ACC, ACR release imaging guidelines for ED patients with chest pain

The American College of Cardiology (ACC) and American College of Radiology (ACR) released guidelines on Jan. 22 regarding the appropriate use of imaging for patients who come to the emergency department with chest pain.

The writing panel included practicing emergency medicine, cardiology and radiology representatives from the ACC, ACR and American College of Emergency Physicians (ACER).

They were asked to describe and evaluate 20 common clinical scenarios in the following four categories: suspected non-ST-segment elevation acute coronary syndromes, suspected pulmonary embolism, suspected acute syndrome of the aorta and patients for whom a leading diagnosis is problematic or not possible.

“This document captures a wide scope of those patients who come to the emergency department with chest pain, although there will always be patients who present unique situations and no document can be a substitute for clinical judgment,” Frank J. Rybicki, MD, PhD, a co-chair of the writing committee and head of medical imaging at The Ottawa Hospital said in a news release.

The report’s authors cited data from the 2010 National Hospital Medical Care Survey that found there were nearly 130 million emergency department visits, of which 5.4 percent presented with chest pain. They added that patients with chest pain can have serious, life-threatening issues such as acute coronary syndromes, pulmonary embolism and acute aortic syndromes but can also have illnesses without long-term consequences.

Although physicians typically assess patients with a physical examination and basic ancillary testing, the authors mentioned diagnostic imaging may be used to identify or exclude life-threatening conditions.

They said that the appropriateness of imaging depends on if imaging is justified for 20 clinical scenarios after patients undergo a physical examination and ancillary testing and have their history of chest pain evaluated. It also depends on if imaging can provide meaningful incremental information.

The ACC and ACR define an appropriate imaging test as follows: “The concept of appropriateness, as applied to healthcare, balances risk and benefit of a treatment, test, or procedure in the context of available resources for an individual patient with specific characteristics. Appropriateness criteria provide guidance to supplement the clinician’s judgment as to whether a patient is a reasonable candidate for the given treatment, test or procedure.”

A rating panel assigned a rating on a 1 to 9 scale to each imaging procedure for the 20 clinical scenarios. The full guideline paper can be viewed in the Journal of the American College of Radiology or Journal of the American College of Cardiology.

The rating panel included representatives from the ACC, ACR, ACER, American Heart Association, American Association for Thoracic Surgery, Society of Thoracic Surgeons, Society of Cardiovascular Computed Tomography, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Magnetic Resonance, North American Society for Cardiovascular Imaging, Society for Cardiovascular Patient Care, American Society of Nuclear Radiology, American College of Physicians, American Society of Echocardiography and Society of Thoracic Radiology.