- The document summarizes guidelines for evaluating and diagnosing chest pain, including characteristics of cardiac vs. non-cardiac chest pain, initial evaluation involving history and physical exam, diagnostic testing considerations, and management strategies for patients with acute chest pain and suspected acute coronary syndrome (ACS) at different risk levels. Key points addressed include nature, location, precipitating/relieving factors of chest pain types, ECG and biomarker use, and testing algorithms for intermediate-risk patients both with and without known coronary artery disease.

1. JOURNAL CLUB
- DR. ANAND RAM

2. 2021AHA/ACC/ASE/CHEST/S
AEM/SCCT/SCMR Guideline
for the Evaluation and
Diagnosis of Chest Pain

3. Take-Home Messages for the
Evaluation and Diagnosis of
Chest Pain

5. Applying ACC/AHA Class of
Recommendation and Level of
Evidence to Clinical
Strategies, Interventions,
Treatments,
or Diagnostic Testing in
Patient Care (Updated May
2019)*

9. Index of Suspicion That
Chest “Pain” Is Ischemic in Origin
on the Basis of Commonly Used
Descriptors

10. Top 10 Causes of Chest Pain in the
ED Based on Age (Weighted
Percentage)

11. INITIAL EVALUATION
HISTORY

12. A Focus on the Uniqueness of
Chest Pain in Women

13. Considerations for Older Patients
With
Chest Pain

14. Considerations for Diverse
Patient
Populations With Chest Pain

15. Patient-Centric
Considerations

16. Physical Examination

17. Chest Pain Characteristics
and Corresponding Causes

18. Nature
 Anginal symptoms are perceived as
retrosternal chest discomfort (eg, pain,
discomfort, heaviness, tightness,
pressure, constriction, squeezing).
 Sharp chest pain that increases with
inspiration and lying supine is unlikely
related to ischemic heart disease (eg,
these symptoms usually occur with
acute pericarditis).

19. Onset and duration
 Anginal symptoms gradually build in
intensity over a few minutes.
 Sudden onset of ripping chest pain
(with radiation to the upper or lower
back)
is unlikely to be anginal and is
suspicious of an acute aortic
syndrome.
 Fleeting chest pain—of few seconds’
duration—is unlikely to be related to

20. Location and radiation
 Pain that can be localized to a very
limited area and pain radiating to
below
the umbilicus or hip are unlikely
related to myocardial ischemia.

21. Severity
 Ripping chest pain (“worse chest pain
of my life”), especially when sudden in
onset and occurring in a hypertensive
patient, or with a known bicuspid
aortic valve or aortic dilation, is
suspicious of an acute aortic
syndrome (eg, aortic dissection).

22. Precipitating factors
 Physical exercise or emotional stress
are common triggers of anginal
symptoms.
 Occurrence at rest or with minimal
exertion associated with anginal
symptoms usually indicates ACS.
 Positional chest pain is usually
nonischemic (eg, musculoskeletal).

23. Relieving factors
 Relief with nitroglycerin is not
necessarily diagnostic of myocardial
ischemia and should not be used as a
diagnostic criterion.

24. Associated symptoms
 Common symptoms associated with
myocardial ischemia include, but are
not limited to, dyspnea, palpitations,
diaphoresis, lightheadedness,
presyncope or syncope, upper
abdominal pain, or heartburn
unrelated to meals and nausea or
vomiting.

25. • Symptoms on the left or right side of
the chest, stabbing, sharp pain, or
discomfort in the throat or abdomen may
occur in patients with diabetes, women,
and elderly patients.

26. Physical Examination in
Patients With Chest Pain

30. Diagnostic Testing

31. Setting Considerations

32. Electrocardiogram

33. Chest Radiography

34. Biomarkers

35. Electrocardiographic-Directed
Management of Chest Pain

37. Chest Pain and Cardiac
Testing Considerations

38. Choosing the Right Diagnostic
Test

42. Patients With Acute Chest Pain and
Suspected ACS (Not Including STEMI)

47. Intermediate-Risk Patients With Acute Chest Pain
and No Known CAD

48. Intermediate-Risk Patients With Acute Chest
Pain

50. Intermediate-Risk Patients With Acute Chest
Pain and Known CAD

51. Evaluation Algorithm for Patients With
Suspected ACS at Intermediate Risk
With No Known CAD

56. Acute Chest Pain in Patients With Prior Coronary
Artery Bypass Graft (CABG) Surgery

79. THANK YOU