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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e401 CLINICAL STATEMENTS AND GUIDELINES the ED. For intermediate-risk patients, admission to an observation unit or discharge from the ED with further, timely evaluation in an outpatient setting is acceptable. Decision aids such as Chest Pain Choice can effectively facilitate shared decision-making regarding the need for admission, observation, or discharge for further evaluation in an outpatient setting.3 Recommendation-Specific Supportive Text 1. Adult ED patients with acute chest pain who are deemed low risk are frequently admitted for observation and cardiac stress testing or CCTA, resulting in increased cost to the patient and the health care system.2 Shared decision-making is the process by which patients and clinicians share information and take steps to build consensus about preferred tests and treatments. In shared decision-making, both parties share information: the clinician offers options and describes the potential harms and benefits, and the patient communicates his or her preferences. Patients are prepared with a better understanding of the relevant factors influencing the decision and share responsibility for deciding how to proceed. Shared decision-making rests on the principles of patient centered care, including respect for patient autonomy (ie, that a patient’s informed preferences should be the basis for medical action).4 Decision aids are patient-centered tools designed to facilitate shared decision-making between a patient and the clinician such that patients’ values and preferences are incorporated into health care decisions.5 Shared decision-making, however, can be performed without a decision aid; lack of a decision aid should not preclude attempts at shared decision-making. 2. In a single-center randomized trial of adults presenting to the ED with a chief complaint of chest pain (n=204) who were being considered by the treating clinician for admission to the observation unit for cardiac stress testing, patients randomized to shared decision-making facilitated by the Chest Pain Choice Decision Aid2,3 had greater knowledge, were more engaged in the decision-making process, and less frequently decided to be admitted to the observation unit for stress testing (58% versus 77%, absolute difference 19%, 95% CI: 6%-31%).2 There were no MACE after discharge in either group. The decision aid was subsequently tested in a population of 898 patients with greater socioeconomic diversity recruited from 6 EDs across the United States.1,6 Similar findings were observed. Analysis of health care use in this trial showed fewer cardiac imaging tests and lower overall 45-day health care use in patients randomized to the decision aid.7,8 4.2 Evaluation of Acute Chest Pain With Nonischemic Cardiac Pathologies Recommendation for Evaluation of Acute Chest Pain With Nonischemic Cardiac Pathologies COR LOE Recommendation 1 C-EO 1. In patients with acute chest pain in whom other potentially life-threatening nonischemic cardiac conditions are suspected (eg, aortic pathology, pericardial effusion, endocarditis), TTE is recommended for diagnosis. Synopsis Alternative nonischemic causes for acute chest pain should be considered if an ischemic cause is not suspected based on initial evaluation. Echocardiography, as a portable bedside noninvasive and almost universally available tool, should be used to unmask some imminently dangerous but potentially treatable cardiac conditions. TTE is the primary tool to diagnose pericardial effusions with and without tamponade, aortic dissections (TTE and transesophageal echocardiography [TEE]), acute right ventricular dysfunction in the setting of PE, as well as mechanical complications of MI (ventricular septal rupture, free wall rupture, papillary muscle dysfunction and rupture). Echocardiography can also identify cardiac masses, emboli, or clots in transit, intracardiac shunting, or endocarditis. Furthermore, beyond the anatomic findings, echocardiography can be used to noninvasively assess volume status, pulmonary hypertension, valvular stenosis, and regurgitation. Many of these entities may present with acute chest pain as well as shortness of breath. Recommendation-Specific Supportive Text 1. Prompt use of TTE allows for an evaluation of cardiac cause for symptoms and evaluation of alternative pathologies for acute chest pain.1-6 Rapid echocardiographic assessment may facilitate imaging of the patient while symptomatic. 4.2.1 Acute Chest Pain With Suspected Acute Aortic Syndrome Recommendations for Acute Chest Pain With Suspected Acute Aortic Syndrome COR LOE Recommendations 1 C-EO 1. In patients with acute chest pain where there is clinical concern for aortic dissection, computed tomography angiography (CTA) of the chest, abdomen, and pelvis is recommended for diagnosis and treatment planning. 1 C-EO 2. In patients with acute chest pain where there is clinical concern for aortic dissection, TEE or CMR should be performed to make the diagnosis if CT is contraindicated or unavailable. Downloaded from http://ahajournals.org by on October 7, 2026