At last! This long-awaited first-ever Guideline for the Evaluation and Diagnosis of Chest Pain for physicians and their patients has done a deep dive to help improve accuracy in evaluating and diagnosing cardiac symptoms(1) – a huge and overwhelming effort. I’m hopeful that updated guidelines might represent a turning point for all women presenting with those symptoms – and for the physicians who diagnose them. Here’s my take on the impressive new Chest Pain Guideline – along with a few concerns: . .
First, a DISCLOSURE: this project was created by a small army of experienced cardiologists, Emergency physicians and over 40 reviewers representing multiple partner cardiology societies.* These contributors are acknowledged experts in their respective cardiac specialties, and their recommendations were based on a comprehensive evaluation of high-quality recent evidence (yet still not without apparent controversy). But I, on the other hand, have no medical or nursing training, and zero professional qualifications to comment on this document – except the salient one that most (okay, I’m guessing ALL) guideline contributors lack: I’m a woman who was misdiagnosed with GERD in mid-heart attack despite textbook cardiac symptoms (including severe central chest pain).
I can already imagine the eye-rolling going on out there among Emergency physicians as they read this, but frankly, heart patients don’t care if only 5 per cent of people with chest pain symptoms who show up in Emergency turn out to have heart disease. We care that we are having a frickety-frackin’ heart attack. We especially care when we’re told it’s NOT a heart attack when it actually is. I compare this laser-like focus to how doctors would feel if they were told that their sick child was suffering from an extremely rare disease. What they’d care about is that their kid is suffering, not how many children do NOT have this condition.
And we know that female heart patients are significantly more likely to be misdiagnosed compared to our male counterparts. The new guideline spells this out specifically, in Figure 2.1.1, “A Focus On the Uniqueness of Chest Pain in Women” (One word: “HALLELUJAH!”) in which you read this:
“Women who present with chest pain are at risk for under-diagnosis, and potential cardiac causes should always be considered. It is recommended to obtain a history that emphasizes accompanying symptoms that are more common in women with Acute Coronary Syndrome.”
And that “high-quality recent evidence” that drives these new guidelines? We already know that most is high-quality recent evidence based on (white, middle-aged) men.
Here’s a fun fact for you: cardiac researchers report that female heart attack survivors are significantly less likely than men to even use the word “pain” to describe their chest symptoms. Harvard researcher Dr. Catherine Kreatsoulas, for example, has observed during her studies on Emergency Department communication that women in mid-heart attack will even argue with the Emergency doc (“Well, it’s not exactly PAIN, it’s more like ______” – fill in the blank with appropriate replacement word: discomfort, heaviness, fullness, burning, pressure, tightness, ache, etc.) And at least two of the 10 key recommendations in the new guideline (see below, #1 and #7) urge physicians to watch for non-chest pain clues – especially in women. To learn more about referred cardiac pain in other body parts, including the shoulders, arms, neck, back, throat, upper abdomen or jaw, see: Why Does Your Arm Hurt During a Heart Attack? Another fun fact: pain in your right arm or shoulder appears to double the likelihood of a heart attack diagnosis compared to symptoms in the left arm. (2)
“The sudden onset of ANY of those symptoms could be a sign of reduced blood flow to the heart muscle,” warns cardiologist Dr. Martha Gulati, president-elect of the American Society for Preventive Cardiology and chair of the writing committee for the new Chest Pain Guideline, published jointly by The American Heart Association and the American College of Cardiology. (DISCLOSURE #2: Dr. Gulati also wrote the beautiful foreword to my book, A Woman’s Guide to Living With Heart Disease (Johns Hopkins University Press).
As Dr. Gulati explains, chest pain as described in the new guideline does not always mean a heart attack, but it does merit immediate medical attention:
“The majority of chest pain is not life-threatening. And in fact, the majority of chest pain is not cardiac – instead due to respiratory, musculoskeletal, gastrointestinal, psychological or other causes. But when it IS cardiac, it can be deadly. We have such good treatment, but time is heart muscle. The sooner we see you, the sooner we can treat you.”
For readers who have not yet read the guideline document, here’s my simplified report card of the top 10 recommendations that the new guideline covers:
1. Chest Pain Means More Than Pain in the Chest: Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue are equivalent symptoms and should be considered to be the same as angina. (My rating: ♥♥♥♥+ – or, as I learned while attending the WomenHeart Science & Leadership patient advocacy training for women with heart disease at Mayo Clinic back in 2008, “any symptom from neck to navel should be considered heart-related until proven otherwise.”)
2. High-Sensitivity Troponin Tests Preferred.(NEW): Troponins are a type of cardiac enzyme biomarker. When detected by a blood test, troponins can usually be predictably linked with heart muscle damage caused by a heart attack. Newer High-Sensitivity cardiac troponin tests are now the preferred Class 1 standard for identifying cardiac enzymes associated with heart attack. My rating: ♥♥♥ – What concerns me: researchers have reported variations in the interpretation of troponin test results. For example: “Patients from different institutions utilize different High-Sensitivity troponin assays. 20 per cent of all specimens tested had results abnormal by one assay and normal by the other.”(3) And in her 2020 research, Dr. Karin Humphries et al suggested that “setting a lower female-specific troponin threshold in High-Sensitivity troponin testing would improve the cardiac diagnosis, treatment and outcomes of women presenting to the Emergency Department.”(4)
3. Early Care for Acute Symptoms: Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 911. Although most patients will not have a cardiac cause, the evaluation of all patients should focus on the early identification or exclusion of life-threatening causes. (My rating: ♥♥♥♥+, a no-brainer. What concerns me: the sobering reality of gender bias in medicine, including pre-hospital care. Consider for example the 4-year study which concluded that paramedics, while transporting heart patients to hospital, are less likely to offer minimal therapies (e.g. aspirin) when those patients are women, and (astonishingly) ambulances are significantly less likely to turn on flashing lights and sirens when a female heart patient is in the back of the bus.(5) On the other hand, the new guideline points out that one in 300 people arriving at Emergency in a private vehicle will suffer a cardiac arrest en route. (How’d you like to be the car’s driver when that happens to your passenger?) This recommendation, by the way, doesn’t fly well with #5 (below) when we are urged to call 911, yet when we do show up in Emergency, we’re told that urgent diagnostic testing will not be necessary.
4. Share the Decision-Making (NEW): Clinically stable patients presenting with chest pain should be included in decision-making about their diagnostic tests; information about their risk of adverse events, radiation exposure, costs, and alternative options should be provided. The new evidence shows that when patients like these shared decision-making, they chose less testing with no difference in outcomes. My rating: ♥♥♥♥ – In shared decision-making, a patient shares their own goals and concerns, and clinicians describe the options as well as both the risks and benefits of each.
5. Testing Not Needed Routinely for Low-Risk Patients (NEW): For patients with acute or stable chest pain but who are assessed as low risk for heart attack based on a medical history and physical exam, urgent diagnostic testing for suspected coronary artery disease is not needed. This recommendation for low-risk patients has been discussed for a number of years. Consider that treadmill stress testing for people with chest pain but no evidence of acute heart attack is associated with higher rates of other tests and procedures, but NOT reduction in deaths or heart attacks.(6) Yet until this new Chest Pain Guideline, stress tests used to be routinely recommended within 72 hours after a heart attack had already been ruled out. What concerns me is the definition of who exactly is deemed to be “low-risk”. This seems problematic at first blush, especially for female heart patients like me (clearly assessed in Emergency as “low-risk” = too young, too healthy, too female. . . – or, as the Emerg doc who confidently misdiagnosed me summarized his assessment: “You are in the right demographic for acid reflux!”) My rating: ♥ (I simply cannot support any recommendation that women presenting with acute chest pain should not be offered cardiac diagnostic tests for suspected coronary artery disease). If only the authors had included, in the words of author Maya Dusenbery in her book Doing Harm, a recommendation to “believe women when we tell you we’re sick.”
6. Clinical Decision Pathways (NEW): Clinical decision pathways for chest pain in the Emergency Department and outpatient settings should be used routinely. The slides accompanying the new guideline contain lots of these tools for clinicians (“if this, then try that”). My rating: ♥♥♥ – What concerns me: emerging studies have found that even when comprehensive clinical treatment guidelines are in place, female patients are less likely than our male counterparts to be treated according to those guidelines. Will this new guideline be any different for women? As cardiologist Dr. Sharonne Hayes, founder of the Mayo Women’s Heart Clinic, observed over a decade ago in a WomenHeart interview: “Treatment guidelines help women get the care that has been shown to improve survival and long term outcomes. Part of the problem now is that the guidelines are less likely to be applied to women compared to men. We know that when hospitals have systems in place to ensure they provide care according to the guidelines, women’s outcomes improve – even more than men’s.” I wonder how confident guideline authors can be (especially given COVID-inspired levels of unprecedented burnout, stress and exhaustion among our healthcare professionals) that more clinicians will somehow be magically ready to adhere to these guideline recommendations?
7. Accompanying Symptoms: Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with Acute Coronary Syndrome – a precursor of heart attack. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath. My rating: ♥♥♥♥ (This is essentially the same as #1; it’s important because those pesky “accompanying” symptoms can represent tempting “non-cardiac” distractions in diagnosis. See #9.)
8. Identify Patients Most Likely to Benefit From Further Testing: These are patients with acute or stable chest pain who are at intermediate risk or intermediate-to-high pre-test risk of obstructive coronary artery disease. My rating: ♥♥♥ – What concerns me is the narrow focus on identifying blocked arteries. we know that women are significantly more likely to present with non-obstructive coronary artery disease (e.g. vasospasm disorder, Takotsubo syndrome, microvascular/small vessel dysfunction) compared to our male counterparts. The Chest Pain Guideline was also meant to be a flexible document, acknowledging, for example, that not every recommended cardiac diagnostic test is available at all hospitals, an obvious reality for many rural, under-served or isolated regions. This puts the onus on individual clinicians to select the test they think is most appropriate for each patient – no matter what the guideline recommends. So these recommendations include decision tools to help clinicians decide, for example, which diagnostic test to order for an intermediate-risk person presenting with acute chest pain when CCTA (Coronary Computed Tomography Angiography – the darling of the guide’s several Class 1 diagnostic recommendations) is not available.
9. Non-cardiac Is IN. Atypical Is OUT. (NEW): “Non-cardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use by health care professionals is discouraged – and may be misinterpreted as ‘benign’. I know this particular “atypical” mention will be good news for my friend Cristina D’Alessandro, York Region paramedic/filmmaker (watch her A Typical Heart film – 22 minutes). Cristina has famously been asking the bleedin’ obvious for years: “Why do they call women’s cardiac symptoms ‘atypical’ when we make up over half the population?” My ratings: ♥♥♥♥ for “atypical”, but ♥ for “non-cardiac.” What concerns me: the interventional cardiologist during my second trip to the cath lab a few months after my heart attack wrote “NON-CARDIAC” with a black Sharpie on my chart. He even showed me what he’d written with a proud flourish – as if to say “Aha! I knew it!” after my angiogram did not reveal stent failure or other new blockages that might explain my ongoing symptoms. (This happened before I was appropriately diagnosed later with coronary microvascular dysfunction). But “non-cardiac” is hardly reassuring if you’re the one lying on the cath lab table, and if your interventional cardiologist has no clue what IS causing your debilitating chest pain, shortness of breath and crushing fatigue. “Non-cardiac” sounds pretty darned definitive, a potentially dangerous conclusion when you’re a woman with known heart disease suffering new onset refractory angina, and about to be sent home – when it IS cardiac. It’s not an appropriate replacement for “atypical”. A preferred alternative for the term “non-cardiac” might be: “We just don’t know yet.”
10. Structured Risk Assessment Should Be Used. For all patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using current evidence-based diagnostic protocols. (My rating: ♥♥♥ – but with the same concerns expressed under #5).
Swap CJ, Nagurney JT. “Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes.” JAMA. 2005;294(20):2623–2629. doi:10.1001/jama.294.20.2623
Diercks DB et al. “High sensitivity troponin testing: is it what we really wanted?” Vessel Plus Journal, 2021;5:52. http://dx.doi.org/10.20517/2574-1209.2021.113
Scheuermeyer FX et al. “Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain.” Ann Emerg Med 2012 Apr; 59:256.
Zhao Y, Humphries KH et al. “High-Sensitivity Cardiac Troponin – Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE-MI).” Am Heart J. 2020 Nov;229:18-28. doi: 10.1016/j.ahj.2020.06.013.
Lewis, JF et al. “Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest.” Women’s Health Issues, December 10, 2018.
Image: ©Journal of the American College of Cardiology
Q: Which of the 10 key recommendations in this new Chest Pain guideline seems most important to you?
* The cardiology societies supporting this guideline were the American Heart Association, American College of Cardiology, Society for Cardiovascular Computed Tomography, American Society of Echocardiography, American College of Chest Physicians, Society for Academic Emergency Medicine, and the Society for Cardiovascular Magnetic Resonance.
Members of the American Society of Nuclear Cardiology (ASNC) also contributed, but this Society ultimately decided they could not agree with all of the recommendations, and chose not to endorse the new document. A statement was sent to all ASNC members this week explaining the Society’s refusal to endorse: “We believe that the document fails to provide unbiased guidance to healthcare professionals on the optimal evaluation of patients with chest pain.” Hard to tell, of course, but could this be a territorial pissing contest at work?
NOTE FROM CAROLYN: I wrote much more about how women’s cardiac symptoms are diagnosed and treated – or not – in my book, “A Woman’s Guide to Living with Heart Disease”. You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use their code HTWN to save 20% off the list price).