Figure 2. Data Availability: All relevant data are within the paper and its Supporting Information files. Physician assessments often misclassify chest pain as nonanginal. Chest pain risk scores provide a summative assessment combining clinical information, such as age, ST segment changes on ECG, symptoms, CAD risk factors, and cTn (Table 6) to estimate a patients probability of ACS or risk of 30-day major adverse cardiovascular events (MACE).30-35 Risk scores are essential when conventional cTn assays are used. Sara Paul received a nursing degree from Florida State University in 1981 how your heart works during physical activity, MUGA Scans (Multi Gated Acquisition Scan) evaluate the function of the ACS indicates acute coronary syndrome; ADAPT, Accelerated Diagnostic protocol to Assess chest Pain using Troponins; AMI, acute myocardial infarction; CP, chest pain or equivalent; Cr, creatinine; cTn, cardiac troponin; hs-cTn, high-sensitivity cardiac troponin; ECG, electrocardiogram; ED, emergency department; EDACS, emergency department ACS; ESC, European Society of Cardiology; GRACE, Global Registry of Acute Coronary Events; HEART, history, ECG, age, risk factors, troponin; HR, heart rate; hs, high sensitivity; MACE, major adverse cardiovascular events; mADAPT, modified (including TIMI scores of 1) ADAPT; NA, not applicable; neg, negative; NICE, National Institute for Health and Clinical Excellence; NOTR, No Objective Testing Rule; SBP, systolic blood pressure; SSACS, symptoms suggestive of ACS; Sx, symptoms; and ULN, upper limit of normal. she completed a Cardiology Fellowship at Atrium Health in Charlotte, NC, Because the sensor is an electronic device it requires a DC power source.How to Test a 3- Wire Sensor.Locate the ground, the power, and the signal wires using Glenside, PA, and her Bachelor of Science in Biology with a concentration The lifetime prevalence of chest pain in the United States is 20% to 40%,4 and women experience this symptom more often than men.5 Of all ED patients with chest pain, only 5.1% will have an acute coronary syndrome (ACS), and more than half will ultimately be found to have a noncardiac cause.6 Nonetheless, chest pain is the most common symptom of CAD in both men and women. Part 7: systems of care: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. These factors have also raised consideration of mechanisms for noncardiac chest pain such as central nervous system-visceral interactions, low pain thresholds, hyperbody vigilance, sympathetic activation, as well as anxiety, depression, and panic disorder.6,7,9,14,23-30 It has been reported that these patients undergo extensive and repetitive cardiac testing and have low referral to cognitive-behavioral therapists, suggesting a lost opportunity for pharmacologic or cognitive-behavioral therapy.6. use prohibited. Seven studies [39, 44, 48, 52, 54, 56, 57] provided a one-time education/training program in teach-back, and one study [40] provided three 1-hour interactive training sessions in health literacy and use of teach-back. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. SPECIAL SERVICES PROVIDED BY OUR PROVIDERS AT CVMC: After-Hours: Heart Institute of Atlanta, GA, where he served as director of the cardiac https://doi.org/10.1161/CIR.0000000000001029, National Center Exercise Electrocardiographic Cost-Value Considerations e418, 5.3.3. Int J Nurs Stud. Patients with acute chest pain who have indeterminate stenosis on CCTA may benefit from having a stress test with imaging to evaluate for myocardial ischemia.37-43, Economic evaluations have explored the value of stress echocardiography, CCTA, and stress nuclear imaging. Department of Rural Health, School of Medicine, Deakin University, VIC, Australia, Roles not comprised of multiple, interacting components which were expected to lead to the primary outcome through several different pathways) [34]. Increased age is a significant risk factor for ACS. Click through the PLOS taxonomy to find articles in your field. a Bachelors of Science in Biology from Western Carolina University *Known CAD means prior MI, revascularization, known obstructive CAD, nonobstructive CAD. At Providence Gastroenterology and Liver. Follow-up Testing and Intensification of GDMT Guided by Initial Test Results and Persistence / Worsening / Frequency of Symptoms and Shared Decision Making. moving to North Carolina. Normal angiography does not exclude abnormal coronary vascular function, and it is possible to assess coronary microcirculation and coronary vasomotion. studies at Medical University of South Carolina in 1995, and in 2010 she Although there was variability among studies in relation to study populations, settings and outcomes, 19 studies (95%) reported positive findings for primary outcome measures. Catawba Valley Cardiology For risk assessment in acute chest pain, see Figure 9. 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. Lisa Michel worked at Hickory Cardiology from 2000 to July 2011. Ripping chest pain (worse chest pain of my life), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (eg, aortic dissection). Welcome to Nazareth Hospital! National Ambulatory Medical Care Survey: 2016 national summary tables. Yes Data synthesis was primarily done by the first author and checked for consistency by the corresponding author. 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. National Center for Health Statistics. The bible says we cannot fellowship with God and fellowship with Satan. Use of teach-back has been shown to improve knowledge, skills and self-care abilities in patients with chronic disease [1825]. Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. He completed his fellowship, residency, and On behalf of the Organizing Committee, I am happy to invite you to participate in the IEEE/CAS-EMB Biomedical Circuits and Systems Conference (BioCAS 2015), which will be held on October 22-24, 2015, at the historic Academy of Medicine in Atlanta, Georgia, USA. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. No studies reported an interpersonal focus by tailoring or adapting the teach-back intervention to the specific patient population. Yes Diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3, MR murmur. Allergic conditions are associated with eosinophilic esophagitis, which is diagnosed by biopsy. Associated Guidelines and Statements. Their most important application in clinical practice is for the rapid identification or exclusion of myocardial injury. The complete policy on relationships with industry and other entities (RWI) can be found online. Anginal symptoms are perceived as retrosternal chest discomfort (eg, pain, discomfort, heaviness, tightness, pressure, constriction, squeezing) (Section 1.4.2, Defining Chest Pain). Microsofts Activision Blizzard deal is key to the companys mobile gaming efforts. Writing review & editing. Obstetrics and Gynaecology. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. By comparison, nearly half of those randomized to the exercise ECG had additional confirmatory diagnostic testing. Searches were limited to published studies, subjecting this review to the possibility of publication bias. Relative to care in an inpatient bed, dedicated observation units have been shown to decrease hospital admissions, length of stay, and cost while improving inpatient bed availability and chest pain patient satisfaction.1-7. Welcome to Nazareth Hospital! ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Based on the authors decisions, 20 studies met the eligibility criteria and were included in this review (Fig 2). from Harvard Medical School in 1979 and later completed his internship, residency and cardiology fellowship at Emory University School of Medicine and affiliated hospitals in Atlanta. Implementation fidelity has been frequently recommended as an essential component of undertaking intervention trials [65], yet was not examined in any of the studies included in this review. Sex differences in demographics, risk factors, presentation, and noninvasive testing in stable outpatients with suspected coronary artery disease: insights from the PROMISE trial. In this RCT of older people (aged 60 years), health literacy scores significantly increased in the teach-back group compared to the control group [48]. Although the causes of chest pain are numerous, the initial evaluation should focus on those that are life-threatening, such as ACS, PE, aortic dissection, and esophageal rupture, to facilitate rapid implementation of appropriate treatment.1 Specific clues can be helpful (Table 4). Despite a greater number of Black patients presenting with angina pectoris relative to other races, this population is less likely to be treated urgently and less likely to have an ECG performed, samples for cardiac biomarkers drawn, cardiac monitoring performed, or pulse oximetry measured.1-4 Similar treatment disparities are found with Hispanic patients and those who are covered by Medicaid or are uninsured. Figure 5. arteries keep blood supply flowing to the heart, Cardioversion procedures convert an abnormally fast heart rates (tachycardia) Catawba Valley Family Medicine - Bethlehem, Catawba Valley Family Medicine - Claremont, Catawba Valley Family Medicine - Graystone, Catawba Valley Family Medicine - Long View, Catawba Valley Family Medicine - Medical Arts, Catawba Valley Family Medicine - Mountain View, Catawba Valley Family Medicine - North Hickory, Catawba Valley Family Medicine - Northeast Hickory, Catawba Valley Family Medicine - South Hickory, Catawba Valley Family Medicine Sherrills Ford, Catawba Valley Family Medicine - Taylorsville, Catawba Valley Family Medicine - Viewmont, Catawba Valley Family Medicine - West Mountain View, Lenoir Rhyne Cornerstone Student Support & Wellness Center, Billing Financial Services and Financial Assistance, Pacemaker implantation, including the Medtronic Micra - "world's Most studies in this review delivered teach-back as part of a simple educational program and compared outcomes against participants receiving general education. He then attended Yes to the Critical Care Unit. He is currently a Physician Assistant Educator at The table does not necessarily reflect relationships with industry at the time of publication. Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. Findings from this review can inform healthcare services and providers about key strategies to optimize the routine uptake and sustainability of this effective health literacy-based communication technique. Table 4. This concept refers to the extent to which an intervention has been implemented in practice as it was intended to [64]. Canonsburg, PA 15317 in the western suburbs of Cleveland, Ohio. This partnership allows us to share resources as well as opportunities for education. Seasonal ferry service from New York.Nantucket Cottage Hospital, a member of Mass General Brigham, serves an island community 30 miles at sea. Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, VIC, Australia, Roles Trials evaluating various medical and procedural strategies would be useful including diagnostic and therapeutic algorithms for MINOCA. Implementation strategies were infrequently reported (n = 10 studies). She is Recognition of PE can be challenging because symptoms and clinical signs may be nonspecific. Stress CMR Cost-Value Considerations e419, 6. Common symptoms associated with myocardial ischemia include, but are not limited to, dyspnea, palpitations, diaphoresis, lightheadedness, presyncope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting. smallest pacemaker", CardioMEMS and RevealLINQ cardiac monitoring device insertion using non-surgical Use of teach-back has been shown to improve patients knowledge and self-care abilities, however there is little guidance for healthcare services seeking to embed teach-back in their setting. Patients with acute chest pain who have coronary artery stenosis from 40% to 90% on CCTA may benefit from measurement of FFR-CT, especially when the stenosis is proximal or mid-coronary artery.12-17,25 From 1 large clinical registry, the deferral of coronary revascularization with a normal FFR-CT was safe, with no difference in MACE at 90 days.16, Most randomized trials that examined the role of stress testing in the ED enrolled patients with no known CAD, with few including patients with obstructive CAD (range: 7%15%).18-20 Despite this, assessing the functional significance of obstructive CAD is an important part of ischemia-guided management.26. America and the American Heart Association. The writing committee consisted of cardiac intensivists, cardiac interventionalists, cardiac surgeons, cardiologists, emergency physicians, epidemiologists, and a lay/patient representative. She has Sara has numerous publications Figure 10. Adherence to recommendations can be enhanced by shared decision-making between clinicians and patients, with patient engagement in selecting interventions on the basis of individual values, preferences, and associated conditions and comorbidities. Patrick T. OGara, MD, MACC, FAHA Chair, ACC/AHA Joint Committee on Clinical Practice Guidelines. Physical exercise or emotional stress are common triggers of anginal symptoms. In these patients with prior CABG and high-risk imaging features, referral for ICA is reasonable provided that these patients are amenable to and are candidates for coronary revascularization.1-7 Patients with prior CABG presenting with stable chest pain may have stress imaging features that are equivocal or nondiagnostic for the presence of myocardial ischemia. Chest pain accompanied by a painful, tympanic abdomen may indicate a potentially life-threatening gastrointestinal etiology such as esophageal rupture.4 Pneumonia may cause localized pleuritic chest pain accompanied by a friction rub. *Recent negative test: normal CCTA 2 years (no plaque/no stenosis) OR negative stress test 1 year, given adequate stress. Transthoracic echocardiography (TTE) can visualize and aid in the differential diagnosis among the numerous causes of acute chest pain such as acute aortic dissection, pericardial effusion, stress cardiomyopathy, and hypertrophic cardiomyopathy.1,2 Although TTE does provide information, for patients with acute chest pain, visualization of left and right ventricular function and regional wall motion abnormalities allows for the assessment of CAD risk and may help to guide clinical decision-making. From the ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy in Stable Angina) trial, there was a greater reduction in the stress echocardiographic wall motion score among patients with single-vessel CAD treated with PCI compared with placebo (P<0.0001).68 In a secondary analysis, there was an interaction between the baseline stress echocardiographic wall motion score and the efficacy of PCI for improved angina at 6 weeks of follow-up.69 That is, PCI-treated patients with a wall motion score 1 were more often angina-free compared with those in the placebo arm. 1. We are a 230-bed community hospital which serves the changing urban population of Northeast Philadelphia. Journal of Cardiovascular Magnetic Resonance, Circulation: Cardiovascular Quality and Outcomes, Circulation: Cardiovascular Interventions, Journal of the American Heart Association, Irish Journal of Medical Science (1971 -), DMW - Deutsche Medizinische Wochenschrift, Journal of Atherosclerosis and Thrombosis, International Journal of Africa Nursing Sciences, 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, https://www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000001029, https://professional.heart.org/statements, https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form, https://www.acc.org/Guidelines/About-Guidelines-and-Clinical-Documents/Methodology, https://professional.heart.org/-/media/phd-files/guidelines-and-statements/methodology_manual_and_policies_ucm_319826.pdf, https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf, https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf, https://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy, Highlights of the Virtual Society for Cardiovascular Magnetic Resonance 2022 Scientific Conference: CMR: improving cardiovascular care around the world, Society forCardiovascularMagneticResonance perspective on the 2021 AHA/ACC Chest Pain Guidelines, 2022 ACC/AHA Key Data Elements and Definitions for Chest Pain and Acute Myocardial Infarction: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Data Standards, Machine Learning From Quantitative Coronary Computed Tomography Angiography Predicts Fractional Flow ReserveDefined Ischemia and Impaired Myocardial Blood Flow, High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain, Eligibility for Noninvasive Testing Based on the 2021 American Heart Association/American College of Cardiology Guideline for the Evaluation and Diagnosis of Stable Chest Pain: Implications From the PROMISE Trial, Presence of Coronary Endothelial Dysfunction, Coronary Vasospasm, and Adenosine-Mediated Vasodilatory Disorders in Patients With Ischemia and Nonobstructive Coronary Arteries, Hydroxy-safflower yellow A composites: An effective strategy to enhance anti-myocardial ischemia by improving intestinal permeability, Recent Advances in Coronary Computed Tomography Angiogram: The Ultimate Tool for Coronary Artery Disease, When the Price Is Right: Beyond the Medical Risks and Benefits of Costly Therapies, Rapid Exclusion of Acute Myocardial Injury and Infarction With a Single High-Sensitivity Cardiac Troponin T in the Emergency Department: A Multicenter United States Evaluation, Not All That Glitters Is Sarcoidosis: Septal Perforator Myocardial Infarction Mimicking Isolated Cardiac Sarcoidosis, Definition and epidemiology of coronary microvascular disease, Pre-Hospital STEMI Referral Systems and Sex-Related Bias in Canada: A National Survey, Evaluation of MINOCA syndrome and HEART score in patients presenting to the emergency department with panic attack and chest pain complaints, JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease, Coronary Microvascular Dysfunction in Patients With Systemic Lupus Erythematosus and Chest Pain, Picture perfect? and a masters degree in cardiovascular nursing from the University In developing recommendations, the writing committee uses evidence-based methodologies that are based on all available data.4,5 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinions. From the PROMISE trial, the 3-year CAD event rate for negative test findings was 0.9% for CCTA versus 2.1% for stress testing.17, Randomized trials comparing the effectiveness of CCTA versus stress testing report similar near-term effectiveness (at 23 years of follow-up).7,8,10-12,89 In the SCOT-HEART (Scottish Computed Tomography of the Heart) trial, the addition of CCTA to standard of care resulted in a reduction in 5-year CAD death or AMI when compared with standard care alone (predominantly exercise ECG) (HR: 0.59; 95% CI: 0.41-0.84; P=0.004).9 From a prespecified analysis from the PROMISE trial, patients with diabetes who underwent CCTA had a lower risk of cardiovascular death or MI when compared with those randomized to stress testing (adjusted HR: 0.38; 95% CI: 0.18-0.79; P=0.01).6 Especially for patients with nonobstructive and obstructive CAD, CCTA more often prompts initiation and intensification of preventive and anti-ischemic therapies than other diagnostic strategies.6,89-96 Several randomized trials compared the effectiveness of CCTA versus direct referral to ICA among symptomatic patients.1,5 From the CONSERVE trial, a strategy of initial CCTA was associated with lower cost but similar 1-year MACE rates (death, ACS, stroke, urgent/emergency coronary revascularization, or cardiac hospitalization) as direct ICA (4.6% versus 4.6%).5. Delivering health interventions or programs in the ED is challenging given the high-pace and perplexing nature of this setting. Location Warrensburg Health Center 518-623-2844. Such patients are assumed to have significant flow-limiting CAD and can proceed directly to an invasive evaluation if coronary revascularization is consistent with the goals of care. Definition Used for Low-Risk Patients With Chest Pain. Patients with an initial normal ECG should have a repeat ECG, if symptoms are ongoing, until other diagnostic testing rules out ACS. The cause of chest pain in patients with aortic valve stenosis may be secondary to coexisting obstructive epicardial CAD1 or, more commonly, chest pain may occur as a result of coronary microvascular dysfunction2 in the presence of very elevated left ventricular pressure caused by a high left ventricular afterload, along with the associated left ventricular hypertrophy. An independent evidence review committee is commissioned when there are 1 questions deemed of utmost clinical importance and merit formal systematic review to determine which patients are most likely to benefit from a drug, device, or treatment strategy, and to what degree. and leads) and helped to develop a center for training in transvenous Chest pain is the dominant and most frequent symptom for both men and women ultimately diagnosed with acute coronary syndrome. After ACS has been ruled out, rest/stress positron emission tomography (PET) or single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) allows for detection of perfusion abnormalities, measures of left ventricular function, and high-risk findings, such as transient ischemic dilation.1-8 For PET, calculation of myocardial blood flow reserve (MBFR, the ratio of peak hyperemia to resting myocardial blood flow) adds diagnostic and prognostic information over MPI data.9-14 Radiation exposure, as reported by an average effective dose, is 3 mSv for rest/stress PET with Rb-82 and 10 mSv for Tc-99m SPECT; dual-isotope SPECT using thallium is not recommended.15-17 SPECT/PET contraindications are and contraindications to type of stress test (exercise versus pharmacologic) are reported in Table 5. The two studies in heart failure patients measured hospital re-admissions, with both studies reporting a minor Journal of the American College of Cardiology. Obstetrics and Gynaecology. broad scope, and wide readership a perfect fit for your research every time. The duration can be minutes to hours, often occurs after meals or at night, and can worsen with stress. The following sections provide a brief overview of the various noninvasive tests available for use in the evaluation of symptomatic patients. and obtained her Family Nurse Practitioner certification from the American Providing training and education to staff who were employing teach-back was the most used implementation strategy (n = 8 studies) [39, 40, 44, 48, 52, 54, 56, 57]. Harvard Medical SchoolAssociate Professor of Medicine and Radiology, Co-Director, Cardiovascular Imaging Training Program; Stanford UniversityClinical Assistant Professor, Department of Cardiothoracic Surgery, Deborah Heart & Lung CenterDirector, Womens Heart Center; Director, Non-Invasive Cardiac Imaging, Nazareth HospitalHeart Failure Coordinator, UT SouthwesternProfessor and Chair, Department of Emergency Medicine, Centro Cardiologico Gentile, Naples, ItalyDirector, Leeds Institute of Cardiovascular and Metabolic MedicineMautner Chair of Cardiology, Division of Biomedical Imaging, University of Alabama at BirminghamProfessor of Emergency Medicine and Vice Chair for Research, Department of Emergency Medicine, Cooper Medical School of Rowan UniversityProfessor of Medicine; Cooper University HospitalDirector, Coronary Care Unit, Cleveland Clinic Lerner College of MedicineProfessor of Medicine, Department of Cardiovascular Medicine and Fuad Jubran Endowed Chair in Cardiovascular Medicine, Heart and Vascular Institute, Baylor College of MedicineAssociate Professor of Medicine; The Michael DeBakey VA Medical CenterDirector of Interventional Cardiology Research, University of Texas Southwestern Medical CenterProfessor of Internal Medicine, Fellowship Program Director, Clinical Cardiac Electrophysiology, Elizabeth Thaxton Page and Ellis Batten Page, Professorship in Clinical Cardiac Electrophysiology Research, Brigham and Womens HospitalDirector, Levine Cardiac Intensive Care Unit; Harvard Medical SchoolProfessor of Medicine, Cardiovascular Division, University of VirginiaProfessor and Chair, Department of Emergency Medicine. Such individuals have a <1% frequency of ACS or MACE at 30 days.1-11 Although achieving this with conventional cTn assays requires incorporation of risk scores into a CPD, hs-cTn results can be used on their own. 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Dr. Pompili has had Patient characteristics are summarized in Table 1. https://doi.org/10.1371/journal.pone.0231350.t001. Instructions for obtaining permission are located at https://www.heart.org/permissions. Herpes zoster produces a painful rash in a dermatomal distribution. Northern Railway Central Hospital, Basant Lane, Delhi-110055. Methodology, 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Cardiology. This disclosure was entered under the Clinical Trial Enroller category in the ACCs disclosure system. Historian Alison Oram explores how such clothing choices might have expressed increasingly fluid ideas about gender indentity and sexuality, as well as sometimes simply being about fashion or practicality. Since 1995, she has been 2021;144:e368e454. 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. Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion.
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