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 "Outpatient evaluation of the adult with chest pain", section on 'Life-threatening etiology'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354.
- Kline JA, Johnson CL, Pollack CV Jr, et al. Pretest probability assessment derived from attribute matching. BMC Med Inform Decis Mak 2005; 5:26.
- Marsan RJ Jr, Shaver KJ, Sease KL, et al. Evaluation of a clinical decision rule for young adult patients with chest pain. Acad Emerg Med 2005; 12:26.
- Glickman SW, Shofer FS, Wu MC, et al. Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. Am Heart J 2012; 163:372.
- Thygesen K, Mair J, Giannitsis E, et al. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J 2012; 33:2252.
- Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation 2010; 122:1756.
- Mitchell AM, Garvey JL, Chandra A, et al. Prospective multicenter study of quantitative pretest probability assessment to exclude acute coronary syndrome for patients evaluated in emergency department chest pain units. Ann Emerg Med 2006; 47:447.
- Hollander JE, Robey JL, Chase MR, et al. Relationship between a clear-cut alternative noncardiac diagnosis and 30-day outcome in emergency department patients with chest pain. Acad Emerg Med 2007; 14:210.
- Campbell CF, Chang AM, Sease KL, et al. Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification. Am J Emerg Med 2009; 27:37.
- McCaig, L, Burt, C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. In: Advance Data from Vital and Health Statistics. Centers for disease control and prevention, Atlanta, GA 2005.
- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol 2007; 50:e1.
- Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000; 342:1163.
- Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284:835.
- 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.
- Pollack CV Jr, Sites FD, Shofer FS, et al. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med 2006; 13:13.
- Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J 2008; 16:191.
- Backus BE, Six AJ, Kelder JC, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol 2010; 9:164.
- Mahler SA, Hiestand BC, Goff DC Jr, et al. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol 2011; 10:128.
- Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 2015; 8:195.
- Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med 2014; 174:51.
- Mahler SA, Miller CD, Hollander JE, et al. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol 2013; 168:795.
- Braunwald E, Jones RH, Mark DB, et al. Diagnosing and managing unstable angina. Agency for Health Care Policy and Research. Circulation 1994; 90:613.
- Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol 2012; 59:2091.
- Hess EP, Jaffe AS. Evaluation of patients with possible cardiac chest pain: a way out of the jungle. J Am Coll Cardiol 2012; 59:2099.
- Body R, Carley S, McDowell G, et al. Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay. J Am Coll Cardiol 2011; 58:1332.
- Rubini Giménez M, Hoeller R, Reichlin T, et al. Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. Int J Cardiol 2013; 168:3896.
- Bandstein N, Ljung R, Johansson M, Holzmann MJ. Undetectable high-sensitivity cardiac troponin T level in the emergency department and risk of myocardial infarction. J Am Coll Cardiol 2014; 63:2569.
- Shah AS, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet 2015; 386:2481.
- Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med 1995; 25:1.
- Farkouh ME, Smars PA, Reeder GS, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med 1998; 339:1882.
- Goodacre S, Nicholl J, Dixon S, et al. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004; 328:254.
- Goodacre S, Cross E, Lewis C, et al. Effectiveness and safety of chest pain assessment to prevent emergency admissions: ESCAPE cluster randomised trial. BMJ 2007; 335:659.
- Jibrin I, Hamirani YS, Mitikiri N, et al. Maryland's first inpatient chest pain short stay unit as an alternative to emergency room-based observation unit. Crit Pathw Cardiol 2008; 7:35.
- Graff LG, Dallara J, Ross MA, et al. Impact on the care of the emergency department chest pain patient from the chest pain evaluation registry (CHEPER) study. Am J Cardiol 1997; 80:563.
- Krantz MJ, Zwang O, Rowan SB, et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol 2005; 4:55.
- Hermann LK, Weingart SD, Duvall WL, Henzlova MJ. The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years. Ann Emerg Med 2009; 54:12.
- 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