, particularly among those \( \geq \) 65 years of age. \( ^{8} \) The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial demonstrated that women with moderate-to-severe ischemia are more symptomatic than men. \( ^{9} \) Women are less likely to have timely and appropriate care. \( ^{10} \) This could be explained by the fact that women are more likely to experience prodromal symptoms when they seek medical care. \( ^{11} \) Women may also present with accompanying symptoms (eg, nausea, fatigue, and shortness of breath) more often than men. \( ^{12-14} \) However, chest pain remains the predominant symptom reported by women among those ultimately diagnosed with ACS, occurring with a frequency equal to men. \( ^{3,5-7,15,16} \)
Recommendation-Specific Supportive Text
1. Traditional risk score tools and physician assessments often underestimate risk in women and misclassify them as having nonischemic chest pain. \( ^{1,2} \) The PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial looked at sex differences in the presentation, risk factors, demographics, noninvasive test referrals, and results of 10003 stable outpatients with suspected CAD. \( ^{1} \) Women commonly presented with chest pain symptoms similar to men but also had a greater prevalence of other symptoms such as palpitations, jaw and neck pain, as well as back pain. Women also had more cardiovascular risk factors, including hypertension (66.6% versus 63.2%; P<0.001), hyperlipidemia (68.9% versus 66.3%; P=0.004), older age (62.4±7.9 years of age versus 59.0±8.4 years of age, P<0.001), cerebral or peripheral artery disease (6.2% versus 4.7%; P<0.001), family history of premature CAD (34.6% versus 29.3%; P<0.001), and sedentary lifestyle (53.5% versus 43.4%; P<0.001). Physician assessments often misclassify chest pain as nonanginal. The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial reported that women with diabetes had a higher prevalence of angina than their male counterparts, with a lower functional capacity and a lower incidence of obstructive CAD. \( ^{16} \)
2. In the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, men and women ≤55 years of age were equally likely to present with chest pain (defined as pain, pressure, tightness, discomfort; 89.5% versus 87%, respectively). Women were more likely to report ≥3 associated symptoms than men (eg, epigastric symptoms,
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palpitations, and pain or discomfort in the jaw, neck, arms, or between the shoulder blades; 61.9% of women versus 54.8% of men; P<0.001). \( ^{3} \) Similar results were found in the YOUNG-MI (Myocardial Infarction) registry where young men and women ( \( \leq \) 50 years of age) were equally likely to present with chest pain, although women were more likely to also have other associated symptoms. \( ^{7} \) The HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke) study used cardiolinguistic machine learning to record patient-reported symptoms and, in those diagnosed with obstructive CAD, there was no sex difference in the occurrence of chest pain. \( ^{6} \) In a prospective trial of 1941 patients (39% women) with suspected ACS examining the diagnostic value of high-sensitivity cardiac troponin (cTn), chest pain was reported in 92% of women and 91% of men. \( ^{5} \) Additionally, women with acute myocardial infarction (AMI) were more likely to present with “typical” symptoms than men (77% versus 59%; P=0.007).
2.1.2. Considerations for Older Patients With Chest Pain
<table><tr><td colspan="3">Recommendation for Considerations for Older Patients With Chest Pain</td></tr><tr><td>COR</td><td>LOE</td><td>Recommendation</td></tr><tr><td>1</td><td>C-LD</td><td>1. In patients with chest pain who are &gt;75 years of age, ACS should be considered when accompanying symptoms such as shortness of breath, syncope, or acute delirium are present, or when an unexplained fall has occurred.1</td></tr></table>
Synopsis
Increased age is a significant risk factor for ACS. However, it is also a risk factor for comorbidities that are associated with alternative diagnoses associated with chest pain. As a result, a more extensive diagnostic workup is required in older patients. Although patients >75 years of age account for 33% of all cases of ACS, alternative diagnoses are still more common than a cardiac cause of chest pain at presentation. \( ^{2,3} \) A substudy of the PROMISE trial has shown that patients >75 years of age, with stable symptoms suggestive of CAD, are more likely to have a positive noninvasive test and more coronary artery calcification than younger people. For these older patients, when compared with anatomic noninvasive testing for obstructive CAD with cardiac CT, a positive stress test result was associated with increased risk of cardiovascular death or MI. \( ^{4} \)
Recommendation-Specific Supportive Text
1. Patients >75 years of age may have symptoms of shortness of breath, syncope, mental impairment, or
abdominal pain, or experienced an unexplained fall. The physician should have a heightened awareness to understand that these symptoms may be associated with ACS, in addition to chest pain. \( ^{1} \)
2.1.3. Considerations for Diverse Patient Populations With Chest Pain
Recommendations for Considerations for Diverse Patient Populations With Chest Pain
<table><tr><td>COR</td><td>LOE</td><td>Recommendations</td></tr><tr><td>1</td><td>C-LD</td><td>1. Cultural competency training is recommended to help achieve the best outcomes in patients of diverse racial and ethnic backgrounds who present with chest pain.2. Among patients of diverse race and ethnicity presenting with chest pain in whom English may not be their primary language, addressing language barriers with the use of formal translation services is recommended.</td></tr></table>
Synopsis
There are marked racial and ethnic disparities when triaging patients who present for the evaluation of chest pain. Despite a greater number of Black patients presenting with angina pectoris relative to other races, this population is less likely to be treated urgently and less likely to have an ECG performed, samples for cardiac biomarkers drawn, cardiac monitoring performed, or pulse oximetry measured. \( ^{1-4} \) Similar treatment disparities are found with Hispanic patients and those who are covered by Medicaid or are uninsured. Derived from a nationally representative sample from the National Hospital Ambulatory Health Care Survey reflecting an estimated 78 million ED visits in the United States over a 10-year period, these findings have been unchanged over time. \( ^{5} \) Such disparity in the management of chest pain among diverse population subgroups contributes to worse outcomes, including the greater incidence of AMI and fatal coronary events seen in these key population subgroups. \( ^{6,7} \) There are also disparities in the management of patients of South Asian descent who present with ACS, with the diagnosis often missed or delayed, resulting in poor outcomes. \( ^{8-11} \) Consideration of race and ethnicity in the evaluation of patients with suspected ACS and in the outpatient evaluation of symptomatic patients is paramount to improving outcomes. Cultural competency training of providers is recommended to address health disparities in the evaluation and management of diverse patient population subgroups with chest pain.
Recommendation-Specific Supportive Text
1. In patients of various diverse groups presenting with chest pain, cultural competency training of providers to address racial and ethnic disparities may help to improve diagnosis, treatment, and
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outcomes. Attention to race, ethnicity, and socio-cultural differences should be considered in the evaluation and management of such patients. Cultural competency training can help address difficulties in the assessment of patients because there may be differences in the description and perception of chest pain among various diverse patient groups. Such training may also help to minimize potential unconscious biases on the part of providers. Disparities in the management of chest pain among diverse populations contribute to worse outcomes, including the greater incidence of MI and fatal coronary events. \( ^{1} \)
2. In patients of various racial and ethnic subgroups presenting with suspected ACS in whom English may not be their primary language, adequately addressing language barriers with the use of language translation is vital to obtain an accurate and complete history. Formal translation services such as those provided through institutions and virtual translation are recommended.
2.1.4. Patient-Centric Considerations
<table><tr><td colspan="3">Recommendation for Patient-Centric Considerations</td></tr><tr><td>COR</td><td>LOE</td><td>Recommendation</td></tr><tr><td>1</td><td>C-LD</td><td>1. In patients with acute chest pain, it is recommended that 9-1-1 be activated by patients or bystanders to initiate transport to the closest ED by emergency medical services (EMS).1</td></tr></table>
Synopsis
Although chest pain remains one of the most common reasons that patients seek evaluation, among both sexes, there is a tendency for some patients to minimize perceived risk for cardiac disease, resulting in potentially avoidable delays in care. \( ^{1} \) To alleviate this problem, efforts should be made to educate all people regarding their risk for a cardiac event and educate patients about the need for timely care if a heart attack is suspected. Education is essential regarding the need to call 9-1-1, provide transportation by EMS to the nearest ED, initiate early assessment and management of suspected ACS, including transmittal of prehospital ECGs, \( ^{2} \) and intervene if complications occur en route to the ED. \( ^{3} \) The ACC's Early Heart Attack Care guide is a resource to help educate the public about early recognition of potential cardiac symptoms and the importance of activating 9-1-1 for transportation. \( ^{4,5} \)
Recommendation-Specific Supportive Text
1. To ensure the timely delivery of appropriate care, especially reperfusion therapy, it is strongly recommended that patients with acute chest pain be
transported to the ED by trained EMS personnel. \( ^{2,3} \) EMS transportation is associated with substantial reductions in ischemic time and treatment delays. Moreover, 1 in 300 patients with chest pain transported to the ED by private vehicle suffers a cardiac arrest en route. \( ^{3} \) Understanding the mode of transportation to the ED for patients with chest pain and educating those who arrive by private vehicle on the associated dangers is an important aspect of management.
2.2. Physical Examination
<table><tr><td colspan="3">Recommendation for Physical Examination</td></tr><tr><td>COR</td><td>LOE</td><td>Recommendation</td></tr><tr><td>1</td><td>C-EO</td><td>1. In patients presenting with chest pain, a focused cardiovascular examination should be performed initially to aid in the diagnosis of ACS or other potentially serious causes of chest pain (eg, aortic dissection, PE, or esophageal rupture) and to identify complications.</td></tr></table>
Synopsis
Life-threatening causes of chest pain include, but are not limited to, ACS, PE, aortic dissection, and esophageal rupture. Because ST-segment-elevation myocardial infarction (STEMI) can be recognized on the ECG, the major challenge is to distinguish between non-ST-segment-elevation (NSTE)-ACS and noncardiac chest pain. \( ^{1} \) With an uncomplicated AMI, the examination may be negative. Sudden onset of severe chest pain or back pain associated with limb pulse differential suggest aortic dissection, \( ^{2} \) but sensitivity of the latter finding alone was only 30%. \( ^{3} \) PE may result in tachycardia, dyspnea, and accentuated P2. Noncoronary causes of chest pain include aortic stenosis, aortic regurgitation, and hypertrophic cardiomyopathy, which produces characteristic murmurs and pulse alterations. Chest pain of pericarditis increases in the supine position and may be associated with a friction rub. Stress cardiomyopathy presents in a similar manner as ACS. Chest pain accompanied by a painful, tympanic abdomen may indicate a potentially life-threatening gastrointestinal etiology such as esophageal rupture. \( ^{4} \) Pneumonia may cause localized pleuritic chest pain accompanied by a friction rub. Pneumothorax may be accompanied by pleuritic chest pain and unilateral absence of breath sounds. Tenderness to palpation of the costochondral joints may indicate a musculoskeletal cause. Herpes zoster produces a painful rash in a dermatomal distribution.
Recommendation-Specific Supportive Text
1. Although the causes of chest pain are numerous, the initial evaluation should focus on those


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