ACC/AHA GUIDELINES
ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina1
A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina)
Raymond J. Gibbons, MD, FACC, Committee Member, Chair,
Kanu Chatterjee, MB, FACC, Committee Member,
Jennifer Daley, MD, FACP, Committee Member,
John S. Douglas, MD, FACC, Committee Member,
Stephan D. Fihn, MD, MPH, FACP, Committee Member,
Julius M. Gardin, MD, FACC, Committee Member,
Mark A. Grunwald, MD, FAAFP, Committee Member,
Daniel Levy, MD, FACC, Committee Member,
Bruce W. Lytle, MD, FACC, Committee Member,
Robert A. O’Rourke, MD, FACC, Committee Member,
William P. Schafer, MD, FACC, Committee Member,
Sankey V. Williams, MD, FACP, Committee Member,
James L. Ritchie, MD, FACC, Task Force Member, Chair,
Raymond J. Gibbons, MD, FACC, Task Force Member, Vice Chair,
Melvin D. Cheitlin, MD, FACC, Task Force Member,
Kim A. Eagle, MD, FACC, Task Force Member,
Timothy J. Gardner, MD, FACC, Task Force Member,
Arthur Garson, Jr, MD, MPH, FACC, Task Force Member,
Richard O. Russell, MD, FACC, Task Force Member,
Thomas J. Ryan, MD, FACC, Task Force Member and
Sidney C. Smith, Jr, MD, FACC, Task Force Member
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Committee members
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Table of contents.
- Introduction and Overview......2093
- Organization of Committee and Evidence Review......2093
- Scope of the Guidelines......2094
- Overlap With Other Guidelines......2094
- Magnitude of the Problem......2095
- Organization of the Guidelines......2097
- Diagnosis......2098
- History and Physical......2098
- Associated Conditions......2105
- Noninvasive Testing......2106
- ECG/Chest X-Ray......2106
- Exercise ECG for Diagnosis......2107
- Echocardiography (Resting)......2111
- Stress Imaging Studies—Echo and Nuclear......2112
- Invasive Testing: Value of Coronary Angiography......2119
- Risk Stratification......2121
- Clinical Assessment......2121
- ECG/Chest X-Ray......2123
- Noninvasive Testing......2123
- Resting LV Function (Echo/Radionuclide Imaging)......2123
- Exercise Testing for Risk Stratification and Prognosis......2124
- Stress Imaging Studies (Radionuclide and Echocardiography)......2127
- Coronary Angiography and Left Ventriculography......2133
- Treatment......2135
- Pharmacologic Therapy......2135
- Definition of Successful Treatment and Initiation of Treatment......2145
- Education of Patients with Chronic Stable Angina2147
- Coronary Disease Risk Factors and Evidence That Treatment Can Reduce the Risk for Coronary Disease Events......2149
- Revascularization for Chronic Stable Angina......2161
- Patient Follow-up: Monitoring of Symptoms and Antianginal Therapy......2167
- Index......2191
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Preamble
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It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies in the management or prevention of disease states. Rigorous and expert analysis of the available data documenting relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and have a favorable impact on the overall cost of care by focusing resources on the most effective strategies.
The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. This effort is directed by the ACC/AHA Task Force on Practice Guidelines, whose charge is to develop and revise practice guidelines for important cardiovascular diseases and procedures. Experts in the subject under consideration are selected from both organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups where appropriate. Writing groups are specifically charged to perform a formal literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers, comorbidities and issues of patient preference that might influence the choice of particular tests or therapies are considered as well as frequency of follow-up and cost-effectiveness.
The ACC/AHA Task Force on Practice Guidelines makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the writing panel. Specifically, all members of the writing panel are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reviewed by the parent task force, reported orally to all members of the writing panel at the first meeting, and updated yearly and as changes occur.
These practice guidelines are intended to assist physicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions. These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the physician and patient in light of all of the circumstances presented by that patient.
The executive summary and recommendations are published in the June 1, 1999 issue of Circulation. The full text is published in the June 1999 issue of the Journal of the American College of Cardiology. Reprints of the full text and the executive summary are available from both organizations.
James L. Ritchie, MD, FACC
Chair, ACC/AHA Task Force on Practice Guidelines
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I. Introduction and overview
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A. Organization of committee and evidence review.
The ACC/AHA Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Ischemic heart disease is the single leading cause of death in the U.S. The most common manifestation of this disease is chronic stable angina. Recognizing the importance of the management of this common entity and the absence of national clinical practice guidelines in this area, the task force formed the current committee to develop guidelines for the management of patients with stable angina. Because this problem is frequently encountered in the practice of internal medicine, the task force invited the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) to serve as a partner in this effort by naming four general internists to serve on the committee.
The committee reviewed and compiled published reports (excluding abstracts) through a series of computerized literature searches of the English language research literature since 1975 and a manual search of selected final articles. Details of the specific searches conducted for particular sections are provided as appropriate. Detailed evidence tables were developed whenever necessary on the basis of specific criteria outlined in the individual sections. The recommendations were based primarily on these published data. The weight of the evidence was ranked high (A) if the data were derived from multiple randomized clinical trials with large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials with small numbers of patients, careful analyses of nonrandomized studies or observational registries. A low rank (C) was given when expert consensus was the primary basis for the recommendation.
The customary ACC/AHA classifications I, II and III are used in tables that summarize both the evidence and expert opinion and provide final recommendations for both patient evaluation and therapy:
Class I
Conditions for which there is evidence or general agreement that a given procedure or treatment is useful and effective.
Class II
Conditions for which there is conflicting evidence or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
Class IIa
Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb
Usefulness/efficacy is less well established by evidence/opinion.
Class III
Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful.
A complete list of many publications on various aspects of this subject is beyond the scope of these guidelines; only selected references are included. The committee consisted of acknowledged experts in general internal medicine from the ACP-ASIM, family medicine from the American Academy of Family Physicians (AAFP), and general cardiology as well as persons with recognized expertise in more specialized areas, including noninvasive testing, preventive cardiology, coronary intervention, and cardiovascular surgery. Both the academic and private practice sectors were represented. This document was reviewed by three outside reviewers nominated by the ACC, three outside reviewers nominated by the AHA, three outside reviewers nominated by the ACP-ASIM, and two outside reviewers nominated by the AAFP. This document was approved for publication by the governing bodies of the ACC, AHA, and ACP-ASIM. The task force will review these guidelines one year after publication and yearly thereafter to determine whether revisions are needed. These guidelines will be considered current unless the task force revises or withdraws them from distribution.
B. scope of the guidelines.
These guidelines are intended to apply to adult patients with stable chest pain syndromes and known or suspected ischemic heart disease. Patients who have "ischemic equivalents," such as dyspnea or arm pain with exertion, are included in these guidelines. Some patients with ischemic heart disease may become asymptomatic with appropriate therapy. As a result, the follow-up sections of the guidelines may apply to patients who were previously symptomatic. However, the diagnosis, risk stratification and treatment sections of the guidelines are intended to apply to symptomatic patients. Asymptomatic patients with "silent ischemia" or known coronary artery disease (CAD) that has been detected in the absence of symptoms are beyond the scope of these guidelines. Pediatric patients are also beyond the scope of these guidelines because ischemic heart disease is very unusual in such patients and is primarily related to the presence of coronary artery anomalies. Patients with chest pain syndromes following cardiac transplantation are also not included in these guidelines.
Patients with nonanginal chest pain are generally at lower risk for ischemic heart disease. Often their chest pain syndromes have identifiable noncardiac causes. Such patients are included in these guidelines if there is sufficient suspicion of heart disease to warrant cardiac evaluation. If the evaluation demonstrates that ischemic heart disease is unlikely and noncardiac causes are the primary focus of evaluation, such patients are beyond the scope of these guidelines. If the initial cardiac evaluation demonstrates that ischemic heart disease is possible, subsequent management of such patients does fall within these guidelines.
Acute ischemic syndromes are not included in these guidelines. For patients with acute myocardial infarction (MI), the reader is referred to the "ACC/AHA Guidelines for the Management of Patients With Acute Myocardial Infarction" (1). For patients with unstable angina, the reader is referred to the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline on unstable angina (2), which was endorsed by the ACC and the AHA. This guideline for unstable angina did describe some low-risk patients who should not be hospitalized but instead evaluated as outpatients. Such patients are indistinguishable from many patients with stable chest pain syndromes and are therefore within the scope of the present guidelines. Patients whose recent unstable angina was satisfactorily treated by medical therapy and who then present with a recurrence of symptoms with a stable pattern fall within the scope of the present guidelines. Similarly, patients with MI who subsequently present with stable chest pain symptoms >30 days after the initial event are within the scope of the present guidelines.
The present guidelines do not apply to patients with chest pain symptoms early after revascularization by either percutaneous techniques or coronary artery bypass grafting. Although the division between "early" and "late" symptoms is arbitrary, the committee believed that these guidelines should not be applied to patients who develop recurrent symptoms within six months of revascularization.
C. Overlap with other guidelines.
These guidelines will overlap with a large number of recently published (or soon to be published) clinical practice guidelines developed by the ACC/AHA Task Force on Practice Guidelines; the National Heart, Lung, and Blood Institute (NHLBI); and the ACP-ASIM (Table 1).
This report includes text and recommendations from many of these guidelines, which are clearly indicated. Additions and revisions have been made where appropriate to reflect more recently available evidence. This report specifically indicates rare situations in which it deviates from previous guidelines and presents the rationale. In some cases, this report attempts to combine previous sets of similar and dissimilar recommendations into one set of final recommendations. Although this report includes a significant amount of material from the previous guidelines, by necessity the material was often condensed into a succinct summary. These guidelines are not intended to provide a comprehensive understanding of the imaging modalities, therapeutic modalities, and clinical problems detailed in other guidelines. For such an understanding, the reader is referred to the original guidelines listed in the references.
D. Magnitude of the problem.
There is no question that ischemic heart disease remains a major public health problem. Chronic stable angina is the initial manifestation of ischemic heart disease in approximately one half of patients (3,4). It is difficult to estimate the number of patients with chronic chest pain syndromes in the U.S. who fall within these guidelines, but clearly it is measured in the millions. The reported annual incidence of angina is 213/100,000 population >30 years old (3). When the Framingham Heart Study (4) is considered, an additional 350,000 Americans each year are covered by these guidelines. The AHA has estimated that 6,200,000 Americans have chest pain (5); however, this may be a conservative estimate.
The prevalence of angina can also be estimated by extrapolating from the number of MIs in the U.S. (1). About one half of patients presenting at the hospital with MI have preceding angina (6). The best current estimate is that there are 1,100,000 patients with MI each year in the U.S. (5); about one half of these (550,000) survive until hospitalization. Two population-based studies (from Olmsted County, Minnesota, and Framingham, Massachusetts) examined the annual rates of MI in patients with symptoms of angina and reported similar rates of 3% to 3.5% per year (4,7). On this basis, it can be estimated that there are 30 patients with stable angina for every patient with infarction who is hospitalized. As a result, the number of patients with stable angina can be estimated as 30 x 550,000, or 16,500,000. This estimate does not include patients who do not seek medical attention for their chest pain or whose chest pain has a noncardiac cause. Thus, it is likely that the present guidelines cover at least six million Americans and conceivably more than twice that number.
Ischemic heart disease is important not only because of its prevalence but also because of its associated morbidity and mortality. Despite the well-documented recent decline in cardiovascular mortality (8), ischemic heart disease remains the leading single cause of death in the U.S. (Table 2) and is responsible for 1 of every 4.8 deaths (9). The morbidity associated with this disease is also considerable: each year >1,000,000 patients have an MI. Many more are hospitalized for unstable angina and evaluation and treatment of stable chest pain syndromes. Beyond the need for hospitalization, many patients with chronic chest pain syndromes are temporarily unable to perform normal activities for hours or days, thereby experiencing a reduced quality of life. According to the recently published data from the Bypass Angioplasty Revascularization Investigation (10), about 30% of patients never return to work following coronary revascularization, and 15% to 20% of patients rated their own health fair or poor despite revascularization. These data confirm the widespread clinical impression that ischemic heart disease continues to be associated with considerable patient morbidity despite the decline in cardiovascular mortality.
The economic costs of chronic ischemic heart disease are enormous. Some insight into the potential cost can be obtained by examining Medicare data for inpatient diagnosis-related groups (DRGs) and diagnostic tests. Table 3 shows the number of patients hospitalized under various DRGs during 1995 and associated direct payments by Medicare. These DRGs represent only hospitalization of patients covered by Medicare. The table includes estimates for the proportion of inpatient admissions for unstable angina, MI, and revascularization for patients with a history of stable angina. Direct costs associated with non-Medicare patients hospitalized for the same diagnoses are probably about the same as the covered charges under Medicare. Thus, the direct costs of hospitalization are >$15 billion.
Table 4 shows the Medicare fees and volumes of commonly used diagnostic procedures in ischemic heart disease. Although some of these procedures may have been performed for other diagnoses and some of the cost of the technical procedure relative value units (RVUs) may have been for inpatients listed in Table 3, the magnitude of the direct costs is considerable. When the 1998 Medicare reimbursement of $36.6873 per RVU is used, the direct cost to Medicare of these 61.2 million RVUs can be estimated at $2.25 billion. Again, assuming that the non-Medicare patient costs are at least as great, the estimated cost of these diagnostic procedures alone would be about $4.5 billion.
These estimates of the direct costs associated with chronic stable angina obviously do not take into account the indirect costs of workdays lost, reduced productivity, long-term medication, and associated other effects. The indirect costs have been estimated to be almost as great as direct costs (4). The magnitude of the problem can be succinctly summarized: chronic stable angina affects many millions of Americans, with associated annual costs that are measured in tens of billions of dollars.
Given the magnitude of this problem, the need for practice guidelines is self-evident. This need is further reinforced by the available information, which suggests considerable regional differences in the management of ischemic heart disease. Figure 1 shows published information from the Medicare database for rates of coronary angiography in different counties of the country (11). Three- and four-fold differences in adjusted rates for this procedure in different counties within the same state are not uncommon, suggesting that the clinical management of such patients is highly variable. The reasons for such variation in management are unknown.
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Figure 1 Map depicting coronary angiography rates in the U.S. HRR = hospital referral region. From Wennberg et al. (11) with permission.
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E. Organization of the guidelines.
These guidelines are arbitrarily divided into four sections: diagnosis, risk stratification, treatment and patient follow-up. Experienced clinicians will quickly recognize that the distinctions between these sections may be arbitrary and unrealistic in individual patients. However, for most clinical decision making, these divisions are helpful and facilitate presentation and analysis of the available evidence.
The three flow diagrams that follow summarize the management of stable angina in three algorithms: clinical assessment (Fig. 2), stress testing/angiography (Fig. 3), and treatment (Fig. 4). The treatment mnemonic (Fig. 5) is intended to highlight the 10 treatment elements that the committee considered most important.
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Figure 2 Clinical assessment. AHCPR = Agency for Health Care Policy and Research; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty; CABG = coronary artery bypass graft; ACC = American College of Cardiology; AHA = American Heart Association; LV = left ventricular; and ECG = electrocardiogram.
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Figure 4 Treatment. CAD = coronary artery disease; NTG = nitroglycerin; MI = myocardial infarction; NCEP = National Cholesterol Education Program; JNC = Joint National Committee. *Vasodilators, excessive thyroid replacement, vasoconstrictors, profound anemia, uncontrolled hypertension, hyperthyroidism, hypoxemia, tachyarrhythmias, bradyarrhythmias, valvular heart disease (especially aortic stenosis) and hypertrophic cardiomyopathy. **On the basis of coronary anatomy, severity of anginal symptoms, and patient preferences, it is reasonable to consider evaluation for coronary revascularization. Unless a patient has documented left main, three-vessel, or two-vessel CAD with significant stenosis of the proximal left anterior descending coronary artery, there is no demonstrated survival advantage associated with revascularization in low-risk patients with chronic stable angina. Thus, medical therapy should be attempted in most patients before considering percutaneous transluminal coronary angioplasty or coronary artery bypass graft.
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Although the evaluation of many patients will require all three algorithms, this is not always true. Some patients may require only clinical assessment to determine that they do not belong within these guidelines. Others may require only clinical assessment and treatment if the probability of CAD is high and patient preferences and comorbidities preclude revascularization (and therefore the need for risk stratification). The stress testing/angiography algorithm may be required either for diagnosis (and risk stratification) in patients with a moderate probability of CAD or for risk stratification only in patients with a high probability of CAD.
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II. Diagnosis
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A. History and physical.
Recommendations
Class I
In patients presenting with chest pain, a detailed symptom history, focused physical examination, and directed risk-factor assessment should be performed. With this information, the clinician should estimate the probability of significant CAD (i.e., low, intermediate, high). (Level of Evidence: B)
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Definition of angina
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Angina is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back or arm. It is typically aggravated by exertion or emotional stress and relieved by nitroglycerin. Angina usually occurs in patients with CAD involving 
1 large epicardial artery. However, angina can also occur in persons with valvular heart disease, hypertrophic cardiomyopathy and uncontrolled hypertension. It can be present in patients with normal coronary arteries and myocardial ischemia related to spasm or endothelial dysfunction. Angina is also a symptom in patients with noncardiac conditions of the esophagus, chest wall or lungs. Once cardiac causes have been excluded, the management of patients with these noncardiac conditions is outside the scope of these guidelines.
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Clinical evaluation of patients with chest pain
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History.
The clinical examination is the most important step in the evaluation of the patient with chest pain, allowing the clinician to estimate the likelihood of clinically significant CAD with a high degree of accuracy (29). Significant CAD is defined angiographically as CAD with 70% diameter stenosis of 1 major epicardial artery segment or 50% diameter stenosis of the left main coronary artery. Although lesions of less stenosis can cause angina, they have much less prognostic significance (30).
The first step, a detailed description of the symptom complex, enables the clinician to characterize the chest pain (31). Five components are typically considered: quality, location, duration of pain, factors that provoke the pain and factors that relieve the pain. Various adjectives have been used by patients to describe the quality of the anginal pain: "squeezing," "griplike," "pressurelike," "suffocating" and "heavy" are common. Not infrequently, patients insist that their symptom is a "discomfort" but not "pain." Angina is almost never sharp or stabbing, and it usually does not change with position or respiration.
The anginal episode is typically minutes in duration. Fleeting discomfort or a dull ache lasting for hours is rarely angina. The location of angina is usually substernal, but radiation to the neck, jaw, epigastrium, or arms is not uncommon. Pain above the mandible, below the epigastrium, or localized to a small area over the left lateral chest wall is rarely anginal. Angina is generally precipitated by exertion or emotional stress and commonly relieved by rest. Sublingual nitroglycerin also relieves angina, usually within 30 s to several minutes.
After the history of the pain is obtained, the physician makes a global assessment of the symptom complex. One classification scheme for chest pain in many studies uses three groups: typical angina, atypical angina or noncardiac chest pain (32) (Table 5).
Angina is further classified as stable or unstable (2). Unstable angina is important in that its presence predicts a much higher short-term risk of an acute coronary event. Unstable angina is operationally defined as angina that presents in one of three principal ways: rest angina, severe new-onset angina, or increasing angina (Tables 6 and 7 ). Most important, unstable angina patients can be subdivided by their short-term risk (Table 8). Patients at high or moderate risk often have coronary artery plaques that have recently ruptured. Their risk of death is intermediate, between that of patients with acute MI and patients with stable angina. The initial evaluation of high- or moderate-risk patients with unstable angina is best carried out in the inpatient setting. However, low-risk patients with unstable angina have a short-term risk not substantially different from those with stable angina. Their evaluation can be accomplished safely and expeditiously in an outpatient setting. The recommendations made in these guidelines do not apply to high- and moderate-risk unstable angina but are applicable to the low-risk unstable angina group.
After a detailed chest pain history is taken, the presence of risk factors for CAD (23) should be determined. Cigarette smoking, hyperlipidemia, diabetes, hypertension and a family history of premature CAD are all important. Past history of cerebrovascular or peripheral vascular disease increases the likelihood that CAD will be present.
Physical.
The physical examination is often normal in patients with stable angina (33). However, an exam made during an episode of pain can be beneficial. An S4 or S3 sound or gallop, mitral regurgitant murmur, a paradoxically split S2 or bibasilar rales or chest wall heave that disappears when the pain subsides are all predictive of CAD (34). Even though the physical is generally not helpful for confirming CAD, a careful cardiovascular exam may reveal other conditions associated with angina, such as valvular heart disease or hypertrophic cardiomyopathy. Evidence of noncoronary atherosclerotic disease—a carotid bruit, diminished pedal pulse or abdominal aneurysm—increases the likelihood of CAD. Elevated blood pressure, xanthomas and retinal exudates point to the presence of CAD risk factors. Palpation of the chest wall often reveals tender areas in patients whose chest pain is caused by musculoskeletal chest wall syndromes (35). However, pain produced by pressure on the chest wall may be present even if the patient has angina due to ischemic heart disease. The presence of a rub will point to pericardial or pleural disease.
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Developing the probability estimate
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When the initial history and physical are complete, the physician and patient find themselves asking the same question: "Is it the heart?" In certain instances, the physician can confidently assure the patient that it is not. Patients with noncardiac chest pain are generally at lower risk for ischemic heart disease. As indicated on the flow diagram, the history and appropriate diagnostic tests will usually focus on noncardiac causes of chest pain. Appropriate treatment and follow-up for the noncardiac condition can be pres
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Committee members
Preamble
