The American Heart Association and American College of Cardiology recently released a comprehensive guideline for evaluation and diagnosis of chest pain.^[1]Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart … Continue reading The optimal approach to this common symptom remains one of the most vexing challenges in medicine, and a major driver of health care expenditures. The new guideline draws on high quality evidence from recent clinical trials and provides patient-centric recommendations based on specific scenarios.

The fundamental approach to evaluating chest pain has not changed. The pretest likelihood that chest pain is due to cardiac ischemia and an assessment of risk for a major cardiac event remain the key determinants of the need for testing. Also unchanged is the recommendation that cardiac testing should not be performed when the likelihood of obstructive coronary disease is low.

On the question of cardiac risk, however, the guideline reflects a growing understanding of how under-diagnosis in certain ethnic and racial groups contributes to health disparities and poorer outcomes in communities of color. Specific recommendations highlight the need to improve cultural sensitivity among clinicians and minimize unconscious bias through training and other means.

With regard to testing strategies, the focus is on optimizing use of lower cost evaluations and reducing layering of tests, a practice which drives up costs without improving diagnostic accuracy. The level of risk is the primary determinant, while the choice between anatomic evaluation (using coronary CT angiography (CCTA)) and stress testing hinges on additional factors such as age, disease history, and the likelihood that intervention will be required. As expected, CCTA has taken on a larger role, eliminating the need for invasive coronary angiography in many cases.

All of this is good news for clinicians and payers struggling to make sense of the growing list of options for cardiac testing and increasing availability of testing modalities outside of tertiary care settings.

Per Dr. Tom Power, medical director of Carelon’s cardiology program:

“Following an abnormal noninvasive test (or tests), fewer than 50% patients referred for coronary angiography have significant disease, pointing to serious flaws in our current approach to chest pain. The new guideline attempts to address this issue through improved patient selection and guidance in choosing the most appropriate test. Carelon will incorporate the recommendations in our continuing efforts to ensure that members have access to the best available care while reducing downstream costs associated with unnecessary testing.”