ACC issues decision pathway for diagnosis of acute chest pain in ED
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The American College of Cardiology Solution Set Oversight Committee has issued an expert consensus decision pathway for the diagnosis and acute chest pain in the ED.
“Over the last 40 years, considerable efforts have been made to streamline and improve the chest pain evaluation process. Successive iterations of evaluation and management strategies have reduced both the number of patients who require admission as well as ED length of stay,” Michael C. Kontos, MD, FACC, co-chair of the Chest Pain Center Committee and medical director of the coronary intensive care unit at Virginia Commonwealth University Health and chair of the consensus document writing committee, and colleagues wrote. “The objectives of this Expert Consensus Decision Pathway are to provide structure around the evaluation of chest pain in the ED and to facilitate rapid disposition and limit unnecessary testing among patients with chest pain who are at low risk and who do not have ACS.”
The new decision pathway is designed to parallel the usual course of evaluation of patients with possible ACS and was published in the Journal of the American College of Cardiology.
After careful evaluation of the patient’s 12-lead ECG after presenting to the ED with potential ACS, those with a nonischemic ECG can enter the accelerated decision path for rapid assessment and exclusion of ACS, according to the document.
For patients classified as low risk — as determined by low high-sensitivity cardiac troponin level — the authors stated they may generally be discharged directly from the ED without additional testing; however, outpatient testing can be considered.
For patients classified as high risk — as determined by elevated high-sensitivity cardiac troponin level or significant dynamic changes over 1 to 3 hours — the authors stated the universal definition of MI as either type 1 or type 2 or acute or chronic nonischemic cardiac injury in the inpatients setting can used to further classify their ED presentation.
For patients classified as intermediate risk, the authors stated that repeat high-sensitivity cardiac troponin measurements at 3 to 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) may be considered.
“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,” the researchers wrote. “This Expert Consensus Decision Pathway recommends implementation of high-sensitivity cardiac troponin assays in conjunction with a Consensus Decision Pathway to reduce ED ‘dwell’ times and increase the proportion of patients with chest pain who can safely be discharged without additional testing. Successful implementation will decrease ED crowding and limit unnecessary testing.”
Please see the document for full details on the decision pathway for the evaluation of acute chest pain in the ED.
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