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Circulation. 2021;144:e368–e454. DOI: 10.1161/CIR.0000000000001029 November 30, 2021 e423 CLINICAL STATEMENTS AND GUIDELINES

moderate or severe ischemia: secondary analysis of the ISCHEMIA randomized clinical trial. JAMA Cardiol. 2020;5:1–14. 10.	 Meisel ZF, Armstrong K, Mechem CC, et al. Influence of sex on the out-ofhospital management of chest pain. Acad Emerg Med. 2010;17:80–87. 11.	 Khan NA, Daskalopoulou SS, Karp I, et al. Sex differences in prodromal symptoms in acute coronary syndrome in patients aged 55 years or younger. Heart. 2017;103:863–869. 12.	 Roger VL, Farkouh ME, Weston SA, et al. Sex differences in evaluation and outcome of unstable angina. JAMA. 2000;283:646–652. 13.	 McSweeney JC, Cleves MA, Zhao W, et al. Cluster analysis of women's prodromal and acute myocardial infarction symptoms by race and other characteristics. J Cardiovasc Nurs. 2010;25:311–322. 14.	 Safdar B, Nagurney JT, Anise A, et al. Gender-specific research for emergency diagnosis and management of ischemic heart disease: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Research Workgroup. Acad Emerg Med. 2014;21:1350–1360. 15.	 Khan NA, Daskalopoulou SS, Karp I, et al. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med. 2013;173:1863–1871. 16.	 Tamis-Holland JE, Lu J, Korytkowski M, et al. Sex differences in presen-

tation and outcome among patients with type 2 diabetes and coronary artery disease treated with contemporary medical therapy with or without prompt revascularization: a report from the BARI 2D Trial (Bypass Angioplasty Revascularization Investigation 2 Diabetes) J Am Coll Cardiol. 2013;61:1767–1776.

2.1.2 Considerations for Older Patients With Chest Pain

1 Grosmaitre P, Le Vavasseur O, Yachouh E, et al. Significance of atypical

symptoms for the diagnosis and management of myocardial infarction in elderly patients admitted to emergency departments. Arch Cardiovasc Dis. 2013;106:586–592. 2.	 Jokhadar M, Wenger NK. Review of the treatment of acute coronary syndrome in elderly patients. Clin Interv Aging. 2009;4:435–444. 3.	 Gupta R, Munoz R. Evaluation and management of chest pain in the elderly. Emerg Med Clin North Am. 2016;34:523–542. 4.	 Lowenstern A, Alexander KP, Hill CL, et al. Age-related differences in the

noninvasive evaluation for possible coronary artery disease: insights from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) Trial. JAMA Cardiol. 2020;5:193–201.

2.1.3 Considerations for Diverse Patient Populations With Chest Pain

1 Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statis-

tics-2020 update: a report from the American Heart Association. Circulation. 2020;141:e139–e596. 2.	 DeVon HA, Burke LA, Nelson H, et al. Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White. Heart Lung. 2014;43:270–277. 3.	 Alrwisan A, Eworuke E. Are discrepancies in waiting time for chest pain at emergency departments between African Americans and Whites improving over time? J Emerg Med. 2016;50:349–355. 4.	 Graham G. Racial and ethnic differences in acute coronary syndrome and myocardial infarction within the United States: from demographics to outcomes. Clin Cardiol. 2016;39:299–306. 5.	 Lopez L, Wilper AP, Cervantes MC, et al. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006 Acad Emerg Med. 2010;17:801–808. 6.	 Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics–2015 update: a report from the American Heart Association. Circulation. 2015;131:e29–e322. 7.	 Olson MB, Kelsey SF, Matthews K, et al. Symptoms, myocardial ischaemia and quality of life in women: results from the NHLBI-sponsored WISE Study. Eur Heart J. 2003;24:1506–1514. 8.	 Volgman AS, Palaniappan LS, Aggarwal NT, et al. Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association. Circulation. 2018;138:e1–e34. 9.	 Kendall H, Marley A, Patel JV, et al. Hospital delay in South Asian patients

with acute ST-elevation myocardial infarction in the UK. Eur J Prev Cardiol. 2013;20:737–742. 10 Zaman MJ, Junghans C, Sekhri N, et al. Presentation of stable an-

gina pectoris among women and South Asian people. CMAJ. 2008;179: 659–667. 11.	 King-Shier K, Quan H, Kapral MK, et al. Acute coronary syndromes presen-

tations and care outcomes in white, South Asian and Chinese patients: a cohort study. BMJ Open. 2019;9:e022479.

2.1.4 Patient-Centric Considerations

1 Leifheit-Limson EC, D'Onofrio G, Daneshvar M, et al. Sex differences in

cardiac risk factors, perceived risk, and health care provider discussion of risk and risk modification among young patients with acute myocardial infarction: the VIRGO Study. J Am Coll Cardiol. 2015;66:1949–1957. 2.	 Mathews R, Peterson ED, Li S, et al. Use of emergency medical service transport among patients with ST-segment-elevation myocardial infarction: findings from the National Cardiovascular Data Registry Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines. Circulation. 2011;124:154–163. 3.	 Becker L, Larsen MP, Eisenberg MS. Incidence of cardiac arrest during selftransport for chest pain. Ann Emerg Med. 1996;28:612–616. 4.	 Deputy Heart Attack Program with Early Heart Attack Care Education. Available at: https://dha.acc.org/. Accessed September 10, 2020. 5.	 Merchant RM, Topjian AA, Panchal AR, et al. Part 1: executive summary:

2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142: S337–S357.

2.2 Physical Examination

1.	 Fanaroff AC, Rymer JA, Goldstein SA, et al. Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review. JAMA. 2015;314:1955–1965. 2.	 McConaghy JR, Oza RS. Outpatient diagnosis of acute chest pain in adults. Am Fam Physician. 2013;87:177–182. 3.	 Ohle R, Um J, Anjum O, et al. High risk clinical features for acute aortic dissection: a case-control study. Acad Emerg Med. 2018;25:378–387. 4.	 Garas G, Zarogoulidis P, Efthymiou A, et al. Spontaneous esophageal rupture as the underlying cause of pneumothorax: early recognition is crucial. J Thorac Dis. 2014;6:1655–1658. 5.	 Grani C, Senn O, Bischof M, et al. Diagnostic performance of reproducible chest wall tenderness to rule out acute coronary syndrome in acute chest pain: a prospective diagnostic study. BMJ Open. 2015;5:e007442. 6.	 Panju AA, Hemmelgarn BR, Guyatt GH, et al. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280:1256– 1263. 7.	 Perrier A, Desmarais S, Miron MJ, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353:190–195. 8.	 Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD) Eur J Vasc Endovasc Surg. 2009;37:149–159. 9.	 von Kodolitsch Y, Schwartz AG, Nienaber CA. Clinical prediction of acute aortic dissection. Arch Intern Med. 2000;160:2977–2982. 10.	 Klompas M. Does this patient have an acute thoracic aortic dissection?

JAMA. 2002;287:2262–2272.

2.3 Diagnostic Testing

2.3.1 Setting Considerations

1 Diercks DB, Kontos MC, Chen AY, et al. Utilization and impact of pre-

hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009;53:161–166. 2.	 Puymirat E, Simon T, Steg PG, et al. Association of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction. JAMA. 2012;308:998–1006. 3.	 Jollis JG, Granger CB, Henry TD, et al. Systems of care for ST-segmentelevation myocardial infarction: a report from the American Heart Association's Mission: Lifeline. Circ Cardiovasc Qual Outcomes. 2012;5:423–428. 4.	 Postma S, Bergmeijer T, ten Berg J, et al. Pre-hospital diagnosis, triage

and treatment in patients with ST elevation myocardial infarction. Heart. 2012;98:1674–1678.

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