Evaluation of patients with chest pain at low or intermediate risk for acute coronary syndrome
- Chadwick Miller, MD, MS
Chadwick Miller, MD, MS
- Professor, Department of Emergency Medicine
- Wake Forest School of Medicine
- Christopher B Granger, MD
Christopher B Granger, MD
- Professor of Medicine
- Duke University Medical Center
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Allan S Jaffe, MD
Allan S Jaffe, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Mayo Medical School
Chest pain accounts for approximately six million annual visits to emergency departments in the United States. Acute coronary syndrome (ACS) accounts for approximately 12 to 15 percent of all cases.
This topic discusses the evaluation of patients with chest pain who are at low or intermediate risk for ACS as assessed by the results of the initial history, physical exam, electrocardiogram, and initial biomarkers. The approaches to patients with chest pain not likely to be due to myocardial ischemia or to those with a high likelihood of ACS are found elsewhere. (See "Evaluation of the adult with chest pain in the emergency department" and "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department".)
DEFINITION OF ACS
The term “acute coronary syndrome” (ACS) is applied to patients in whom there is evidence of myocardial ischemia or infarction. There are three types of ACS: ST elevation myocardial infarction, non-ST elevation myocardial infarction, and unstable angina (UA). The first two are characterized by a typical rise and/or fall in serum troponin . UA is characterized by myocardial ischemia without elevated biomarkers and is often a clinical diagnosis based on history, dynamic electrocardiogram (ECG) changes, or inducible ischemia on stress testing. Establishing whether a patient has ACS requires integration of information obtained from a careful patient interview and examination as well as from serial evaluation of the ECG, troponin levels, and occasionally provocative testing results. (See "Criteria for the diagnosis of acute myocardial infarction", section on 'Third Universal Definition of MI'.)
WHAT IS THE GOAL OF EVALUATION
Ruling in an acute coronary syndrome (ACS) in a timely manner is a high priority, as early intervention in patients with ACS has been shown to lead to better outcomes. Conversely, for patients without an ACS, it is important that time and resources not be spent pursuing the diagnosis of ACS.
Similarly, other patients who present to the healthcare system with chest pain have another cause or chest pain that requires urgent attention such as trauma, pulmonary embolism, or aortic dissection. (See "Diagnostic approach to chest pain in adults".)
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- DEFINITION OF ACS
- WHAT IS THE GOAL OF EVALUATION
- INITIAL EVALUATION
- Immediate in-hospital
- Risk assessment and subsequent care
- AFTER RETURN OF TROPONIN
- Care pathways using a sensitive troponin
- - Risk scores
- - Care pathways
- Highly sensitive troponin
- Observation unit approach
- NONINVASIVE EVALUATION
- DISPOSITION AFTER NONINVASIVE EVALUATION
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS