Update to the American College of Cardiology Guidelines for the Evaluation and Diagnosis of Chest Pain

Although acute chest pain is the presenting complaint in less than 1% of primary care office visits, it requires immediate decisions on evaluation and management. After injuries, chest pain has been the second most common reason for adults to present to the emergency department (ED) in the United States.1 The American College of Cardiology (ACC), at the end of 2021, updated this guideline which is intended for the evaluation of acute or stable chest pain and other angina equivalents for a variety of clinical settings, with an emphasis on the diagnosis on ischemic causes.2

An initial assessment of chest pain is recommended to triage patients effectively based on the likelihood that symptoms are attributable to myocardial ischemia. The guideline has ten “take home” messages that are worded to form the acronym CHEST PAINS:       

  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 should all be considered anginal equivalents.
  2. High-Sensitivity Troponins Preferred.
    High-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury.
  3. Early Care for Acute Symptoms.
    Patients with acute chest pain or chest pain equivalent symptoms should seek medical care immediately by calling 9-1-1. 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.
  4. Share the Decision-Making.
    Clinically stable patients presenting with chest pain should be included in decision-making; information about risk of adverse events, radiation exposure, costs, and alternative options should be provided to facilitate the discussion.
  5. Testing Not Needed Routinely for Low-Risk Patients.
    For patients with acute or stable chest pain determined to be low risk, urgent diagnostic testing for suspected coronary artery disease is not needed.
  6. Pathways.
    Clinical decision pathways for chest pain in the emergency department and outpatient settings should be used routinely.
  7. Accompanying Symptoms.
    Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome. Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath.
  8. Identify Patients Most Likely to Benefit From Further Testing.
    Patients with acute or stable chest pain who are at intermediate risk or intermediate to high pre-test risk of obstructive coronary artery disease, respectively, will benefit the most from cardiac imaging and testing.
  9. Noncardiac Is In. Atypical Is Out.
    The term “Noncardiac” should be used if heart disease is not suspected. “Atypical” is a misleading descriptor of chest pain, and its use is discouraged.
  10. Structured Risk Assessment Should Be Used.
    For patients presenting with acute or stable chest pain, risk for coronary artery disease and adverse events should be estimated using evidence-based diagnostic protocols.

The figures and tables published in the Journal of the American College of Cardiology version are very useful, especially for clinical staff. They can be downloaded and printed as wall charts for the medical office or emergency room; many are provided both as jpg photo files and MS PowerPoint files.2

The guideline recommends starting by obtaining a focused history emphasizing the characteristics and duration of symptoms. Although ischemia does not always manifest as chest pain, the patient’s description of the pattern when present is often highly predictive and frequently helpful in the key triage decision of “is this cardiac or non-cardiac”. Obviously other causes of chest pain may also require urgent evaluation, but “time is myocardium” in acute obstruction of coronary blood flow. The presentation of acute coronary syndrome in women may not even include chest pain. If not, a review of all acute symptoms should be considered. In patients over the age of 75, accompanying symptoms like acute change in mental status or an unexplained fall may be a manifestation of cardiac ischemia. Patients’ culture and language may affect the description of symptoms and the understanding of questions about them, so language interpreters are often essential in obtaining a good history.

Physical exam should include not only vital signs and brief cardiovascular evaluation, but findings suggestive of non-ischemic cardiac, pulmonary, gastrointestinal, or local manifestations of systemic disease as causes of acute chest pain.

Unless a non-cardiac cause is evident, an ECG should be performed for patients seen in the office setting with stable chest pain; if an ECG is unavailable, the patient should be referred to the ED so one can be obtained. If there is any evidence of ischemia on the ECG, serial ECGs are recommended.

There is a guide to risk stratification of chest pain suggestive of cardiac ischemia and a guide to the differential diagnosis of chest pain without symptoms or signs of cardiac ischemia.

Until all the life-threatening causes of chest pain have been ruled out, the emergency medical system should be alerted and any patient transport should have advanced life support capability.

Recommended laboratory testing for patients with a high risk of cardiac ischemia should include high-sensitivity cardiac troponin and, if abnormal, serial measurements. Creatine kinase myocardial band (CK-MB) and myoglobin are no longer used in diagnosing myocardial ischemia.

There are multiple clinical decision pathways to support investigation of chest pain associated with coronary artery disease and for many other life-threatening causes of acute chest pain. There are also clinical decision pathways for the investigation of chest pain in women and in patients with comorbidities including stimulant drug abuse, anxiety syndromes, and sickle cell disease.

Charles A Sneiderman, MD, PhD, DABFM
Medical Director, Culmore Clinic
Bailey’s Crossroads, VA


  1. National Ambulatory Medical Care Survey: 2018 National Summary Tables accessed 6/1/22 https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2018-namcs-web-tables-508.pdf
  2. Gulati M, Levy P, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary. J Am Coll Cardiol. 2021 Nov, 78 (22) 2218–2261. https://doi.org/10.1016/j.jacc.2021.07.052