Deborah Heart and Lung Cardiologist Dr. Renee Bullock-Palmer Co-Author of New Assessment Guidelines to Identify Cardiac vs. Non-Cardiac Chest Pain

Renee Bullock-Palmer, MD, cardiologist and Director of Non-Invasive Cardiac Imaging, and Director of the Women’s Heart Center, at Deborah Heart and Lung Center, has co-authored the new multisocietal chest pain guidelines issued by the American College of Cardiology (ACC) and American Heart Association (AHA) joint Committee on Clinical Practice Guidelines which offer recommendations for the assessment and diagnosis of chest pain.

This is the first comprehensive guideline on chest pain issued by both organizations.

Dr. Bullock-Palmer explained why the guidelines were needed. “Nationally, there are more than 6.5 million emergency department visits each year for chest pain, as well as another 4 million outpatient clinic visits. This pain can extend to the shoulders, arms, jaw, neck, back and upper abdomen, and even though most chest pain episodes are not heart-related, it still remains the most common sign for a serious cardiac event. There was a real need for recommended guidelines for standardized risk assessment, clinical pathways, and tools to evaluate patients with chest pain.”

“This will both provide evaluation guidelines for quickly determining if a patient is having a heart attack, while also reducing the expense and time of unnecessary and expensive testing for those who are not.”

Dr. Bullock-Palmer noted that more than half of patients who experience chest pain will ultimately be diagnosed with a non-cardiac problem – respiratory, musculoskeletal, gastrointestinal, psychological, or something else. “The new guidelines use risk assessment tools to determine if a patient is at low, intermediate, or high risk for having a cardiac event, and further testing decisions can be made based on that.”

She stressed that patient and family communication is also key in the new guidelines. “Naturally if you or a family member are worried that a loved one is having a serious cardiac episode the first thought is to ‘get all the tests possible’. Our goal is to reassure patients and bring them in to the decision-making process. If a provider can reasonably rule out a serious cardiac episode from preliminary testing, additional cardiac tests may not provide any additional real information about their condition. These cardiac tests generally should be reserved for those who have at least an intermediate risk of having an acute cardiac event.”

Dr. Bullock-Palmer, who specializes in women’s heart care, knows that both women and men experience chest pain differently during a heart attack. “These guidelines address those differences. It’s important to note that women are just as likely as men to experience chest pain, however oftentimes there are other accompanying symptoms such as fatigue, nausea and shortness of breath. Providers need to include these types of symptoms in their overall assessment. The guidelines also address the vital importance of cultural competency training to address diverse racial backgrounds and language barriers that could impede an accurate diagnosis.”

The guidelines provide additional specific testing parameters based on the identified level of risk, including those for patients with life-threatening acute chest pain. Testing recommendations cover the spectrum on the use of electrocardiograms, cardiac Troponin measurement, coronary artery calcium testing, computed tomographic angiography, stress imaging, transthoracic echocardiography, and coronary angiography.

The guidelines also outline recommendations for diagnosing special populations of chest pain patients such as those presenting with pericardial disease or those presenting with coronary micro vascular disease.

“We have all these sophisticated tools for cardiac evaluation and diagnosis,” said Dr. Bullock-Palmer. “The goal of the new guidelines is to target the most appropriate testing to save lives, prevent unnecessary expenses, and to rule out non-cardiac issues, which often occurs with chest pain. These guidelines for clinicians were way overdue, and will provide a framework for treating those who call 911 and arrive in an emergency department with acute chest pain and also for patients presenting in the office with stable chest pain. The recommendations are designed to identify patients who may be having an acute cardiac event or ‘something else’ and direct the right testing and treatment for the best patient outcomes.”

To read the full report:  Circulation