Tips and tools to help refine your approach to chest pain

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doi:doi: 10.12788/jfp.0301

Applied Evidence

Tips and tools to help refine your approach to chest pain

J Fam Pract. 2021 November;70(9):420-430 | doi: 10.12788/jfp.0301

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References

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26. Laureano-Phillips J, Robinson RD, Aryal S, et al. HEART score risk stratification of low-risk chest pain patients in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2019;74:187-203. doi: 10.1016/j.annemergmed.2018.12.010

27. Fernando SM, Tran A, Cheng W, et al. Prognostic accuracy of the HEART score for prediction of major adverse cardiac events in patients presenting with chest pain: a systematic review and meta-analysis. Acad Emerg Med. 2019;26:140-151. doi: 10.1111/acem.13649

28. Sakamoto JT, Liu N, Koh ZX, et al. Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department. Int J Cardiol. 2016;221:759-764. doi: 10.1016/j.ijcard.2016.07.147

29. Harskamp RE, Laeven SC, Himmelreich JCL, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9:e027081. doi: 10.1136/bmjopen-2018-027081

30. Aerts M, Minalu G, Bösner S, et al. Internal Working Group on Chest Pain in Primary Care (INTERCHEST). Pooled individual patient data from five countries were used to derive a clinical prediction rule for coronary artery disease in primary care. J. Clin Epidemiol. 2017;81:120-128. doi: 10.1016/j.jclinepi.2016.09.011

31. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients in the emergency department. Int J Cardiol. 2013;168:2153-2158. doi: 10.1016/j.ijcard.2013.01.255

32. Backus BE, Six AJ, Kelder JC, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010;9:164-169. doi: 10.1097/HPC.0b013e3181ec36d8

33. Poldervaart JM, Langedijk M, Backus BE, et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017;227:656-661. doi: 10.1016/j.ijcard.2016.10.080

34. Reaney PDW, Elliott HI, Noman A, et al. Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events. Emerg Med J. 2018;35:420-427. doi: 10.1136/emermed-2017-207172

35. Bittencourt MS, Hulten E, Polonsky TS, et al. European Society of Cardiology-recommended coronary artery disease consortium pretest probability scores more accurately predict obstructive coronary disease and cardiovascular events than the Diamond Forrester score: The Partners Registry. Circulation. 2016;134:201-211. doi: 10.1161/CIRCULATIONAHA.116.023396

36. Mordi IR, Badar AA, Irving RJ, et al. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag. 2017;13:427-437. doi: 10.2147/VHRM.S106838

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41. Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society of Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Circulation. 2010;122:e525-e555. doi: 10.1161/CIR.0b013e3181fcae66

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Noninvasive imaging-based diagnostic methods

Positron-emission tomography stress testing, stress echocardiography, myocardial perfusion scanning, exercise treadmill testing. The first 3 of these imaging tests have a sensitivity and specificity ranging from 74% to 87%³⁶; exercise treadmill testing is less sensitive (68%) and specific (77%).³⁷

In a patient with a very low (< 5%) probability of CAD, a positive stress test (of any modality) is likely to be a false-positive; conversely, in a patient with a very high (> 90%) probability of CAD, a negative stress test is likely to be a false-negative.¹⁹The American Heart Association, therefore, does not recommend any of these modalities for patients who have a < 5% or > 90% probability of CAD.¹⁹

Triage assessment of the chestpain patient, including vital signs, general appearance, and basic symptom questions, can clarify whether they need transfer to a higher level of care.

Noninvasive testing to rule out ACS in low- and intermediate-risk patients who present to the ED with chest pain provides no clinical benefit over clinical evaluation alone.³⁸ Therefore, these tests are rarely used in the initial evaluation of chest pain in an acute setting.

Coronary artery calcium score (CACS), coronary computed tomography angiography (CCTA). These tests have demonstrated promise in the risk stratification of chest pain, given their high sensitivity and negative predictive value in low- and intermediate-risk patients.^39,40 However, their application remains unclear in the evaluation of acute chest pain: Appropriate-use criteria do not favor CACS or CCTA alone to evaluate acute chest pain when there is suspicion of ACS.⁴¹ The Choosing Wisely initiative (for “avoiding unnecessary medical tests, treatments, and procedures”; www.choosingwisely.org) recommends against CCTA for high-risk patients presenting to the ED with acute chest pain.⁴²

Cardiac magnetic resonance imaging does not have an established role in the evaluation of patients with suspected ACS.⁴³

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