Abstract

This issue of EM Practice Guidelines Update reviews 3 scientific statements that focus on strategies for the management of chest pain patients with possible acute coronary syndromes (ACS). There are estimated to be more than 8 million annual visits to United States emergency departments (EDs) for chest pain or other symptoms that may represent myocardial ischemia.¹ Inadvertent discharge from the ED of patients with ACS is associated with increased mortality and liability, whereas the admission of patients without sufficient evidence of serious disease is neither indicated nor cost-effective.¹ While chest pain literature and expert opinion have not generated a unified approach to the evaluation of the low-risk chest pain patient, published guidelines and scientific statements are helpful in directing clinicians toward care that is endorsed by nationally recognized scientific organizations.

Practice Guideline Impact

• The initial evaluation of the chest pain patient deemed low-risk for ACS should include a thorough history and physical examination, serial electrocardiograms (ECGs), and serial troponin assays.
• Patients who arrive > 8 hours after symptom onset may need only a single troponin measurement to exclude acute myocardial infarction (AMI).
• Clinical risk scores are recommended as guides for risk stratification and should be applied as adjuncts to, not substitutes for, clinical judgment in the evaluation of patients presenting with chest pain.
• Patients with a negative initial evaluation who are assessed as lowrisk for ACS may be effectively managed in a clinical decision unit (CDU) or chest pain unit (CPU).
• After ruling out myocardial infarction (MI), chest pain patients deemed low-risk for ACS may receive further risk stratification using a variety of provocative tests.

Keywords: chest pain; low-risk chest pain; angina; acute coronary syndromes, ACS