Identifying Emergency Department Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes
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Identifying Emergency Department Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes -
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Identifying Emergency Department Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes
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Publication Date: July 2017 (Volume 19, Number 7)

Author

David Markel, MD
Attending Physician, Tacoma Emergency Care Physicians, Tacoma, WA
 
Peer Reviewers
 
Keith A. Marill, MD, MS
Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
 
Andrew Schmidt, DO, MPH
Assistant Professor of Emergency Medicine; Deputy Medical Director, TraumaOne Flight Program, University of Florida College of Medicine - Jacksonville, Jacksonville, FL

Abstract

Though a minority of patients presenting to the emergency department with chest pain have acute coronary syndromes, identifying the patients who may be safely discharged and determining whether further testing is needed remains challenging. From the prehospital care setting to disposition and follow-up, this systematic review addresses the fundamentals of the emergency department evaluation of patients determined to be at low risk for acute coronary syndromes or adverse outcomes. Clinical risk scores are discussed, as well as the evidence and indications for confirmatory testing. The emerging role of new technologies, such as high-sensitivity troponin assays and advanced imaging techniques, are also presented.

Excerpt From This Issue

A 65-year-old man with a history of hypertension, diabetes, and prior myocardial infarction presents to the ED after he experienced a 20-minute episode of dull, aching, left-sided chest discomfort while doing yard work an hour ago. His wife tells you that he’s been having similar episodes on and off for the past 2 weeks. He is pain-free on arrival, and his vital signs are unremarkable. His ECG, chest x-ray, and troponin are all normal. When you go back into the room to reassess him, he says he feels fine and asks if he can go home. You hesitate and wonder if it would be safe to send him home without further testing.

A 22-year-old college student presents with sharp, left-sided chest pain and shortness of breath. He recently returned from a spring break trip to Mexico and reports symptoms of an upper respiratory infection. He feels that his chest pain is worse when lying flat, and is concerned he’s having a heart attack. His vital signs and physical examination are normal. He has no past medical history, no cardiac risk factors, and no family history of heart disease. His triage ECG is normal. ACS seems unlikely, but as you’re thinking through your differential diagnosis, you wonder if you need to do any other tests to rule it out definitively.

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