Big Endorsement of Coronary CT Angiography in Chest Pain Guidelines

American professional societies released their inaugural guideline on risk stratification and diagnostic workup for patients presenting with chest pain — inadvertently sparking a turf war with nuclear cardiologists.

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

Notably, the term “atypical chest pain” is out, to be replaced by “cardiac,” “possibly cardiac,” or “noncardiac” chest pain, said the writing committee chaired by Martha Gulati, MD, MS, of the University of Arizona College of Medicine in Phoenix.

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

The document suggests that emergency departments and outpatient centers routinely use structured clinical decision pathways to evaluate chest pain and separate patients into low-, intermediate-, and high-risk groups (with high-sensitivity troponin preferred over conventional troponin assays in such evaluation).

Diagnostic testing downstream of that is recommended as follows:

• Low-risk patients may be discharged without admission or urgent cardiac testing in a class IIa recommendation

• Intermediate-risk patients should undergo non-invasive anatomic and stress testing with various modes preferred according to whether pain is acute or stable and whether coronary artery disease is known. Here, coronary CT angiography snagged new class I recommendations, and fractional flow reserve derived from CT (FFR-CT) was a class IIa recommendation for add-on testing in some cases

• High-risk patients with suspected acute coronary syndrome have a class I recommendation for an invasive coronary angiogram

Release of the ACC/AHA guideline garnered much praise on social media.

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

Notably absent from the list, however, was the American Society of Nuclear Cardiology (ASNC), which had opted to break away from peer groups.

“The lack of balance in the document’s presentation of the science on FFR-CT and its inappropriately prominent endorsement detract from ASNC’s core principle of patient first imaging. We believe that the document fails to provide unbiased guidance to healthcare professionals on the optimal evaluation of patients with chest pain,” the ASNC board of directors wrote in an editorial currently in press at the Journal of Nuclear Cardiology.

“A major concern that many members of the Board of Directors expressed was the oversized role given to FFR-CT, especially given the limited availability, efficacy, level of adoption, substantial cost, and inconsistent insurance coverage,” according to Randall Thompson, MD, of St. Luke’s Mid America Heart Institute in Kansas City, Missouri, and colleagues of the 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 lumping 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 and strengths and limitations between exercise ECG, stress echo, SPECT MPI, PET MPI, and stress MRI,” Thompson and colleagues wrote.

“The concept of the dichotomy of functional testing versus anatomic testing is a common theme in the guideline in many important patient groups. This approach runs the risk of (a) giving over-emphasis to coronary CT angiography and (b) blurring distinction between different types of functional tests,” the group complained.

Gulati’s team acknowledged that much research is still ongoing in the diagnosis and management of chest pain. Randomized trials and registries alike both play important roles in generating future evidence.

“Assessment of long-term outcomes, patient-centered metrics, and cost will be integrated into these studies to enhance the evidence base for care of patients presenting with chest pain with greater precision,” according to the writing committee.