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November 30, 2021 Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 e420 CLINICAL STATEMENTS AND GUIDELINES benefit in terms of improved outcomes or lower costs before widespread implementation.1 hscTn assays are now the global standard of care for identifying myocardial injury, although questions remain about whether minimal elevations, which carry prognostic value, are actionable in a manner that improves outcomes. Trials evaluating various medical and procedural strategies would be useful including diagnostic and therapeutic algorithms for MINOCA. The number of potential questions that could be addressed will demand innovative trial designs to use resources efficiently and meaningfully. 5. Increasingly, randomized trials will be performed to determine which diagnostic tests can be eliminated from initial and follow-up care, both to streamline management algorithms and to decrease health care costs. In part, this approach will encompass evaluation of where patients with chest pain should be initially evaluated and monitored. Comparison of the various imaging modalities in randomized trials should help refine test selection and use.8 Thus, the diagnosis and management of chest pain will remain a fertile area of investigation, with randomized evaluations complementing insights provided by registries of patients presenting with chest pain.9-12 In the future, registries will more frequently serve as platforms within which to conduct randomized trials. Accreditation activities coupled with registry participation will also need to be evaluated to determine if they not only improve processes of care but also affect clinical endpoints.12 Assessment of long-term outcomes, patientcentered metrics, and cost will be integrated into these studies to enhance the evidence base for care of patients presenting with chest pain with greater precision. ACC/AHA JOINT COMMITTEE MEMBERS Patrick T. O’Gara, MD, MACC, FAHA, Chair; Joshua A. Beckman, MD, MS, FAHA, FACC, Chair-Elect; Glenn N. Levine, MD, FACC, FAHA, Immediate Past Chair*; Sana M. Al-Khatib, MD, MHS, FACC, FAHA*; Anastasia L. Armbruster, PharmD, FACC; Kim K. Birtcher, MS, PharmD, AACC*; Ralph G. Brindis, MD, MPH, MACC*; Joaquin E. Cigarroa, MD, FACC*; Lisa de las Fuentes, MD, MS, FASE, FAHA; Anita Deswal, MD, MPH, FACC, FAHA; Dave L. Dixon, PharmD, FACC*; Lee A. Fleisher, MD, FACC, FAHA*; Federico Gentile, MD, FACC*; Zachary D. Goldberger, MD, MS, FACC, FAHA*; Bulent Gorenek, MD, FACC; Norrisa Haynes, MD; Adrian F. Hernandez, MD; Mark A. Hlatky, MD, FACC, FAHA*; John S. Ikonomidis, MD, PhD, FAHA*; José A. Joglar, MD, FAHA, FACC; W. Schuyler Jones, MD, FACC; Joseph E. Marine, MD, FACC*; Daniel B. Mark, MD, MPH, FACC; Debabrata Mukherjee, MD, MS, FACC, FAHA; Latha P. Palaniappan, MD, MS, FAHA, FACC; Mariann R. Piano, RN, PhD, FAHA; Tanveer Rab, MD, FACC; Barbara Riegel, PhD, RN, FAHA*; Erica S. Spatz, MD, MHS, FACC; Jacqueline E. Tamis-Holland, MD, FACC; Duminda N. Wijeysundera, MD, PhD*; Y. Joseph Woo, MD, FAHA, FACC STAFF American College of Cardiology Dipti N. Itchhaporia, MD, FACC, President Cathleen C. Gates, Chief Executive Officer MaryAnne Elma, MPH, Senior Director, Enterprise Content and Digital Strategy Timothy W. Schutt, MA, Clinical Practice Guidelines Analyst Grace D. Ronan, Team Leader, Clinical Policy Publications American College of Cardiology/American Heart Association Thomas S.D. Getchius, Director, Guideline Strategy and Operations Abdul R. Abdullah, MD, Director, Guideline Science and Methodology Hannah Planalp, Guideline Advisor Zainab Shipchandler, MPH, Guideline Advisor American Heart Association Mitchell S.V. Elkind, MD, MS, FAAN, FAHA, President Nancy Brown, Chief Executive Officer Mariell Jessup, MD, FAHA, Chief Science and Medical Officer Radhika Rajgopal Singh, PhD, Senior Vice President, Office of Science and Health Paul St. Laurent, DNP, RN, Senior Science and Medicine Advisor, Office of Science, Medicine and Health Jody Hundley, Production and Operations Manager, Sci- entific Publications, Office of Science Operations *Former ACC/AHA Joint Committee member; current member during the writing effort. Downloaded from http://ahajournals.org by on October 7, 2026