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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e400 CLINICAL STATEMENTS AND GUIDELINES itself. Causes include AMI or ACS, pericarditis, PE, pleuritis, hemolysis, gastroesophageal reflux, subclavian steal, and musculoskeletal disorders.7 Myocardial ischemia is the most frequent serious cause and can be induced by hypotension6,7 or tachyarrhythmias2 occurring during dialysis in patients with CAD. AMI in patients undergoing dialysis is less frequently associated with chest pain than in patients who are not on dialysis, but warning signs may include diaphoresis or dyspnea.3 Unusual but serious causes of chest pain during dialysis are embolism6 and vessel perforation by catheter.4,5 When indicated, cardiac testing for patients on dialysis should be the same as those who are not on dialysis. Recommendation-Specific Supportive Text 1. Because the risk of CAD is relatively high in patients undergoing dialysis, when acute unremitting chest pain occurs during dialysis, a 12-lead ECG should be performed and the patient should be urgently transferred by EMS to an acute care setting for evaluation for cause of symptoms and further clinical engagement.3 4.1.6 Evaluation of Acute Chest Pain in Patients With Cocaine and Methamphetamine Use Recommendation for Evaluation of Acute Chest Pain in Patients With Cocaine and Methamphetamine Use Referenced studies that support the recommendation are summarized in Online Data Supplement 21. COR LOE Recommendation 2a B-NR 1. In patients presenting with acute chest pain, it is reasonable to consider cocaine and methamphetamine use as a cause of their symptoms.1-3 Synopsis The most frequent presenting complaint of cocaine abuse is acute chest pain, resulting from ≥1 of the alkaloid’s many cardiovascular actions.1,4,5 Cocaine produces a hyperadrenergic state by blocking neuronal reuptake of norepinephrine and dopamine. The accumulation of these catecholamines increases heart rate and blood pressure, sometimes dramatically. These actions and the drug’s simultaneous effect of coronary vasoconstriction and elevated myocardial oxygen demand can produce myocardial ischemia and even infarction in the absence of obstructive CAD. Additional hazardous actions include increased myocardial contractility, cardiac arrhythmias, myocardial toxicity directly or through augmented adrenergic stimulation, increased platelet aggregability, endothelial dysfunction, and hypertensive vascular catastrophes (aortic dissection, cerebrovascular hemorrhage).4-6 Methamphetamine has also been shown to lead to myocardial ischemia from mechanisms similar to cocaine. Studies have shown that methamphetamine can result in decreased myocardial perfusion. Like cocaine, methamphetamine also may reduce coronary sinus blood flow.7 It has been reported that up to 70% of methamphetamine users have an abnormal ECG, with the most common finding being tachycardia.8 Additional abnormalities on the ECG have been attributed to presence of hypertension, pulmonary artery hypertension, and cardiomyopathy, all of which have been associated with methamphetamine use.9 General principles for risk stratification of patients with chest pain apply to patients with cocaine or methamphetamine use.4 Recommendation-Specific Supportive Text 1. Cocaine and methamphetamine use can be considered in young patients presenting with chest pain and evidence of ACS; the frequency of ACS is <10% among cocaine and methamphetamine users in most studies, and death is rare.1-4 A person’s urine typically tests positive for cocaine or methamphetamine within 1 to 4 hours of consuming the drug and will continue to test positive for 2 to 4 days. 4.1.7 Shared Decision-Making in Patients With Acute Chest Pain Recommendations for Shared Decision-Making in Patients With Acute Chest Pain Referenced studies that support the recommendations are summarized in Online Data Supplement 22. COR LOE Recommendations 1 B-R 1. For patients with acute chest pain and suspected ACS who are deemed low risk by a CDP, patient decision aids are beneficial to improve understanding and effectively facilitate risk communication.1,2 1 B-R 2. For patients with acute chest pain and suspected ACS who are deemed intermediate risk by a CDP, shared decision-making between the clinician and patient regarding the need for admission, for observation, discharge, or further evaluation in an outpatient setting is recommended for improving patient understanding and reducing low-value testing.1,2 Synopsis Risk communication and shared decision-making using a decision aid such as Chest Pain Choice have been shown to increase patient knowledge, engagement, and satisfaction and decrease the rate of observation unit admission and 30-day cardiac stress testing in both single-center and multicenter randomized trials.1-3 For low-risk patients, decision aids can facilitate risk communication between the clinician and the patient and increase patients’ understanding of their risk and the importance of outpatient follow-up after discharge from Downloaded from http://ahajournals.org by on October 7, 2026