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Top 10 Take-Home Messages:*
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.
