The new document is intended to provide guidance on how to "practically apply" recommendations from the 2021 American Heart Association (AHA)/ACC/multisociety Guideline for the Evaluation and Diagnosis of Chest Pain, focusing specifically on patients who present to the ED, the writing group explains.
"A systematic approach — both at the level of the institution and the individual patient — is essential to achieve optimal outcomes for patients presenting with chest pain to the ED," say writing group chair Michael Kontos, MD, Virginia Commonwealth University, Richmond, and colleagues.
At the institution level, this decision pathway recommends high-sensitivity cardiac troponin (hs-cTn) assays coupled with a clinical decision pathway (CDP) to reduce ED "dwell" times and increase the number of patients with chest pain who can safely be discharged without additional testing. This will decrease ED crowding and limit unnecessary testing, they point out.
At the individual patient level, this document aims to provide structure for the ED evaluation of chest pain, accelerating the evaluation process and matching the intensity of testing and treatment to patient risk.
The 36-page document was published online October 11 in the Journal of the American College of Cardiology.
Key summary points in the document include the following:
Electrocardiogram (ECG) remains the best initial test for evaluation of chest pain in the ED and should be performed and interpreted within 10 minutes of ED arrival.
In patients who arrive via ambulance, the prehospital ECG should be reviewed, because ischemic changes may have resolved before ED arrival.
When the ECG shows evidence of acute infarction or ischemia, subsequent care should follow current guidelines for management of acute ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS).
Patients with a nonischemic ECG can enter an accelerated CDP designed to provide rapid risk assessment and exclusion of ACS.
Patients who are hemodynamically unstable, have significant arrhythmias, or evidence of significant heart failure should be evaluated and treated appropriately and are not candidates for an accelerated CDP.
High-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI) are the preferred biomarkers for evaluation of possible ACS.
Patients classified as low risk (rule out) using the current hs-cTn-based CDPs can generally be discharged directly from the ED without additional testing, although outpatient testing may be considered in selected cases.
Patients with substantially elevated initial hs-cTn values or those with significant dynamic changes over 1-3 hours are assigned to the abnormal/high-risk category and should be further classified according to the universal definition of myocardial infarction (MI) type 1 or 2 or acute or chronic nonischemic cardiac injury.
High-risk patients should usually be admitted to an inpatient setting for further evaluation and treatment.
Patients determined to be intermediate risk with the CDP should undergo additional observation with repeat hs-cTn measurements at 3-6 hours and risk assessment using either the modified HEART (history, ECG, age, risk factors, and troponin) score or the ED assessment of chest pain score (EDACS).
Noninvasive testing should be considered for the intermediate-risk group unless low-risk features are identified using risk scores or noninvasive testing has been performed recently with normal or low-risk findings.
The writing group notes that "safe and efficient" management of chest pain in the ED requires appropriate follow-up after discharge. Timing of follow-up and referral for outpatient noninvasive testing should be influenced by patient risk and results of cardiac testing.