Strong endorsement of coronary angiography in chest pain guidelines

U.S. professional societies have released their first guideline on risk stratification and diagnostic workup for patients with chest pain, inadvertently starting a turf war with nuclear cardiologists.

First, the definition of chest pain in the new directive: “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, “according to the joint guidelines of the American College of Cardiology (ACC) and the American Heart Association (AHA).

Notably, the term “atypical chest pain” is deleted, to be replaced with “cardiac chest pain”, “possibly cardiac” or “non-cardiac”, said the editorial board chaired by Martha Gulati, MD, MS, of the University of Arizona. Phoenix School of Medicine.

The ACC / AHA directive was published in the Journal of the American College of Cardiology and in Circulation.

The paper suggests that emergency departments and ambulatory care centers routinely use structured clinical decision pathways to assess chest pain and separate patients into low, intermediate, and high risk groups (with high-sensitivity troponin preferred over conventional troponin assays in such an assessment).

Downstream diagnostic tests are recommended as follows:

  • Low-risk patients can be discharged without admission or urgent cardiac testing in a Class IIa recommendation
  • Intermediate risk patients should undergo noninvasive anatomical and stress testing with different preferred modes depending on whether the pain is acute or stable and coronary artery disease is known. Here, coronary angiography obtained new Class I recommendations, and computed tomography-derived fractional flow reserve (FFR-CT) was a Class IIa recommendation for further testing in some cases.
  • High-risk patients with suspected acute coronary syndrome have a class I recommendation for invasive coronary angiography

The publication of the ACC / AHA directive has garnered much praise on social networks.

The document has been approved by the American Society of Echocardiography, the American College of Chest Physicians, the Society for Academic Emergency Medicine, the Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance.

However, the American Society of Nuclear Cardiology (ASNC) was particularly absent from the list, which had chosen to separate itself from the peer groups.

“The lack of balance in the presentation of the science paper on FFR-CT and its overly endorsement undermines the basic principle of ASNC of patient-first imaging. We believe that the document does not provide unbiased advice to healthcare professionals on the optimal assessment of patients. suffering from chest pain, ”wrote the ASNC Board of Directors in an editorial now in press at Journal of Nuclear Cardiology.

“A major concern expressed by many board members was the oversized role assigned to FFR-CT, especially given the availability, efficiency, level of adoption, substantial cost and coverage. inconsistent insurance, ”according to Randall Thompson, MD, of the St. Luke’s Mid America Heart Institute in Kansas City, Missouri, and colleagues at ASNC.

They said myocardial perfusion imaging (MPI) would be a better choice in some cases.

Among ASNC’s other qualms about the ACC / AHA document is the grouping of various stress tests into one category.

“All stress imaging tests have their unique advantages and limitations, and there are important differences in sensitivity and specificity, as well as strengths and limitations between exercise ECG, echo. stress, SPECT MPI, PET MPI, and stress MRI, ”wrote Thompson and colleagues.

“The concept of the dichotomy of functional versus anatomical testing is a common theme in the guideline across many important patient groups. This approach risks (a) giving too much importance to coronary angiography and (b) blurring the distinction between the different types of functional tests, ”complained the group.

Gulati’s team recognized that a great deal of research is still being done in the diagnosis and management of chest pain. Randomized trials and registries both play an important role in generating future evidence.

“Evaluation of long-term outcomes, patient-centered measures and costs will be incorporated into these studies to improve the evidence base for caring for patients with chest pain with greater precision,” according to the committee drafting.

  • Nicole Lou is a reporter for MedPage Today, where she covers current events in cardiology and other developments in medicine. To follow


Gulati and Thompson had no disclosure.

Other guideline and editorial writers have listed various connections to the industry.

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