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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e404 CLINICAL STATEMENTS AND GUIDELINES valve stenosis is more likely to be secondary to epicardial obstructive CAD1 although, less likely, chest pain may occur in isolated mitral valve stenosis resulting from low cardiac output and decreased coronary perfusion.1 Recommendation-Specific Supportive Text 1. Patients with VHD may present with chest pain particularly in the setting of stenotic VHD, severe valvular regurgitation in the setting of AMI with ruptured papillary muscle resulting in acute severe mitral valve insufficiency, or acute aortic valve insufficiency in the setting of acute aortic pathology, such as aortic dissection.3,4 TTE is useful in assessing valvular pathologies because it is widely available and is therefore a good first-line test in these patients to determine the presence, severity, and cause of VHD.3 2. The ability to attain adequate 3-dimensional (3D) transthoracic images depends on the ability to obtain adequate 2-dimensional images.5 In these clinical situations where TTE images are technically inadequate, TEE with 3D images, if required, is useful to determine the severity and cause of VHD.3,6 3. There may be clinical situations when TTE and TEE may not be technically adequate to assess the severity and cause of VHD. In such circumstances, CMR may be useful to objectively assess the severity and cause of VHD.6 The aorta can also be visualized on CMR and can therefore be used to assess acute aortic pathologies accompanying aortic valve insufficiency such as aortic dissection.4 4.3 Evaluation of Acute Chest Pain With Suspected Noncardiac Causes Recommendation for Evaluation of Acute Chest Pain With Suspected Noncardiac Causes COR LOE Recommendation 1 C-EO 1. Patients with acute chest pain should be evaluated for noncardiac causes if they have persistent or recurring symptoms despite a negative stress test or anatomic cardiac evaluation, or a low-risk designation by a CDP. Synopsis The differential diagnosis for noncardiac causes of acute chest pain is quite broad and includes respiratory, musculoskeletal, gastrointestinal, psychological, and other causes (Table 9). Of these, musculoskeletal causes are the most common, including costochondritis, muscle strain, and potential consequences of recent or occult chest trauma such as rib fracture. Various gastrointestinal causes, com- monly esophageal, can present with chest pain, including gastrointestinal reflux and esophageal dysmotility as well as gastritis from either medications or peptic ulcer disease. Respiratory causes are less frequent but potentially more serious and include PE, pneumonia, and pneumothorax. Many patients will have dyspnea in addition to chest pain. Psychological causes are usually diagnoses of exclusion but merit consideration in the right context. Table 9. Differential Diagnosis of Noncardiac Chest Pain Respiratory Pulmonary embolism Pneumothorax/hemothorax Pneumomediastinum Pneumonia Bronchitis Pleural irritation Malignancy Gastrointestinal Cholecystitis Pancreatitis Hiatal hernia Gastroesophageal reflux disease/gastritis/esophagitis Peptic ulcer disease Esophageal spasm Dyspepsia Chest wall Costochondritis Chest wall trauma or inflammation Herpes zoster (shingles) Cervical radiculopathy Breast disease Rib fracture Musculoskeletal injury/spasm Psychological Panic disorder Anxiety Clinical depression Somatization disorder Hypochondria Other Hyperventilation syndrome Carbon monoxide poisoning Sarcoidosis Lead poisoning Prolapsed intervertebral disc Thoracic outlet syndrome Adverse effect of certain medications (eg, 5-fluorouracil) Sickle cell crisis Downloaded from http://ahajournals.org by on October 7, 2026