New Diagnostic Imaging Guidelines for Treating ER Patients with Chest Pains

On January 22, 2016, the American College of Cardiology (ACC) and the American College of Radiology (ACR) together released new clinical guidelines regarding the appropriate use of diagnostic imaging for Emergency Room patients presenting with chest pains.  The guidelines were published in both the Journal of the American College of Cardiology (JACC) and in the Journal of the American College of Radiology (JACR).

The ACC reports that for the purposes of creating these guidelines, clinical presentations were categorized into four groups:

• Suspected non-ST-segment elevation acute coronary syndrome (NSTE ACS)
• Suspected pulmonary embolism
• Suspected acute syndrome of the aorta, and
• Patients for whom a leading diagnosis is problematic or not possible

For each of these categories, multiple diagnostic scenarios were considered. These included cardiac catheterization, coronary computed tomography angiography (CCTA), electrocardiogram (ECG), echocardiography (echo), cardiac magnetic resonance imaging (CMR), and single-photon emission computed tomography (SPECT).  

The appropriateness of each of these diagnostic tests was then rated by a separate panel and using these ratings, the guidelines were drafted. These guidelines are written according to a wide variety of possible scenarios. A few examples include:

• Scenario: ECG diagnostic for ST-segment elevation myocardial infarction (STEMI): cardiac catheterization is considered appropriate; all other imaging modalities are considered rarely appropriate.
• Scenario: Initial ECG and/or biomarker unequivocally positive for ischemia: cardiac catheterization is considered appropriate; all other imaging modalities rated as rarely appropriate.
• Scenario: Equivocal initial troponin or single troponin elevation without additional evidence of ACS: CCTA and rest SPECT were considered appropriate, catheterization is rarely appropriate, and resting echo and CMR were graded as may be appropriate.
• Scenario: Patients in the “observational pathway” after initial assessment (typically 9-24 hours out from presentation) with unequivocal evidence for NSTEMI/ACS: cardiac catheterization was considered appropriate; all other imaging modalities including rest and stress modalities were graded as may be appropriate.

Bear in mind that the main purpose of these guidelines is to provide clinicians with appropriate recommendations for treating the majority of patients who present in the ER with chest pains, which is one of the most common reasons for Emergency Department visits.

You can read more about these guidelines at the ACC’s article, Appropriate Use of Cardiac Imaging in Emergency Department Patients with Chest Pain,  or in an article posted by Medscape entitled, New Guidelines: Diagnostic Imaging of Chest Pain in ED.