The 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain was released on 28 October 2021. This report represents years of work by the Joint Committee on Clinical Practice Guidelines to define protocols and algorithms based on the evidence. This guideline represents a significant shift from prior guidelines because it begins with the patient’s experience- chest pain, rather than specific diagnoses, such as the guidelines on stable ischemic heart disease (2012, 2014), atrial fibrillation (2019), heart failure (2017). The guideline explicitly encourages shared decision-making with patients. It recommends avoiding unnecessary diagnostic testing for low-risk patients, and it combines pathways for intermediate and high-risk patients. The use of Coronary CTA is recommended for intermediate and high-risk patients with stable chest pain and no known CAD. For the first time in an ACC /AHA guideline, FFR-CT is officially recommended in some clinical pathways for diagnosis of vessel-specific ischemia and to guide decision-making for the use of coronary revascularization.

CCTA as a First-Line Test and FFR-CT as an Add-on Test

This consensus guideline represents seven professional societies and finally brings the US guidelines into harmony with guidance from the UK and Europe. Both the European Society of Cardiology and the UK’s National Institute for Health and Care Excellence now encourage the use of Coronary CT as a first-line test for patients with stable heart pain and, for some patients, the additional use of CT-derived FFR simulation algorithms to non-invasively assess functional ischemia from the images captured during the Coronary CTA.

SCCT Webcasts

The Society for Coronary CT (SCCT) conducted two excellent webcasts on the new Chest Pain Guideline that are available on YouTube. The first summarizes guidance for Acute Chest Pain and the second summarizes the updated guidelines for the management of Stable Chest Pain. These two webcasts are worth watching. They summarize what’s new in these guidelines, describe how the use of Coronary CTA has changed for both Acute and Stable chest pain patients, how physicians can select further testing options, and describe what is missing from the 2021 guidelines that might appear in future guidelines.

Part 1: Update on Management of Acute Chest Pain
Part 2: Update on Management of Stable Chest Pain

Structured Assessment

The new guidelines emphasize the importance of early triage of whether the symptoms could be attributable to myocardial ischemia. A structured assessment should be made to classify the patient’s chest pain (which could also be a pain in the shoulder, jaw, epigastric area, neck, or back). The normative classifications are  “cardiac”, “possibly cardiac”, and “non-cardiac”. These three terms are specific to the underlying diagnosis. The 2021 guideline deprecates the continued use of the term “atypical chest pain” in favor of these terms. The 2021 guideline also recommends cultural competency training and translation series to achieve the best outcomes for patients with diverse racial and ethnic backgrounds who present with chest pain. Encouraging structured assessment of patient conditions to drive clinical pathway decisions distinguishes the 2021ACC AHA Chest Pain Guideline as a major advance in evidence-based clinical leadership.

CCTA and FFR-CT Utilization Growth Seen

The 2021 ACA AHA Chest Pain Guideline may serve to increase interest in the use of Coronary CTA and FFR-CT as an add-on test for certain patients for whom the anatomic assessment is inconclusive. The guideline includes Coronary CTA and stress tests (such as Stress CMR, Stress PET, Stress SPECT, and Stress Echo).  Recent evidence from randomized clinical trials supports the use of Coronary CTA to rule out coronary artery disease (CAD). We expect to see utilization to increase as more radiologists and cardiologists become familiar with the clinical and economic benefits of these tests.

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