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Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department

  • Management of Acute Coronary Syndromes (H Jneid, Section Editor)
  • Published:
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Abstract

Purpose of the Review

To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations.

Recent findings

Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED.

Summary

This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

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References

Papers of particular interest, published recently, have been highlighted as:  • Of importance  •• Of major importance

  1. Statistics NCfH. 2020 NHAMCS Emergency Department Summary Tables. Ambulatory Health Care Data. 2020.

  2. Hsia RY, Hale Z, Tabas JA. A national study of the prevalence of life-threatening diagnoses in patients with chest pain. JAMA Intern Med. 2016;176:1029–32.

    PubMed  Google Scholar 

  3. •• Writing C, Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, et al. 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022;80:1925-60. This report is a comprehensive expert consensus statement regarding the evaluation of chest pain in the emergency department.

  4. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the evaluation and diagnosis of chest pain: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;78:2218–61.

    PubMed  Google Scholar 

  5. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e139–228.

    PubMed  Google Scholar 

  6. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Circulation. 2018;138:e618–51.

    PubMed  Google Scholar 

  7. Dababneh E, Siddique MS. Pericarditis. StatPearls. Treasure Island (FL)2023.

  8. McKnight CL, Burns B. Pneumothorax. StatPearls. Treasure Island (FL)2023.

  9. Damluji AA, van Diepen S, Katz JN, Menon V, Tamis-Holland JE, Bakitas M, et al. Mechanical complications of acute myocardial infarction: a scientific statement from the American Heart Association. Circulation. 2021;144:e16–35.

    PubMed  PubMed Central  Google Scholar 

  10. Levy D, Goyal A, Grigorova Y, Farci F, Le JK. Aortic dissection. StatPearls. Treasure Island (FL)2023.

  11. Richards JR, Laurin EG. Methamphetamine toxicity. StatPearls. Treasure Island (FL)2023.

  12. Richards JR, Le JK. Cocaine Toxicity. StatPearls. Treasure Island (FL)2023.

  13. Kearon C, de Wit K, Parpia S, Schulman S, Afilalo M, Hirsch A, et al. Diagnosis of pulmonary embolism with d-dimer adjusted to clinical probability. N Engl J Med. 2019;381:2125–34.

    CAS  PubMed  Google Scholar 

  14. Takach Lapner S, Julian JA, Linkins LA, Bates S, Kearon C. Comparison of clinical probability-adjusted D-dimer and age-adjusted D-dimer interpretation to exclude venous thromboembolism. Thromb Haemost. 2017;117:1937–43.

    PubMed  Google Scholar 

  15. Nazerian P, Mueller C, Soeiro AM, Leidel BA, Salvadeo SAT, Giachino F, et al. Diagnostic accuracy of the aortic dissection detection risk score plus D-dimer for acute aortic syndromes: the ADvISED Prospective Multicenter Study. Circulation. 2018;137:250–8.

    CAS  PubMed  Google Scholar 

  16. Rogers AM, Hermann LK, Booher AM, Nienaber CA, Williams DM, Kazerooni EA, et al. Sensitivity of the aortic dissection detection risk score, a novel guideline-based tool for identification of acute aortic dissection at initial presentation: results from the international registry of acute aortic dissection. Circulation. 2011;123:2213–8.

    PubMed  Google Scholar 

  17. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE, Jr., et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. J Am Coll Cardiol. 2010;55:e27-e129.

  18. Falster C, Jacobsen N, Coman KE, Hojlund M, Gaist TA, Posth S, et al. Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis. Thorax. 2022;77:679–89.

    PubMed  Google Scholar 

  19. van Rossum AB, van Houwelingen HC, Kieft GJ, Pattynama PM. Prevalence of deep vein thrombosis in suspected and proven pulmonary embolism: a meta-analysis. Br J Radiol. 1998;71:1260–5.

    PubMed  Google Scholar 

  20. Vyas V, Goyal A. Acute pulmonary embolism. StatPearls. Treasure Island (FL)2023.

  21. Bachmann JM, Willis BL, Ayers CR, Khera A, Berry JD. Association between family history and coronary heart disease death across long-term follow-up in men: the Cooper Center Longitudinal Study. Circulation. 2012;125:3092–8.

    PubMed  PubMed Central  Google Scholar 

  22. Sanchis-Gomar F, Perez-Quilis C, Leischik R, Lucia A. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med. 2016;4:256.

    PubMed  PubMed Central  Google Scholar 

  23. Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni AG, et al. Cardiovascular health in African Americans: a scientific statement from the American Heart Association. Circulation. 2017;136:e393–423.

    PubMed  Google Scholar 

  24. Rodriguez CJ, Allison M, Daviglus ML, Isasi CR, Keller C, Leira EC, et al. Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association. Circulation. 2014;130:593–625.

    PubMed  PubMed Central  Google Scholar 

  25. Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ, et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009;6: e1000058.

    PubMed  PubMed Central  Google Scholar 

  26. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics–2015 update: a report from the American Heart Association. Circulation. 2015;131:e29-322.

    PubMed  Google Scholar 

  27. Pan A, Wang Y, Talaei M, Hu FB. Relation of smoking with total mortality and cardiovascular events among patients with diabetes mellitus: a meta-analysis and systematic review. Circulation. 2015;132:1795–804.

    PubMed  PubMed Central  Google Scholar 

  28. McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P, et al. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008;117:1897–907.

    PubMed  Google Scholar 

  29. Frangogiannis NG. The inflammatory response in myocardial injury, repair, and remodelling. Nat Rev Cardiol. 2014;11:255–65.

    CAS  PubMed  PubMed Central  Google Scholar 

  30. Goldberg RJ, Spencer FA, Gore JM, Lessard D, Yarzebski J. Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective. Circulation. 2009;119:1211–9.

    PubMed  PubMed Central  Google Scholar 

  31. Cs BECK. Two cardiac compression triads. J Am Med Assoc. 1935;104:714–6.

    Google Scholar 

  32. de Winter RJ, Verouden NJ, Wellens HJ, Wilde AA, Interventional Cardiology Group of the Academic Medical C. A new ECG sign of proximal LAD occlusion. N Engl J Med. 2008;359:2071–3.

  33. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996;334:481–7.

  34. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012;60:766–76.

    PubMed  Google Scholar 

  35. Allencherril J, Bandeali S, Nikus K, Birnbaum Y. Acute chest pain in a patient with left bundle branch pacing. J Electrocardiol. 2023;77:51–4.

    PubMed  Google Scholar 

  36. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. 1982;103:730–6.

    PubMed  Google Scholar 

  37. Reindl M, Lechner I, Reinstadler SJ, Metzler B. Transient STEMI - No STEMI at all? Int J Cardiol. 2021;339:12–3.

    PubMed  Google Scholar 

  38. Janssens GN, van der Hoeven NW, Lemkes JS, Everaars H, van de Ven PM, Marques KMJ, et al. 1-year outcomes of delayed versus immediate intervention in patients with transient ST-segment elevation myocardial infarction. JACC Cardiovasc Interv. 2019;12:2272–82.

    PubMed  Google Scholar 

  39. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation. 2008;118:2754–62.

    PubMed  PubMed Central  Google Scholar 

  40. Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, et al. International expert consensus document on Takotsubo Syndrome (Part II): diagnostic workup, outcome, and management. Eur Heart J. 2018;39:2047–62.

    PubMed  PubMed Central  Google Scholar 

  41. McGINN S, WHITE PD. Acute cor pulmonale resulting from pulmonary embolism: its clinical recognition. Journal of the American Medical Association. 1935;104:1473–80.

  42. Ben-Baruch Golan Y, Sadeh R, Mizrakli Y, Shafat T, Sagy I, Slutsky T, et al. Early point-of-care ultrasound assessment for medical patients reduces time to appropriate treatment: a pilot randomized controlled trial. Ultrasound Med Biol. 2020;46:1908–15.

    PubMed  Google Scholar 

  43. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23:1225–30.

    PubMed  Google Scholar 

  44. Sorensen B, Hunskaar S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. Ultrasound J. 2019;11:31.

    PubMed  PubMed Central  Google Scholar 

  45. Zanobetti M, Scorpiniti M, Gigli C, Nazerian P, Vanni S, Innocenti F, et al. Point-of-care ultrasonography for evaluation of acute dyspnea in the ED. Chest. 2017;151:1295–301.

    PubMed  Google Scholar 

  46. Chan KK, Joo DA, McRae AD, Takwoingi Y, Premji ZA, Lang E, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. Cochrane Database Syst Rev. 2020;7:CD013031.

  47. Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart. 2017;103:987–94.

    PubMed  Google Scholar 

  48. Ma IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, et al. Internal medicine point-of-care ultrasound curriculum: consensus recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med. 2017;32:1052–7.

    PubMed  PubMed Central  Google Scholar 

  49. Das D, Kapoor M, Brown C, Ndubuisi A, Gupta S. Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States. Crit Ultrasound J. 2016;8:6.

    PubMed  PubMed Central  Google Scholar 

  50. Januzzi JL Jr, Mahler SA, Christenson RH, Rymer J, Newby LK, Body R, et al. Recommendations for institutions transitioning to high-sensitivity troponin testing: JACC scientific expert panel. J Am Coll Cardiol. 2019;73:1059–77.

    CAS  PubMed  Google Scholar 

  51. Chapman AR, Sandeman D, Ferry AV, Stewart S, Strachan FE, Wereski R, et al. Risk stratification using high-sensitivity cardiac troponin T in patients with suspected acute coronary syndrome. J Am Coll Cardiol. 2020;75:985–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  52. Shah ASV, Anand A, Strachan FE, Ferry AV, Lee KK, Chapman AR, et al. High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial. Lancet. 2018;392:919–28.

    CAS  PubMed  PubMed Central  Google Scholar 

  53. Reichlin T, Schindler C, Drexler B, Twerenbold R, Reiter M, Zellweger C, et al. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med. 2012;172:1211–8.

    PubMed  Google Scholar 

  54. Chew DP, Lambrakis K, Blyth A, Seshadri A, Edmonds MJR, Briffa T, et al. A randomized trial of a 1-hour troponin T protocol in suspected acute coronary syndromes: the Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT). Circulation. 2019;140:1543–56.

    PubMed  Google Scholar 

  55. Vigen R, Diercks DB, Hashim IA, Pandey A, Zhong L, Kutscher P, et al. Association of a novel protocol for rapid exclusion of myocardial infarction with resource use in a US safety net hospital. JAMA Netw Open. 2020;3:e203359. 

    PubMed  PubMed Central  Google Scholar 

  56. • Ganguli I, Cui J, Thakore N, Orav EJ, Januzzi JL, Baugh CW, et al. Downstream cascades of care following high-sensitivity troponin test implementation. J Am Coll Cardiol. 2021;77:3171-9. This recent study utilized new hs-cTn pathways and demonstrated that these decrease the amount of stress tests, PCIs, cardiology evaluations, and hospital admissions in patients presenting with chest pain. 

  57. Sandoval Y, Askew JW 3rd, Newman JS, Clements CM, Grube ED, Ola O, et al. Implementing high-sensitivity cardiac troponin T in a US regional healthcare system. Circulation. 2020;141:1937–9.

    PubMed  Google Scholar 

  58. Writing Committee M, Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr. 2022;16:54–122.

    Google Scholar 

  59. Than M, Flaws D, Sanders S, Doust J, Glasziou P, Kline J, et al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014;26:34–44.

    PubMed  Google Scholar 

  60. Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8:195–203.

    PubMed  PubMed Central  Google Scholar 

  61. Hulten E, Pickett C, Bittencourt MS, Villines TC, Petrillo S, Di Carli MF, et al. Meta-analysis of coronary CT angiography in the emergency department. European Heart Journal - Cardiovascular Imaging. 2013;14:607–8.

    PubMed  Google Scholar 

  62. Knuuti J, Ballo H, Juarez-Orozco LE, Saraste A, Kolh P, Rutjes AWS, et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J. 2018;39:3322–30.

    PubMed  Google Scholar 

  63. Hulten E, Pickett C, Bittencourt MS, Villines TC, Petrillo S, Di Carli MF, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 2013;61:880–92.

    PubMed  Google Scholar 

  64. O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.

    PubMed  Google Scholar 

  65. Morrow DA, Antman EM, Snapinn SM, McCabe CH, Theroux P, Braunwald E. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes. Application of the TIMI Risk Score for UA/NSTEMI in PRISM-PLUS. Eur Heart J. 2002;23:223–9.

  66. Association AH. Adult Bradycardia Algorithm. 2020.

  67. Association AH. Adult tachycardia with a pulse algorithm. 2020.

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Authors and Affiliations

  1. Department of Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, UH I-248, Newark, NJ, 07101, USA

    Paul Y. Lee & Kyrollos Saad

  2. Department of Cardiology, Rutgers New Jersey Medical School, Newark, NJ, USA

    Afif Hossain

  3. Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA

    Irene Lieu

  4. Department of Medicine, Division of Cardiovascular Medicine, The University of Texas Medical Branch at Galveston, Galveston, TX, USA

    Joseph Allencherril

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Lee, P.Y., Saad, K., Hossain, A. et al. Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department. Curr Cardiol Rep 25, 1677–1686 (2023). https://doi.org/10.1007/s11886-023-01984-6

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