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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e399 CLINICAL STATEMENTS AND GUIDELINES

causes such as myocardial ischemia from acute graft stenosis or occlusion,1,2 pericarditis, PE, sternal wound infection, or nonunion should also be considered. Poststernotomy pain syndrome is defined as discomfort after thoracic surgery, persisting for at least 2 months, and without apparent cause.15 The incidence of post-sternotomy pain syndrome has been found to be as low as 7% and as high as 66%,16-19 with a higher prevalence in women compared with men within the first 3 months of thoracic surgery (51.4% versus 31.3%; P<0.01) but, after 3 months, postoperative sex difference in prevalence was not seen.20 Graft failure within the first year post- CABG using saphenous venous grafts is usually a result of technical issues, intimal hyperplasia, or thrombosis.5 Internal mammary artery graft failure within the first-year post-CABG is most commonly attributable to issues with the anastomotic site of the graft. Reasons for acute chest pain several years after CABG include either graft stenosis or occlusion or progression of disease in a non-bypassed vessel. One year after CABG, ∼10% to 20% of saphenous vein grafts fail, while by 10 years, only about half of saphenous vein grafts are patent.5 In contrast, the internal mammary artery has patency rates of 90% to 95% 10 to 15 years after CABG.6 Compared with the use of saphenous vein grafts, the use of radial artery grafts for CABG also resulted in a higher rate of patency at 5 years of follow-up.7 In addition, knowledge of the native coronary anatomy and type of revascularization (complete or incomplete) is useful for interpretation of functional testing.

Recommendation-Specific Supportive Text

1.	 Acute chest pain in patients with prior CABG may be caused by myocardial ischemia as a result of technical errors at the graft anastomotic site, thrombosis within the graft, graft intimal hyperplasia, or vasospasm within arterial grafts. Progressive atherosclerosis within bypass grafts or the native coronary vessels may also result in acute chest pain caused by myocardial ischemia. Noninvasive stress imaging testing is reasonable in these patients as stress imaging will identify ischemic myocardial territories that will further guide revascularization for patients who are amenable to and are candidates for revascularization. CCTA has a great degree of accuracy with a sensitivity and specificity of detecting complete graft occlusions, 99% and 99%, respectively, when compared with the standard of ICA.21 Furthermore, CCTA was ideal in assessing bypass grafts because of the large size of these vessels, decreased vessel calcification, and decreased motion of these vessels when compared with native coronary vessels. Evaluation of bypass grafts has been shown to be successful in 93% to 100% of patients.21 In patients who have acute chest pain without features of ACS, CCTA is especially useful for assessing graft patency and is less robust for assessing native coronary vessel stenosis in this population.1-7

2.	 There are clinical features and stress imaging test features in patients with prior CABG presenting with acute chest pain with no ACS that may indicate a high likelihood of severe ischemic heart disease such as new resting left ventricular systolic dysfunction (left ventricular ejection fraction <35%) not readily explained by noncoronary causes, stress electrocardiographic findings including 2 mm of ST-segment depression at low workload or persisting into recovery, exercise-induced ST-segment elevation, or exercise-induced VT/ventricular fibrillation (VF), severe stress-induced left ventricular systolic dysfunction, stress-induced perfusion abnormalities involving ≥10% of the myocardium, or stressinduced left ventricular dilation. In those with prior CABG with high-risk stress imaging features, referral for ICA is useful provided that these patients are amenable to, and are candidates for, coronary revascularization.8-14 Patients with prior CABG presenting with acute chest pain without the presence of ACS may have stress imaging features that are equivocal or nondiagnostic for the presence of myocardial ischemia. Equivocal or nondiagnostic stress imaging may be as a result of patient’s body habitus, inadequate or suboptimal heart rate, arrhythmias such as atrial fibrillation, left bundle branch block, or patient motion. In these patients, performing an ICA is reasonable when the angiographic findings have a high likelihood of impacting therapeutic decisions.8

4.1.5 Evaluation of Patients With Acute Chest Pain Receiving Dialysis

Recommendation for Evaluation of Patients With Acute Chest Pain Receiving Dialysis Referenced studies that support the recommendation are summarized in Online Data Supplement 20.

COR LOE Recommendation

1 B-NR 1.	 In patients who experience acute unremitting chest pain while undergoing dialysis, transfer by EMS to an acute care setting is recommended.1-5

Synopsis In 2015, there were nearly 500 000 people in the United States who received maintenance dialysis to treat endstage renal disease.1 Chest pain occurs during hemodialysis in 2% to 5% of patients.6,7 Causes are numerous and related to the high prevalence of severe cardiovascular disease in this population and the dialysis procedure

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