Chest Pain Guidelines Make Hospitals More User Friendly

February is Heart Month. As a former cardiac ultrasound tech with hundreds of hours supporting interventionalists in the cath lab, I am reminded of the importance of cardiovascular health and how to improve care pathways and health outcomes for patients facing cardiovascular disease. The international chest pain guidelines recently released have the potential to achieve both.

In the 2021 AHA/ACC/ASE/CHEST/SAEM/ SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain, there's a particular focus on contemporary imaging modalities for risk assessment and management planning in patients with stable or acute chest discomfort. One of the significant shifts in the guideline is the elevated role of coronary CTA (CCTA) for the non-invasive assessment of these patients. In fact, coronary CTA is the only non-invasive testing modality given a Class 1 recommendation supported by Level A quality of evidence. Other widely used modalities such as stress echo are classified lower than CTA, as Class 1 but with Level B quality of evidence.

Physicians across the country now can recommend coronary computed tomography angiography (CCTA) as a frontline test for their patients if they judge these patients to be stable with acute chest pain and no known coronary artery disease.

An important evidence-based option for physicians and the patients in their care, these guidelines mean patients may now receive a CCTA test in the emergency department that may more quickly allow clinicians to take the worst fears off the table and ultimately get patients home sooner. Unlike in the past, perhaps they don't need to be rushed to the cardiac catheterization lab for an invasive test through an incision in their groin. In addition, they may not need to spread the word to their alarmed family that they will be staying overnight, with scheduled stress and exercise tests coming together and a worry over what may be coming next.

The new guidelines, formulated by the American College of Cardiology (ACC) and the American Heart Association (AHA), together with the American Society of Echocardiography (ASE), Society of Cardiovascular Computed Tomography (SCCT), Society of Cardiovascular Magnetic Resonance (SCMR), the American College of Chest Physicians (CHEST), and the Society for Academic Emergency Medicine (SAEM) are an essential step toward better, harmonized care and decision-making for all cardiac patients.

Harmonizing care and decision making

As often happens with new guidelines, there will be ongoing examination about aspects of the procedures. However, on the whole, speeding better decisions in the emergency setting is an important step to take across the board. In addition, moving toward having the exact anatomy needed to determine risk moves care and long-term patient health outcomes in the right direction. 

And this is the critical point that can sometimes be overlooked. Chest pain is a broad and complex complaint. We need to continue in this area, and others like it in medicine, to bring together a more common and easier-to-execute process that's built on shared evidence. Easier execution includes preserving the freedom of physicians to exercise the right decisions for their population and their institution's capabilities.

With the new guidelines, the ACC and AHA have taken a significant step towards a precise, patient-driven approach in assessing and managing CAD. However, as with any guidelines or protocols, the question will now be how easily they can be woven into practice in diverse settings. That's the challenge in the coming months. Future important steps will have less to do with the guidelines' details and more the capacity of different health systems to implement and scale them.

It will likely come down to a mix of adoption and technology. All hospitals can become more effective and better at reducing the patient and physician friction that gets in the way of standards like these. Chest pain can have a more user-friendly solution, as the many clinicians we know and still speak to can confirm.

Stay tuned for more on that in the coming weeks and months, and make sure your institution is taking part!