Evaluation of Emergency Department Patients With Chest Pain at Low or Intermediate Risk For Acute Coronary Syndrome - UpToDate

Evaluation of emergency department patients with chest pain at low or in... https://www.uptodate.com/contents/evaluation-of-emergency-department...
O fficial reprint from UpToDate ®

www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Evaluation of emergency department patients with chest

pain at low or intermediate risk for acute coronary
syndrome
Authors: Chadwick Miller, MD, MS, Christopher B Granger, MD
Section Editors: Christopher P Cannon, MD, James Hoekstra, MD, Allan S Jaffe, MD
Deputy Editor: Gordon M Saperia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature rev iew current through: Mar 2020. | This topic last updated: Oct 30, 2019.
INTRODUCTION
Chest pain accounts for approximately eight million annual visits to emergency departments
(EDs) in the United States [1]. Acute coronary syndrome (ACS) evaluations account for
approximately 10 to 20 percent of all these cases. The approaches to chest pain patients in
general or those who are likely to have an ACS are discussed separately. (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".)
This group of patients is among the most challenging in acute care medicine in part because of
the frequency of the clinical problem. Challenges, which at times compete with one another,
include the need to rapidly diagnose ACS so that appropriate interventions can be initiated, the
pressure to discharge patients appropriately from busy EDs, and the tendency to overinvestigate
chest pain patients, which leads to increased resource utilization.
Two primary goals of the early evaluation of patients with chest pain suggestive of myocardial
ischemia are to rapidly confirm the diagnosis of an ACS if possible (a "rule-in") or exclude the
diagnosis. Diagnosing ACS in a timely manner is a high priority, as early intervention in patients
1 of 29 4/30/2020, 9:27 PM
with ACS has been shown to lead to better outcomes. Conversely, for patients with a low to
intermediate risk of an ACS, it is important that unnecessary time and resources not be spent
overpursuing the diagnosis.
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 (including age and risk factors),
physical exam, and electrocardiogram (ECG). The use of troponin testing, risk assessment, and
care pathways is presented. A major goal of the topic is to help clinicians identify patients who
are candidates for early discharge from the ED.
DEFINITION OF ACUTE CORONARY SYNDROME
The term "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 (STEMI), non-ST-
elevation myocardial infarction (NSTEMI), and unstable angina (UA). The first two are
characterized by a typical rise and/or fall in serum troponin [2]. UA is characterized by myocardial
ischemia without elevated biomarkers and is often a clinical diagnosis based on history,
dynamic ECG changes, or inducible ischemia on stress testing. UA accounts for a smaller
proportion of ACS with the widespread use of highly sensitive troponin, which can detect very
small amounts of myocardial injury. 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
"Diagnosis of acute myocardial infarction", section on 'Definitions'.)
INITIAL EVALUATION
The primary focus in the very early evaluation (generally within the first 15 minutes after
presentation) of patients with possible ACS is to reasonably confirm or exclude in an expeditious
manner ACS as the cause for the patient's symptoms (algorithm 1). In this early time period,
reasonable confirmation of ACS is generally secured by the finding of diagnostic ECG changes.
ACS is reasonably excluded when the probability of ACS is very low (generally considered below
a 1 to 2 percent threshold [3,4]). (See 'Risk assessment' below.)
For patients who have or are likely to have an ACS, appropriate management strategies should
be initiated. (See "Initial evaluation and management of suspected acute coronary syndrome
(myocardial infarction, unstable angina) in the emergency department", section on
'Management'.)
2 of 29 4/30/2020, 9:27 PM
In addition, other life-threatening illnesses should be rapidly identified that would remove the
patient from a low- to medium-risk ACS category. (See "Evaluation of the adult with chest pain in
the emergency department".)
Prehospital — Patients with symptoms of possible ACS (eg, chest discomfort with or without
radiation, shortness of breath, weakness, diaphoresis, nausea, or light headedness) should
generally be instructed to call 9-1-1, be evaluated by Emergency Medical Services, and be
brought to the hospital by ambulance. Emergency Medical Service evaluation and transport
result in more rapid and focused evaluation by streamlining the triage process. Prehospital
evaluation should include obtaining a prehospital 12-lead ECG and continuous ECG monitoring.
Immediate in-hospital evaluation — On hospital arrival, patients with symptoms that raise the
possibility of myocardial ischemia should have the following performed (see "Initial evaluation
and management of suspected acute coronary syndrome (myocardial infarction, unstable
angina) in the emergency department"):
● Continuous ECG monitoring.
● An initial 12-lead ECG within 10 minutes of arrival (even if one has been performed in an
ambulance, unless that ECG showed ST-segment elevation) in patients ≥25 years of age
with chest pain, or age ≥50 years with chest pain or other symptoms that could represent
myocardial ischemia like shortness of breath, altered mental status, upper extremity pain,
syncope, or generalized weakness. Very elderly (≥80 years of age) patients with abdominal
pain or nausea/vomiting should have an immediate 12-lead ECG as well [2,5].
It is recommended that the ECG be repeated at 20- to 30-minute intervals for any patient
with ongoing pain in whom a suspicion of ACS continues. Patients whose ECGs are
diagnostic for or strongly suggestive of either STEMI or NSTEMI should be managed for
those diagnoses. (See "Overview of the acute management of ST-elevation myocardial
infarction" and "Overview of the acute management of non-ST elevation acute coronary
syndromes".)
● A brief history and physical examination to screen for signs or symptoms of

cardiopulmonary distress. The history should include questions that evaluate whether the
chest pain is likely to represent myocardial ischemia. (See "Angina pectoris: Chest pain
caused by fixed epicardial coronary artery obstruction", section on 'History'.)
As will be discussed below, risk scores also use patient age and coronary artery disease
risk factors. (See 'Risk scores' below.)
3 of 29 4/30/2020, 9:27 PM
● At a minimum, the following laboratory tests should be ordered as soon as possible in

patients with possible ACS: high sensitivity cardiac troponin (where available), serum
electrolytes, serum creatinine, and a complete blood count. (See "Evaluation of the adult
with chest pain in the emergency department", section on 'Laboratory studies'.)
While patients who are assessed to be at very low risk of an ACS do not need a troponin
test, many institutions have protocols that direct nursing staff to order them based on their
assessment, which may be prior to physician evaluation. We believe this is a reasonable
strategy.
The results of the first high sensitivity troponin should be available within 60 minutes. (See
"Troponin testing: Clinical use", section on 'Diagnosis of acute MI'.)
● A chest radiograph is usually performed in patients suspected of having an ACS, since

alternative diagnoses such as heart failure, pneumonia, aortic dissection, pulmonary
embolism, or acute pericardial disease may be detected [6].
Risk assessment — We attempt to assign patients to low, intermediate, or high risk for ACS
category, or definite ACS (table 1), based on information obtained from the history, physical
examination, ECG, and continuous ECG monitoring (algorithm 1) but before the first troponin
level is available. Multiple scoring systems have been evaluated. We prefer the History, ECG,
Age, Risk factors, and a single sensitive Troponin (HEART) score, which is used in the HEART
Pathway (see 'Care pathways' below). Using this score, individuals with a score of 0 to 3 are
considered low risk. There is an element of subjectivity in the HEART score, so internal
discussions to improve consistency of use are suggested [7].
Low-risk patients generally have none of the risk factors found in the table (table 1). Specifically,
low-risk patients cannot have a history of coronary artery disease or have ST-segment elevation,
significant ST-segment depression, or new T wave inversion.
We manage patients as follows:
● If the patient's likelihood of ACS is very low (<1 to 2 percent) based on the history, physical
examination, and initial ECG, additional testing for ACS is not likely to be beneficial.
● All other patients with possible (but not definite) ACS should be further risk stratified by the
measurement of serum troponin, if not already ordered. (See "Troponin testing: Clinical
use" and 'Troponin testing' below.)
These patients should be monitored with continuous ECG rhythm monitoring at least until
4 of 29 4/30/2020, 9:27 PM
return of the first troponin value. Any changes in clinical condition (eg, patient complaints or
change in vital signs) should prompt reassessment. Serial ECGs should be performed on
patients with continuous pain or changes in symptoms to detect dynamic changes.
● Patients felt to have definite ACS or are at high risk should be managed accordingly. (See
"Overview of the acute management of non-ST elevation acute coronary syndromes" and
"Overview of the acute management of ST-elevation myocardial infarction" and "Initial
evaluation and management of suspected acute coronary syndrome (myocardial infarction,
unstable angina) in the emergency department".)
At some lower threshold of pretest probability, the clinician is more likely to cause harm by
further testing. It has been suggested that an acceptable lower limit of pretest probability for
ACS, above which further testing should be done, is 1 to 2 percent [3,4]. We believe patients
below this threshold are very low risk and are unlikely to benefit from additional testing for an
ACS. All other patients should receive further testing and risk stratification.
Providers commonly identify very low-risk patients using an experienced clinician's unstructured
clinical estimate. In an evaluation of this method, approximately 25 percent of chest pain patients
were classified as very low risk (<2 percent risk), and these patients experienced an event rate of
0.7 percent (95% CI 0-2.4) [8]. With the introduction of clinical decision aids, many clinicians and
health systems have moved toward more objective classification systems, typically incorporating
serum troponin measurements. (See 'Troponin testing' below.)
When formulating the clinician's pretest (before the troponin) probability, it is important to avoid
eliminating the possibility of an ACS even when an alternative diagnosis is possible. In patients
being evaluated for chest pain, it has been shown that those with a "clear-cut" alternative
noncardiac diagnosis still have a 4 percent rate of ACS at 30 days [9]. Similarly, patients with a
"clear-cut" alternative noncardiac diagnosis and a Thrombolysis in Myocardial Infarction (TIMI)
risk score of 0 had a 2.9 percent rate of ACS at 30 days [10]. As an example, among patients with
ACS, a common misdiagnosis is gastroesophageal reflux disease. In two different datasets, it
has been shown that patients with ACS commonly describe their pain as burning [11,12]. A
gastrointestinal etiology should be assigned only after the diagnosis of a cardiac emergency
has been excluded. Further, a trial of antacids or nitroglycerin should not be used as a reliable
method to determine whether pain is of gastrointestinal or cardiac origin.
Certain populations also have increased risk for missed ACS. Four populations that are more
likely to be discharged from the emergency department with ACS include: women <55 years old,
non-white patients, those dyspnea as the primary complaint, and patients with a normal ECG
[13]. In addition, the elderly often present with atypical histories. We recommend that clinicians
5 of 29 4/30/2020, 9:27 PM
incorporate all data elements when forming an unstructured estimate of ACS probability, avoid
overreliance on the presence of an alternative diagnosis, and use caution when defining the very
low-risk patient population.
While we have identified specific times in this process when evaluation must take place rapidly,
evaluation is a continuous process, and new information at any time point can alter a patient's
risk category. For example, worsening of symptoms, arrhythmias, or new ECG changes on
continuous monitoring can make the possibility of an ACS more likely.
TROPONIN TESTING
In those patients for whom the diagnosis of ACS remains a possibility after rapid evaluation of
the history, physical examination, and 12-lead ECG (see 'Risk assessment' above), a high-
sensitivity cardiac troponin T (hs-cTn) should be obtained as soon as possible. (See "Troponin
testing: Clinical use", section on 'Diagnosis of acute MI'.)
Background — Compared with a standard troponin assay, hs-cTn leads to the diagnosis of
acute MI in a modest additional number of chest pain patients and may do so earlier in the
patients' emergency department (ED) stay [14]. This occurs because hs-cTn detects
biochemical evidence of myocardial injury at lower concentrations, and hs-cTn assays allow for
discrimination of small changes in concentration even within the normal reference range.
However, MI is not ruled in unless there is both a rising and/or falling pattern of values and one
value above the upper reference limit (URL) [15] (see "Diagnosis of acute myocardial infarction",
section on 'Definitions'). However, the issue of whether this improves long-term cardiovascular
outcomes is debated [16]. In addition, very low hs-cTn values identify patients at low risk of MI in
the ED.
With hs-cTn, serial values <99 th percentile of the URL make the diagnosis of acute MI quite
unlikely, but the value does not exclude the possibility of unstable angina [17,18]. The use of sex-
dependent 99 th percentile URL is advocated by the Universal Definition of Myocardial Infarction
and will be different depending on the assay used. A value of <5 ng/L with the Abbott hs-cTnI
assay or with the Roche hs-cTnT assay is capable of identifying patients at extremely low risk of
acute MI and whose long-term prognosis is good [19-21].
The negative predictive value of a very low value of a high-sensitivity assay (Abbott cardiac
troponin I assay) at presentation to the hospital was evaluated in the High-STEACS prospective
cohort (derivation) study of 4870 patients with suspected ACS [19]. With this assay, the limitation
of detection was 1.2 ng/L, and a URL (99 th percentile) was 34 ng/L in men and 16 ng/L in
6 of 29 4/30/2020, 9:27 PM
women. The primary outcome was index MI, or subsequent MI or cardiac death at 30 days. A
troponin concentration <5 ng/L had a negative predictive value of 99.6 percent. The effectiveness
of combining this test with clinical information for the purpose of selecting patients for early
discharge remains to be determined. The one group that had a less robust negative predictive
value (NPV) included individuals who presented in two hours or less from the onset of
symptoms. Caution is necessary with these early rapid approaches for early presenting
patients.
Elevated first troponin — If the first troponin returns clearly elevated in a patient with clinical
findings consistent with ACS, the management for NSTEMI likely begins. (See "Overview of the
acute management of non-ST elevation acute coronary syndromes".)
However, this paradigm may be changing with the routine use of increasingly sensitive troponin
assays. Data from outside the United States suggest that 11 to 15 percent of patients will be
classified as having NSTEMI based on that initial hs-cTn result, of whom 68 to 79 percent will
ultimately be adjudicated as having NSTEMI [22]. As these hs-cTn assays are applied to broader
patient populations with concomitant medical conditions such as sepsis and renal failure, this
positive predictive value is likely to be reduced. This fact needs to be considered by clinicians.
Normal first troponin — For those patients whose first sensitive troponin is not elevated,
monitoring continues until a second troponin returns. The second troponin should be obtained
one to three hours after the first, depending on the algorithm being used. In some select
patients with a reliable symptom onset and a low suspicion for ACS, a single troponin
measured six hours after symptom onset is acceptable.
After return of the second troponin, tools such as an algorithm (for high sensitivity troponin levels
and changes), and/or the Thrombolysis in Myocardial Infarction (TIMI) and History, ECG, Age,
Risk factors, and a single sensitive Troponin (HEART) risk scores should be used in
conjunction with care pathways to guide decisions regarding further testing (eg, stress testing or
cardiac imaging) and disposition, and to guide interim medical therapies.
On occasion, some patients will require a third troponin. Examples include those with stuttering
pain, new return of pain while in the ED, patients presenting very soon after the onset of
symptoms, and those in whom the clinician has a high degree of concern.
For low-risk patients or those with normal ECGs who present more than two hours after the
onset of chest pain [21,23], a value of hs-cTn below the limit of detection of the assay is a
sensitive way to rule out acute MI. However, even those who endorse the European Society of
Cardiology (ESC) guidelines concur with the need for caution in those who present early after
7 of 29 4/30/2020, 9:27 PM
the onset of symptoms [24,25]. The sensitivity of this approach of 99 percent is what ED
physicians argue that they need [26]. The prognosis during follow-up suggests that the risk of
patients who might be discharged using such a strategy is low. In fact, these values are in the
range where the frequency of a positive stress test is also low [27]. This strategy, using a single
value below the limit of detection, is possible in most regions that use hs-cTn but is not
presently validated for application in the United States (for the hs-cTnT assay) because the
lowest value that the US Food and Drug Administration (FDA) will permit to be reported in the
United States is a higher concentration (6 ng/L) than the limit of detection (3 ng/L for one piece of
equipment and 5 ng/L for another). An analysis confirms that the use of a value of 6 ng/L
provides slightly less robust information [28]. Other approaches using higher cut-offs are less
well validated [19,29,30]. However, with multiple newer assays on the horizon, the likelihood of
this becoming a viable option with many assays is substantial. The higher the value used, the
greater percentage of the population that can be included with such an approach. The ESC
guidelines advocate for a one-hour rule-out, and clinical trials suggest this may work reasonably
[31,32]. However, these approaches have used very small changes in values to make decisions.
Those small changes in values have been criticized as being outside of the ability of the assays
to measure [31,33]. Data substantiate this concern, suggesting that repeating values will
change the designation of a given patient 25 percent of the time [34]. In addition, the validation of
the one-hour approach has been criticized for lacking enough patients who present within two
hours of the onset of symptoms [24,29]. However, the majority of the data indicate that in most
patients, a rule-out diagnosis can be accomplished in two to three hours. This is facilitated by
the fact that most patients do not arrive early (within two hours of the onset of symptoms). Thus,
any patient who is >6 hours after the onset of symptoms (assuming no recurrences) and who
has a normal cTn value (either hs-cTn or contemporary cTn) can be considered to have ruled out
for acute MI [35]. With hs-cTn assays, one- to three-hour rule-outs using assay specific change
criteria are usually adequate. There are only rare patients who rule in thereafter [33].
Late presenters — Patients who present 12 hours or more after the onset of symptoms can be
diagnostically challenging. If the first hs-cTn is elevated in these patients, clinicians should be
careful in their interpretation of changes or deltas between first and second values. Patients with
adjudicated NSTEMI with less acute presentations, and those with longer ischemic times, are
more likely to present near their peak hs-cTn value. Subsequent values may downtrend or stay
about the same, providing false reassurance or misleading the clinician away from the
diagnosis of NSTEMI, but still leaving the patient with substantial risk for mortality from ACS [36].
These patients potentially require additional testing. (See 'Noninvasive evaluation' below.)
Risk scores — Risk scores or prediction models have been developed and integrated into care
8 of 29 4/30/2020, 9:27 PM
pathways. These tools predict the risk of adverse short-term outcomes (eg, 30-day risk of death,
nonfatal MI, or recurrent ischemia). We do not discharge patients at low to moderate risk of an
ACS based on the results of the risk prediction models.
The following are summaries of a few of the more widely used risk scores:
● The TIMI risk prediction score (for unstable angina/NSTEMI) has proven predictive ability in
patients with suspected or known ACS and has undergone multiple validation
investigations [37,38]. The TIMI score (calculator 1) was derived and validated in patients
enrolled in clinical trials with ACS, but has since been validated in patients suspected to
have ACS [39]. Advantages include simplicity, lack of a need for a nomogram or computer
algorithm, and its ability to predict a risk of short-term (30 days) outcome [39]. Among the
elements of the TIMI risk score, troponin elevation was the most powerful factor. However,
even TIMI 0 patients had a significant 2.1 percent incidence of the composite outcome. As
such, the TIMI score has limited utility as a tool to determine who can be discharged as very
low risk with no further testing.
● The HEART score uses similar components to the TIMI risk score (table 1). The HEART
score [40,41] has been widely validated [40-42]. However, validation studies have shown the
need to add a three-hour troponin to achieve acceptable sensitivity [7]. A score of 0 to 3
identifies a patient at low risk of major adverse cardiovascular events; patients with a score
of 4 to 6 have intermediate risk, and those with a score of 7 or greater are high risk. A meta-
analysis of 30 studies of the HEART risk score found that a score of 4 or greater had a
sensitivity of about 96 percent for the prediction of short-term (39 days or 6 weeks) incidence
of major adverse cardiovascular events [43]. The HEART pathway is discussed below. (See
'Care pathways' below.)
● The Calculation Of MI risk probabilities to Manage Patients with SuSpicion of Myocardial

Infarction (COMPASS-MI) Project developed a risk assessment tool using data from 23,327
patients with symptoms of MI in 15 European cohorts [44]. Patients with STEMI were
excluded. Two assays were studied: hs-cTnT and hs-cTnI, which are the only two presently
included in the COMPASS calculator; only hs-cTnT is approved for use in the United States.
The algorithm was developed based on samples measured at presentation and once
thereafter. A distinction was made between an early second sample (one to two hours) and
a later one (>2 hours). The diagnostic and prognostic performance of multiple hs-cTn cutoff
combinations were assessed in derivation and validation groups. An interactive risk
assessment tool that predicted the risk of MI in the ED and the subsequent 30-day risk of MI
or MI/death based on the 15 studies was included in the analysis. In the derivation group,
9 of 29 4/30/2020, 9:27 PM
hs-cTnI <6 ng/L and an absolute change of less than 4 ng/L after 45 to 120 minutes
resulted in a negative predictive value of 99.5 percent for MI. The associated 30-day risk of
MI or death was 0.2 percent. None of the studies included were from the United States,
where cTn samples often involve more diverse populations than in many places where the
testing is mostly used when the primary issue is evaluation for possible MI. The tool is likely
to be helpful for young patients who are being evaluated for possible MI. Prior to
recommending wide-spread use of this tool, additional validation is needed, particularly in
populations with differing baseline risk.
Care pathways — Most EDs use a care pathway, also called an "accelerated diagnostic
pathway," for patients at low to moderate risk of an ACS. In our practices, we use the HEART
Pathway. These pathways are used to facilitate the discharge of patients with a low risk of a
cardiovascular event at 30 days (and who have no other diagnosis requiring further ED
evaluation or treatment), using the results from an initial (and sometimes a follow-up) troponin
and from an ECG. Some pathways integrate information from a risk prediction score.
It is generally agreed upon by the medical community that protocols designed to facilitate early
discharge of patients who are initially suspected to be at low or moderate risk of ACS should
have a negative predictive value of greater than 99 percent; that is, 99 percent of individuals
chosen for early discharge will not have an adverse cardiovascular event within 30 days.
The following pathways have been evaluated and are in clinical use to varying degrees:
● Single hs-cTn – In early studies, the negative predictive value of an undetectable level of hs-
cTn troponin at presentation in a single sample was about 99 percent, somewhat lower
than the agreed-upon cut-off [19,21]. When used in conjunction with ECG findings, the NPV
is likely greater than 99 percent [45]. In a 2017 meta-analysis of studies that included data
regarding patients with a single hs-cTn <5ng/L, the NPV was 99.5 percent [46]. Given the
inability to use a low enough value in the United States, this strategy is not endorsed for use
here.
● ESC 3-Hour Pathway – The ESC 3-Hour pathway rules out MI in patients without ischemia
on the ECG when the cardiac troponin is <99 percent at presentation in patients with
symptoms lasting more than six hours [32]. For those with symptoms lasting less than six
hours, a second troponin is performed three hours after the first troponin, and MI is ruled out
if the troponin remains <99 th percentile or is >99 th percentile without a significant change in
concentration from the first.
● HEART Pathway – The HEART Pathway consists of the HEART score (see 'Risk
10 of 29 4/30/2020, 9:27 PM
assessment' above) plus a three-hour sensitive serum troponin measurement (table 1).
Very low risk is considered a HEART score of 3 or less, plus two negative troponin
measurements at times 0 and 3 hours below the 99 th percentile, if symptoms are present
for less than six hours [47,48]. These patients have a 30-day rate of all-cause death or MI of
0.4 percent [49].
Multiple validation studies have examined the HEART Pathway in thousands of patients and
have consistently shown a sensitivity of >99 percent for 30-day adverse cardiac events
[7,40,47,50]. The HEART Pathway was validated in a randomized trial in which it allowed the
safe, early discharge of 40 percent of patients without the need for stress testing [50]. No
patients had adverse cardiac events at 30 days; the rate of objective cardiac testing after
discharge was decreased, and the time to discharge was shortened. These data suggest
that the HEART Pathway identifies a very low-risk population and reduces the need for
provocative testing.
● High-STEACS Pathway – The High-STEACS Pathway measures hs-cTnI at presentation

and three hours and incorporates a risk stratification threshold at presentation [19].
● ADAPT was a prospective, observational study of nearly 2000 patients with chest pain due to
suspected ACS that evaluated an accelerated diagnostic protocol [51]. The protocol
included pretest probability scoring by the TIMI risk score, ECG, and 0- and 2-hour troponin I
values. In ADAPT, the accelerated diagnostic protocol successfully identified very low-risk
patients; the sensitivity and an NPV were 99.7 percent for the primary end point of major
adverse cardiac events within 30 days. In a single-center, randomized validation of the
accelerated diagnostic protocol, the proportion of patients safely discharged within six hours
of ED arrival increased from 11 to 19 percent with use of the protocol [48]. However, patients
identified for early discharge received outpatient stress testing within 72 hours.
● Pathways that use an initial and one-hour troponin have been evaluated but are not used
widely [22,52-55].
● Two 2017 studies compared two or more of these approaches and found that all but the
single-hs-cTn approach have an acceptable NPV [25,56-58].
Patients identified as low risk with these approaches can be discharged home with primary care
follow-up. However, with all decision aids, it is important to incorporate the provider's clinical
gestalt into this decision. The decision to pursue outpatient evaluation, especially if additional
testing is likely to be required, should be discussed with the patient. There are many reasonable
evaluation strategies, including performing the entire evaluation and stress imaging during the
11 of 29 4/30/2020, 9:27 PM
index encounter. We recommend a structured evaluation with the HEART Pathway and expedited
discharge of patients stratified as low risk. When pursuing this strategy, we encourage clinicians
to discuss this with their patients and consider patient preferences in this decision. (See
'Noninvasive evaluation' below.)
Some patients will have been assessed to be at high risk, despite a normal biomarker, because
of the presence of ongoing chest pain, new ECG changes, or heart failure. These patients
should be admitted and managed as having unstable angina and/or heart failure. (See
"Overview of the acute management of non-ST elevation acute coronary syndromes".)
In patients classified as not low risk, subsequent noninvasive provocative testing remains an
important part of the evaluation. Among patients with normal or nondiagnostic ECG and normal
troponin results, up to 10 percent may still have ACS [3], and 2 to 4 percent may have early
adverse events [4,59]. Such patients may be cared for in the ED, in an observation unit, or are
admitted.
Observation unit approach — Observation units can be used to complete subsequent

assessment with additional troponin values and/or stress chemical cardiac imaging in patients
requiring further evaluation. While the use of high sensitivity troponin algorithms has reduced the
need for observation units, those without elevated serum troponin but who remain above a 1 to 2
percent probability of ACS will require these additional tests. We recommend observation unit
use in such patients who are not low risk according to the HEART Pathway (see 'Care pathways'
above). In hospitals without an observation unit, these patients can be placed on the hospital
ward in observation or inpatient status.
Observation units can take several forms. At the most basic level, observation is a patient status
during which ongoing testing occurs in the ED. The more common scenario is a specialized
area, under control of either ED physicians, inpatient physicians, or both, in which patients
receive ongoing testing and monitoring in a systematic way.
Chest pain observation units (CPUs) or clinical decision units are a safe and efficient use of
resources to evaluate patients with chest pain with both intermediate and low probability of
having ACS. In a study of over 1000 mostly low-risk patients, the discharge rate was 82 percent
[60]. Since that time, randomized trials have proven their effectiveness and safety [61,62],
including one single-center trial of 424 patients at intermediate risk for having ACS,
demonstrating that observation units decreased resource utilization without increasing risk [61].
However, a cluster randomized trial of observation unit implementation has questioned the
improvement in resource utilization at 14 EDs in the United Kingdom, in which there was no
decrease in admission rates [56]. A comparison of inpatient short-stay units with ED observation
12 of 29 4/30/2020, 9:27 PM
units was completed among 332 ED patients with chest pain at one center, demonstrating that
both are safe and cost effective options [63]. The safety of assigning patients to CPUs has been
demonstrated in multiple studies [61,64].
A controversial area in observation unit care is the inclusion of patients with known coronary
disease, or those who are unable to exercise. Many studies of chest pain observation units
excluded patients with known coronary disease. Similarly, most excluded patients unable to
exercise. In principle, however, an observation unit is appropriate for any patient in whom serial
negative ECGs, biomarkers, and cardiac imaging will identify a situation where hospital
admission will not be necessary. Therefore, we recommend this as an option in centers
equipped to conduct this evaluation.
Noninvasive evaluation — Noninvasive evaluation is performed on patients for whom there

remains a suspicion of an ACS despite two acceptably low troponin values (algorithm 1). Such
patients might be those with a high-risk designation using the HEART Pathway or those in
whom the healthcare provider is still concerned based on the patient's risk, as calculated by a
risk score such as TIMI (calculator 1). Typically, these patients have a greater than 1 to 2 percent
risk of ACS. It should be kept in mind that stress testing is unlikely to be helpful if the pretest
probability of coronary artery disease is very low (table 2) [65]. (See 'Risk scores' above.)
We rarely recommend a noninvasive evaluation for patients with a positive troponin. These
patients should first be evaluated by a cardiology consultant. Patients with a positive troponin
who might be candidates for noninvasive testing include those with chronic elevation of troponin.
For those patients in whom a decision is made to perform further testing, the timing and location
should be guided by patient and institutional characteristics. Patients for whom there is a
concern about the reliability of follow-up should undergo testing prior to discharge. For all
patients undergoing further testing, we believe it is reasonable to obtain such testing within 72
hours and usually perform it sooner. Others have suggested that a longer interval is reasonable.
The following is a summary of our approach to noninvasive testing. This topic is discussed in
detail separately. (See "Selecting the optimal cardiac stress test" and "Noninvasive testing and
imaging for diagnosis in patients at low to intermediate risk for acute coronary syndrome",
section on 'Inpatient or outpatient'.)
● Patients with an ECG that is interpretable for ischemic changes can undergo exercise ECG
test.
● Patients who are unable to exercise should undergo pharmacologic stress testing
combined with imaging (vasodilator stress radionuclide myocardial perfusion imaging
13 of 29 4/30/2020, 9:27 PM
[rMPI] or dobutamine stress echocardiography), or computed tomography angiography.
● Patients who have an uninterpretable ECG for ischemia (eg, left bundle branch block,
ventricular paced rhythm, left ventricular hypertrophy with strain pattern, or digoxin therapy)
should undergo stress testing with imaging (either rMPI or echocardiography).
● Noninvasive rest imaging may be performed in some patients with low-to-intermediate

probability of ACS and no prior history of MI who have ongoing or recent chest pain (or
equivalent).
• For patients with ongoing chest pain, we recommend injection with radioactive isotope
for rMPI or rest two-dimensional echocardiography.
• For patients who present within two hours of symptoms and on whom diagnostic
imaging is performed, we suggest rest rMPI. However, a negative study does not
exclude unstable angina. In many cases, it should be followed by some form of stress
testing.
● Computed tomography angiography, including evaluation of fraction flow reserve, provides

another technology to identify patients with low probability of significant coronary disease
and/or hemodynamically significant obstructive coronary disease.
Disposition after noninvasive evaluation — After noninvasive evaluation, a final disposition can
usually be made (algorithm 1):
● Patients with indeterminate stress testing or imaging results may benefit from cardiology
consultation if not already obtained. Many such patients will be admitted.
● Patients with positive stress testing or imaging results should be evaluated by a

cardiologist and should generally be admitted to the hospital.
● If the results of stress testing or imaging are negative for a cardiac cause, and other life-
threatening components of the differential diagnosis have been ruled out, discharge is
appropriate for stable patients. These patients are labeled as having noncardiac chest pain.
Many of these patients will carry the diagnosis of nonspecific chest pain while some will
ultimately be diagnosed with cardiac causes such as myocarditis/pericarditis, stress
cardiomyopathy, or heart failure [66].
We suggest the following at the time of discharge:
• Provide care for the most likely cause of pain.
14 of 29 4/30/2020, 9:27 PM
• Inform the patient about the basis for the presumptive diagnosis and discuss areas of
uncertainty in the diagnosis.
• Establish a plan for follow-up with a care provider, ideally within 72 hours.
• Provide clear and concise written discharge instructions that describe specific reasons
for reevaluation and where and when to return.
CONSULTATIONS
Indications for cardiology consultation will vary among institutions. The following are reasonable
indications for obtaining consultation from a cardiologist:
● Definite evidence of ACS, or when chest pain is accompanied by acute heart failure or
hemodynamic instability.
● ECG with difficult-to-interpret ST segments (including paced rhythm or old left bundle branch
block) should have a low threshold for consultation.
● Biomarker elevation that may or may not represent ACS.
● High likelihood that signs and symptoms represent ACS (table 1), high short-term risk of
death or nonfatal MI (table 3), and patients with refractory chest pain.
● Patients with positive stress testing or imaging results should be evaluated by a

cardiologist (and generally admitted to the hospital).
● Imaging reveals ongoing or inducible ischemia, significant coronary artery stenosis, or

indeterminate results. Consultation may also be considered for patients with a known
history of coronary artery disease, as their tests are more difficult to interpret.
● Complicated cardiac histories, such as multiple prior coronary revascularization

procedures.
● Assistance with disposition.
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Non-ST elevation acute
15 of 29 4/30/2020, 9:27 PM
coronary syndromes (non-ST elevation myocardial infarction)".)
SUMMARY AND RECOMMENDATIONS
● The focus of the evaluation of patients with possible acute coronary syndrome (ACS) is to
confirm or exclude the diagnosis in an expeditious manner. Early in the process, alternative
life-threatening diagnoses should be considered. (See 'Introduction' above.)
● Our approach (outlined below) focuses on specific time points. However, new patient
information (eg, new or changing symptoms, adverse changes in vital signs, or new
changes on the electrocardiogram [ECG]) may influence patient care. For patients who have
or are likely to have an ACS, appropriate management strategies should be initiated. (See
"Initial evaluation and management of suspected acute coronary syndrome (myocardial
infarction, unstable angina) in the emergency department", section on 'Management'.)
• An early determination of the likelihood of ACS should be made after the history,
physical examination, and serial (two or three) ECGs have been performed (table 1 and
algorithm 1). (See 'Initial evaluation' above.)
- Some patients will be assessed to have another likely cause of chest pain (eg,
herpetic skin lesion), or be at very low risk, and the evaluation for ACS can stop.
- All other patients should continue to be monitored, awaiting the result of a first
troponin.
• After return of the first sensitive troponin value, most patients with a positive result will
be treated as having an ACS. Monitoring should continue in patients with a normal first
troponin (see 'Troponin testing' above). The second troponin should be obtained one to
three hours after the first, depending on the algorithm being used. (See 'Normal first
troponin' above.)
• After return of the second sensitive troponin value, reassess the likelihood of ACS using
the History, ECG, Age, Risk factors, and a single sensitive Troponin (HEART) Pathway
or other preferred institutional pathway. (See 'Troponin testing' above and 'Care
pathways' above.)
- If the patient is felt to be at low risk (or very low risk in some pathways) of an
adverse event (eg, low HEART risk score and two negative troponins), the patient
may be discharged and follow-up can be arranged with a primary care physician.
16 of 29 4/30/2020, 9:27 PM
- In patients with two negative troponins but whose clinical characteristics lead to a
designation of high risk, noninvasive diagnostic testing may need to be performed.
- Patients with a positive troponin need further designation: definite, possible, or no

ACS with troponin, possibly due to some cause other than myocardial ischemia.
Some patients with a positive troponin may reasonably be referred for stress
testing or cardiac imaging. This should be done prior to discharge or as an
outpatient if patient compliance is likely to be high.
• After completion of the appropriate noninvasive diagnostic test (eg, stress test, cardiac
imaging), determine the patient's final disposition. (See 'Disposition after noninvasive
evaluation' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf (Accessed o
n October 29, 2019).
2. 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.
3. Kline JA, Johnson CL, Pollack CV Jr, et al. Pretest probability assessment derived from
attribute matching. BMC Med Inform Decis Mak 2005; 5:26.
4. 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.
5. 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.
6. 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
17 of 29 4/30/2020, 9:27 PM
Association. Circulation 2010; 122:1756.
7. 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.
8. 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.
9. 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.
10. 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.
11. McCaig, L, Burt, C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency De
partment Summary. In: Advance Data from Vital and Health Statistics. Centers for disease c
ontrol and prevention, Atlanta, GA 2005.
12. 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.
13. 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.
14. Nejatian A, Omstedt Å, Höijer J, et al. Outcomes in Patients With Chest Pain Discharged
After Evaluation Using a High-Sensitivity Troponin T Assay. J Am Coll Cardiol 2017;
69:2622.
15. Morrow DA. Clinician's Guide to Early Rule-Out Strategies With High-Sensitivity Cardiac
18 of 29 4/30/2020, 9:27 PM
Troponin. Circulation 2017; 135:1612.
16. Shah ASV, Anand A, Strachan FE, et al. High-sensitivity troponin in the evaluation of patients
with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised
controlled trial. Lancet 2018; 392:919.
17. 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.
18. 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.
19. 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.
20. Sandoval Y, Smith SW, Sexter A, et al. Clinical Features and Outcomes of Emergency
Department Patients With High-Sensitivity Cardiac Troponin I Concentrations Within Sex-
Specific Reference Intervals. Circulation 2019; 139:1753.
21. Pickering JW, Than MP, Cullen L, et al. Rapid Rule-out of Acute Myocardial Infarction With a
Single High-Sensitivity Cardiac Troponin T Measurement Below the Limit of Detection: A
Collaborative Meta-analysis. Ann Intern Med 2017; 166:715.
22. Twerenbold R, Neumann JT, Sörensen NA, et al. Prospective Validation of the 0/1-h
Algorithm for Early Diagnosis of Myocardial Infarction. J Am Coll Cardiol 2018; 72:620.
23. Mueller C, Giannitsis E, Möckel M, et al. Rapid rule out of acute myocardial infarction: novel
biomarker-based strategies. Eur Heart J Acute Cardiovasc Care 2017; 6:218.
24. Crea F, Jaffe AS, Collinson PO, et al. Should the 1h algorithm for rule in and rule out of
acute myocardial infarction be used universally? Eur Heart J 2016; 37:3316.
25. Boeddinghaus J, Nestelberger T, Twerenbold R, et al. Direct Comparison of 4 Very Early

Rule-Out Strategies for Acute Myocardial Infarction Using High-Sensitivity Cardiac Troponin
I. Circulation 2017; 135:1597.
26. Than M, Herbert M, Flaws D, et al. What is an acceptable risk of major adverse cardiac
event in chest pain patients soon after discharge from the Emergency Department?: a
clinical survey. Int J Cardiol 2013; 166:752.
19 of 29 4/30/2020, 9:27 PM
27. Lee G, Twerenbold R, Tanglay Y, et al. Clinical benefit of high-sensitivity cardiac troponin I in
the detection of exercise-induced myocardial ischemia. Am Heart J 2016; 173:8.
28. McRae AD, Innes G, Graham M, et al. Undetectable Concentrations of a Food and Drug
Administration-approved High-sensitivity Cardiac Troponin T Assay to Rule Out Acute
Myocardial Infarction at Emergency Department Arrival. Acad Emerg Med 2017; 24:1267.
29. Jaffe AS, White H. Ruling-In Myocardial Injury and Ruling-Out Myocardial Infarction With the
European Society of Cardiology 1-Hour Algorithm. Circulation 2016; 134:1542.
30. Sandoval Y, Smith SW, Shah AS, et al. Rapid Rule-Out of Acute Myocardial Injury Using a
Single High-Sensitivity Cardiac Troponin I Measurement. Clin Chem 2017; 63:369.
31. Möckel M, Giannitsis E, Mueller C, et al. Editor's Choice-Rule-in of acute myocardial

infarction: Focus on troponin. Eur Heart J Acute Cardiovasc Care 2017; 6:212.
32. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute
coronary syndromes in patients presenting without persistent ST-segment elevation: Task
Force for the Management of Acute Coronary Syndromes in Patients Presenting without
Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J
2016; 37:267.
33. Hammarsten O, Fu ML, Sigurjonsdottir R, et al. Troponin T percentiles from a random

population sample, emergency room patients and patients with myocardial infarction. Clin
Chem 2012; 58:628.
34. Kavsak PA, Clark L, Jaffe AS. Effect of Repeat Measurements of High-Sensitivity Cardiac
Troponin on the Same Sample Using the European Society of Cardiology 0-Hour/1-Hour or
2-Hour Algorithms for Early Rule-Out and Rule-In for Myocardial Infarction. Clin Chem
2017; 63:1163.
35. Hamm CW, Goldmann BU, Heeschen C, et al. Emergency room triage of patients with
acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med
1997; 337:1648.
36. Bjurman C, Larsson M, Johanson P, et al. Small changes in troponin T levels are common
in patients with non-ST-segment elevation myocardial infarction and are linked to higher
mortality. J Am Coll Cardiol 2013; 62:1231.
37. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST
20 of 29 4/30/2020, 9:27 PM
elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;
284:835.
38. 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.
39. 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.
40. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART
score. Neth Heart J 2008; 16:191.
41. Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of Using the HEART Score in Patients
With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized
Trial. Ann Intern Med 2017; 166:689.
42. 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.
43. Fernando SM, Tran A, Cheng W, et al. Prognostic Accuracy of the HEART Score for
Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A
Systematic Review and Meta-analysis. Acad Emerg Med 2019; 26:140.
44. Neumann JT, Twerenbold R, Ojeda F, et al. Application of High-Sensitivity Troponin in

Suspected Myocardial Infarction. N Engl J Med 2019; 380:2529.
45. Sandoval Y, Smith SW, Love SA, et al. Single High-Sensitivity Cardiac Troponin I to Rule Out
Acute Myocardial Infarction. Am J Med 2017; 130:1076.
46. Chapman AR, Lee KK, McAllister DA, et al. Association of High-Sensitivity Cardiac Troponin
I Concentration With Cardiac Outcomes in Patients With Suspected Acute Coronary
Syndrome. JAMA 2017; 318:1913.
47. 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.
48. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest
21 of 29 4/30/2020, 9:27 PM
pain in the emergency department: a randomized clinical trial. JAMA Intern Med 2014;
174:51.
49. Mahler SA, Lenoir KM, Wells BJ, et al. Safely Identifying Emergency Department Patients
With Acute Chest Pain for Early Discharge. Circulation 2018; 138:2456.
50. 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.
51. 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.
52. Pickering JW, Greenslade JH, Cullen L, et al. Assessment of the European Society of
Cardiology 0-Hour/1-Hour Algorithm to Rule-Out and Rule-In Acute Myocardial Infarction.
Circulation 2016; 134:1532.
53. Carlton E, Greenslade J, Cullen L, et al. Evaluation of High-Sensitivity Cardiac Troponin I

Levels in Patients With Suspected Acute Coronary Syndrome. JAMA Cardiol 2016; 1:405.
54. Rubini Gimenez M, Twerenbold R, Jaeger C, et al. One-hour rule-in and rule-out of acute
myocardial infarction using high-sensitivity cardiac troponin I. Am J Med 2015; 128:861.
55. Mueller C, Giannitsis E, Christ M, et al. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm

in the Diagnosis of Myocardial Infarction With High-Sensitivity Cardiac Troponin T. Ann
Emerg Med 2016; 68:76.
56. 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.
57. Peacock WF, Baumann BM, Bruton D, et al. Efficacy of High-Sensitivity Troponin T in
Identifying Very-Low-Risk Patients With Possible Acute Coronary Syndrome. JAMA Cardiol
2018; 3:104.
58. Chapman AR, Anand A, Boeddinghaus J, et al. Comparison of the Efficacy and Safety of
Early Rule-Out Pathways for Acute Myocardial Infarction. Circulation 2017; 135:1586.
59. Braunwald E, Jones RH, Mark DB, et al. Diagnosing and managing unstable angina.
Agency for Health Care Policy and Research. Circulation 1994; 90:613.
22 of 29 4/30/2020, 9:27 PM
60. 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.
61. 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.
62. 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.
63. 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.
64. 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.
65. 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.
66. Barrabés JA, Bardají A, Jiménez-Candil J, et al. Characteristics and Outcomes of Patients
Hospitalized With Suspected Acute Coronary Syndrome in Whom the Diagnosis is not
Confirmed. Am J Cardiol 2018; 122:1604.
Topic 88 Version 26.0
23 of 29 4/30/2020, 9:27 PM
GRAPHICS
Assessment of low/intermediate-risk acute coronary

syndrome in the emergency department
O v erv iew of approac h to the management of patients in the emergenc y

department who are felt to be at low or moderate (not high) ris k of A C S .
T his algorithm s hould be us ed in c onjunc tion with other c ontent. I t does
not apply to patients at v ery low ris k of an A C S , s uc h as thos e with
aty pic al c hes t pain, s table v ital s igns , and a normal elec troc ardiogram.
ACS: acute coronary syndrome; ECG: electrocardiogram.

* After initial history, physical examination, and electrocardiogram.
¶ Recurrent or ongoing angina (chest pain), unstable vital signs, ischemia on repeat
electrocardiogram or monitoring.
Δ Refer to topic for details.
◊ We generally instruct patients to confer with their primary care physician within 48
hours of discharge.
Graphic 107583 Version 2.0
24 of 29 4/30/2020, 9:27 PM
Composition of the HEART score for chest pain patients in the emergency
room
HEA RT score for chest pain patients Score
History Highly suspicious 2
Moderately suspicious 1
Slightly suspicious 0
ECG Significant ST depression 2
Nonspecific repolarisation disturbance 1
Normal 0
Age ≥65 years 2
45-65 years 1
<45 years 0
Risk factors ≥3 risk factors or history of 2

atherosclerotic disease
1 or 2 risk factors 1
No risk factors known 0
Troponin >2x normal limit 2
1-2x normal limit 1
≤normal limit 0
Total _____
Reproduced with permission from: Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART
score. Neth Heart J 2008; 16:191. Copyright © 2008 Bohn Stafleu van Loghum.
25 of 29 4/30/2020, 9:27 PM
Likelihood of acute coronary syndrome secondary to coronary heart

disease in patients without ST-segment elevation
High likelihood
Any of the following features:
Primary symptom is pain or discomfort in chest or left arm AND current pain is similar to pain of prior documented angina/MI
Patient has known CHD OR MI
Transient mitral regurgitation OR hypotension OR diaphoresis OR pulmonary edema OR rales
New (or presumably new) transient ST deviation (≥1 mm)
New T-wave inversion in multiple precordial leads
Elevated cardiac troponin
Intermediate likelihood
Absence of high-likelihood features, a normal cardiac troponin, and presence of any of the following:
Primary symptom is pain or discomfort in chest or left arm
Older than 70 years of age
Male
Diabetes mellitus
Extracardiac vascular disease
Fixed Q waves
ST depression 0.5 to 1 mm or T-wave inversion >1 mm
Low likelihood
Absence of high- or intermediate-likelihood features and a normal cardiac troponin. May have any of the following
and still be low likelihood:
History of symptoms that are probably ischemic
Recent use of cocaine
T-wave flattening or inversion <1 mm
N ote: T- wav e inv ers ion refers to a T- wav e with oppos ite polarity to the dominant Q R S in that lead.
MI: myocardial infarction; CHD: coronary heart disease.
Adapted from: Anderson J, Adams C, Antman E, 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).
26 of 29 4/30/2020, 9:27 PM
Short-term risk of death or nonfatal myocardial infarction (MI) in patients

with unstable angina/non-ST-elevation MI
High risk (at least one of the following features must be present):
History:
Accelerating tempo of ischemic symptoms in preceding 48 hours
Character of pain:
Prolonged ongoing (>20 min) rest pain
Clinical findings:
Pulmonary edema, most likely due to ischemia
New or worsening MR murmur
S 3 or new/worsening rales
Hypotension, bradycardia, tachycardia
Age >75 years
ECG:
Angina at rest with transient ST-segment changes >0.5 mm
Bundle-branch block, new or presumed new
Sustained ventricular tachycardia
Cardiac markers:
Elevated cardiac TnT, TnI, or CK-MB (eg, TnT or TnI >0.1 ng per mL)
Intermediate risk (no high-risk feature but must have one of the following):
History:
Prior MI, peripheral or cerebrovascular disease, or CABG; prior aspirin use
Character of pain:
Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD
Rest angina (>20 min) or relieved with rest or sublingual NTG
Nocturnal angina
New onset or progressive CCS class III or IV angina in the past two weeks without prolonged (>20 min) rest pain
but with intermediate or high likelihood of CAD
Clinical findings:
Age >70 years
ECG:
T-wave changes
Pathological Q waves or resting ST-depression less than 1 mm in multiple lead groups (anterior, inferior, lateral)
Cardiac markers:
Slightly elevated cardiac TnT, TnI, or CK-MB (eg, TnT greater than 0.01 but less than 0.1 ng per mL)
Low risk (no high- or intermediate-risk features, but may have any of the following
features):
Character of pain:
Increased angina frequency, severity, or duration
27 of 29 4/30/2020, 9:27 PM
Angina provoked at a lower threshold
New onset angina with onset two weeks to two months prior to presentation
ECG:
Normal or unchanged ECG
Cardiac markers:
Normal
MR: mitral regurgitation; ECG: electrocardiogram; TnT: cardiac troponin T; TnI: cardiac troponin I; CK-MB: creatine kinase
MB; CCS: Canadian Cardiovascular Society; CAD: coronary artery disease; NTG: nitroglycerin.
Adapted from 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.
28 of 29 4/30/2020, 9:27 PM
Contributor Disclosures
Chadw ick Miller, MD, MS Grant/Research/Clinical Trial Support: Siemens [Cardiac imaging, cardiac
biomarkers]; Abbott [Cardiac biomarkers]; Creavo Medical Technologies [Chest pain]; Marcus Foundation
[Sepsis care]. Patent Holder: Patent application w ith self listed as inventor [Biomarker for
CAD]. Christopher B Granger, MD Grant/Research Support/Clinical Trial Support: AKROS [Pulmonary
hypertension]; Apple [Cardiovascular study]; AstraZeneca [Myocardial infarction]; Beohringer Ingelheim
[Cardiovascular medicine and new er oral anticoagulants]; BMS [New er oral anticoagulants]; Daiichi Sankyo
[New er oral anticoagulants]; GlaxoKlineSmith [Cardiovascular medicine]; Janssen [New er oral
anticoagulants]; Medtronic [ST-elevation myocardial infarction]; Novartis [Cardiovascular medicine]; Pfizer
[New er oral anticoagulants]; Duke Clinical Research Institute; FDA. Consultant/Advisory Boards: Abbvie
[Cardiovascular medicine and testosterone]; AstraZeneca [Myocardial infarction]; Bayer [Heart failure];
Boehringer Ingelheim [Cardiovascular medicine and new er oral anticoagulants]; Boston Scientific [New er oral
anticoagulants]; Bristol Meyers Squibb [New er oral anticoagulants]; Espero [Cardiovascular medicine];
Janssen [New er oral anticoagulants]; Medscape; Medtronic [ST-elevation myocardial infarction and cardiac
arrest]; Merck [Heart failure]; Novo Nordisk [Cardiovascular medicine and obesity]; Novartis [Cardiovascular
medicine]; Pfizer [New er oral anticoagulants]; Roche [Cardiovascular medicine]; Celecor [Cardiovascular
medicine]; Correvo [Cardiovascular medicine]; Rhoshan [Cardiovascular medicine]. Christopher P
Cannon, MD Grant/Research/Clinical Trial Support: Amgen [Lipids (Evolocumab), heart failure (Ivabradine)];
Boehringer-Ingelheim [AF (Dabigatran), DM (Empaglifozin, Linagliptin)]; Bristol-Myers Squibb [AF (Apixaban)];
Daiichi Sankyo [AF (Edoxaban)]; Janssen [AF (Rivaroxaban), DM (Canagliflozin)]; Merck [Lipids (Ezetimibe),
DM (Ertugliflozin, Sitaglipitin)]; Pfizer ([AF (Apixaban), DM (Ertugliflozin), lipids (Atorvastatin)].
Consultant/Advisory Boards: Alnylam [Lipids (Inclisiran)]; Amarin [Lipids (Vascepa icosapent ethyl)]; Amgen
[Lipids (Evolocumab), heart failure (Ivabradine)]; BI [AF (Dabigatran), DM (Empaglifozin, Linagliptin)]; Bristol-
Myers Squibb [AF (Apixaban)]; Janssen [AF (Rivaroxaban), DM (Canagliflozin)]; Kow a [Lipids (Pitavastatin)];
Lipimedix [Lipids]; Merck [Lipids (Ezetimibe), DM (Ertugliflozin, Sitaglipitin)]; Pfizer [AF (Apixaban), DM
(Ertugliflozin), lipids (Atorvastatin)]; Sanofi [Lipids (Alirocumab), ACS (Clopidogrel)], diabetes (Lixisenatide,
Sotagliflozin); Aegerion [lipids (lomitapide)]; HLS Therapeutics [lipids (Vascepa icosapent ethyl)]; Applied
Therapeutics [lipids]; Ascendia [lipids]; Corvidia [lipids]; Innovent [lipids]. Jam es Hoekstra, MD Nothing to
disclose Allan S Jaffe, MD Consultant/Advisory Boards: Beckman; Abbott; ET Healthcare; Siemens;
Sphingotec; Novartis [Biomarkers (Diagnostic tests)]; Quindel [hs--cTnI assay]; Blade; Roche;
Brava. Gordon M Saperia, MD Nothing to disclose
Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy
29 of 29 4/30/2020, 9:27 PM

Evaluation of Emergency Department Patients With Chest Pain at Low or Intermediate Risk For Acute Coronary Syndrome - UpToDate

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Evaluation of Emergency Department Patients With Chest Pain at Low or Intermediate Risk For Acute Coronary Syndrome - UpToDate

Caricato da

Copyright:

Formati disponibili

Evaluation of emergency department patients with chest pain at low or in... https://www.uptodate.com/contents/evaluation-of-emergency-department...

O fficial reprint from UpToDate ®

Evaluation of emergency department patients with chest

DEFINITION OF ACUTE CORONARY SYNDROME

● Continuous ECG monitoring.

● A brief history and physical examination to screen for signs or symptoms of

● At a minimum, the following laboratory tests should be ordered as soon as possible in

● A chest radiograph is usually performed in patients suspected of having an ACS, since

We manage patients as follows:

● The Calculation Of MI risk probabilities to Manage Patients with SuSpicion of Myocardial

● High-STEACS Pathway – The High-STEACS Pathway measures hs-cTnI at presentation

Observation unit approach — Observation units can be used to complete subsequent

Noninvasive evaluation — Noninvasive evaluation is performed on patients for whom there

[rMPI] or dobutamine stress echocardiography), or computed tomography angiography.

● Noninvasive rest imaging may be performed in some patients with low-to-intermediate

● Computed tomography angiography, including evaluation of fraction flow reserve, provides

● Patients with positive stress testing or imaging results should be evaluated by a

We suggest the following at the time of discharge:

• Provide care for the most likely cause of pain.

● Biomarker elevation that may or may not represent ACS.

● Patients with positive stress testing or imaging results should be evaluated by a

● Imaging reveals ongoing or inducible ischemia, significant coronary artery stenosis, or

● Complicated cardiac histories, such as multiple prior coronary revascularization

● Assistance with disposition.

SOCIETY GUIDELINE LINKS

coronary syndromes (non-ST elevation myocardial infarction)".)

SUMMARY AND RECOMMENDATIONS

- Patients with a positive troponin need further designation: definite, possible, or no

Use of UpToDate is subject to the Subscription and License Agreement.

Association. Circulation 2010; 122:1756.

Troponin. Circulation 2017; 135:1612.

25. Boeddinghaus J, Nestelberger T, Twerenbold R, et al. Direct Comparison of 4 Very Early

31. Möckel M, Giannitsis E, Mueller C, et al. Editor's Choice-Rule-in of acute myocardial

33. Hammarsten O, Fu ML, Sigurjonsdottir R, et al. Troponin T percentiles from a random

44. Neumann JT, Twerenbold R, Ojeda F, et al. Application of High-Sensitivity Troponin in

53. Carlton E, Greenslade J, Cullen L, et al. Evaluation of High-Sensitivity Cardiac Troponin I

55. Mueller C, Giannitsis E, Christ M, et al. Multicenter Evaluation of a 0-Hour/1-Hour Algorithm

Topic 88 Version 26.0

Assessment of low/intermediate-risk acute coronary

O v erv iew of approac h to the management of patients in the emergenc y

ACS: acute coronary syndrome; ECG: electrocardiogram.

Graphic 107583 Version 2.0

HEA RT score for chest pain patients Score

History Highly suspicious 2

ECG Significant ST depression 2

Nonspecific repolarisation disturbance 1

Age ≥65 years 2

Risk factors ≥3 risk factors or history of 2

No risk factors known 0

Troponin >2x normal limit 2

1-2x normal limit 1

Graphic 105869 Version 2.0

Likelihood of acute coronary syndrome secondary to coronary heart

Patient has known CHD OR MI

Transient mitral regurgitation OR hypotension OR diaphoresis OR pulmonary edema OR rales

New (or presumably new) transient ST deviation (≥1 mm)

New T-wave inversion in multiple precordial leads

Elevated cardiac troponin

Primary symptom is pain or discomfort in chest or left arm

Older than 70 years of age

Extracardiac vascular disease

ST depression 0.5 to 1 mm or T-wave inversion >1 mm

History of symptoms that are probably ischemic