Cardiology Corner: JACC Chest Pain Update

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Ian L. -

You know the guidelines will be interesting when the first recommendation of the ten recommendations is : "Chest pain means more than pain in the chest " -'pain can be in the chest shoulders arms neck back upper abdomen or jaw as well as shortness of breath and fatigue should all be called Anginal Equivalents '. Atypical is out because it is said to infer a benign cause . There will be a belief that the guidelines ought to have written -Acute Coronary Syndrome means more than pain in the chest . Atypical pain would possibly now be Anginal Equivalents .

Jonathan G. -

Amal! Thanks as always for the great information. Two questions for you:
1) Not doubting you, but can you provide 1 or 2 articles on the issue of relying on patient descriptors of their chest pain/discomfort, like the JAMA paper you mentioned?
2) Can you give 1 or 2 articles negating the 1 year cardiac stress test “warranty”? (I agree that’s a bad term)

Sean R. -

not that we all have the same EMR but we use E*** and it does have "chest pain with low risk of cardiac etiology" so maybe we can use the right phrasing even if rec's suggest otherwise. it

Amal M. -

that sounds great to me!

Ian L. -

In Rural and Remote areas especially if you had an automatic defibrillator could you not do an adaption of the HARVARD STEP TEST dsigned by designed by Belgian Doctor Dr Brough in 1942 ?

Ian L. -

re Jonathan G. Some claim achieving more than Ten METS on a stress test provided there is no early family history of cardiac disease the symptom description is constant and you dont take up smoking or drinking after passing the test the stress test has excellent prognosis over an intermediate follow up .Jamieson M Bourque et al Journal of Nuclear Cardiology APRIL 2011 In 2020 Lavone Smith et al reported that on 382 adults over 65 who underwent 99m TC SPECT MPI . of the 25.4 % who achieved greater than 10 mets cardiac death was 0.6 % per year and mace 2.6 % per year not quite 100 % warranty .

Kenneth D. -

Thank you, guys! Over my career I have cured GERD with nitroglycerin and angina with Mylanta!!!

Nicolas F. -

Hi Amal,

thanks for this excellent review. Any thoughts on the timing of further testing including CCTA or stress testing? Looking specifically at Intermediate-Risk Patients With Acute Chest Pain and No Known (CAD)? Back in the old days it was 72 hrs? I didn't see the info on my read of that section.

Amal M. -

Nicolas, in the old days there was a recommendation that for low-risk patients, IF you discharge them, they should get the stress test or CCTA within 72 hours. The presumption was that intermediate risk patients were being admitted, and there wasn't anything that I recall saying when those patients would get the test, so I guess the assumption was that they were getting the test prior to discharge.

Now, we have moved away from admitting and testing (stress or CCTA) low risk patient at all. But I haven't seen any new recs regarding the intermediate risk patient. So the presumption is that the intermediate risk patients are still getting admitted and getting their test expeditiously, but that is just a presumption because I haven't seen anything new on this topic.

I haven't specifically seen any guidelines on when to test intermediate risk patients if they are outpatients, so I'm assuming the workup is still in the hospital before discharge. If not, those are probably good patients with whom to do shared decision making, until there are guidelines.

If anyone knows of such guidelines, please share them. I haven't seen them in the EM or cardiology literature....maybe they are in the IM or hospitalist literature.

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