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    Chest Pain: Ruling Out Acute Coronary Syndrome

    Cardinal Presentations / Presenting Problems, Cardiovascular

    Last Updated Sep 15, 2018
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    • Chest pain is one of the most common presentations to the emergency department (ED) and approximately 10 – 15% of such patients will have an acute coronary syndrome. (ACS; either acute myocardial infarction or unstable angina).
    • This approach applies to:
      • stable patients
      • suspected ACS only and cannot be used to rule out other causes such as pulmonary embolus or aortic dissection
      • patients with no other clear cause for their pain.
    • Stable patients have the following features: normal vital signs, no evidence of ischemia on EKG, (no ST elevations or depressions, and no T wave inversions) no ongoing pain in the ED, and negative troponin(s).
    • Stable patients do not require cardiac monitoring while awaiting serial troponins.
    • 20-30% of these patients do not need further testing. We can determine who can go home within 2-3 hours and who can go home after within 6 hours. The result is increased patient satisfaction, decreased ED crowding, and a reduction in unnecessary testing.

    The Diagnostic Process

    • Patients who are under 50 with no prior ACS or nitrate use, and who have normal EKGs and troponin at 2 hours, can be safely discharged home with no follow-up testing.
    • Patients over 50 with no prior ACS or nitrate use, a normal EKG and negative troponin at 2 hours AND who have pain reproducible with direct palpation, can also be safely discharged home with no follow-up testing.
    • Patients with an elevated troponin or abnormal EKG and no other cause for their pain should be referred for further investigation.
    • Patients who do not fall into the above categories should undergo ED observation with sequential investigations (EKGs and troponins) over 6 hours. If all investigations are normal, they should have outpatient follow-up with a cardiologist or internist within two weeks. Ideally, the emergency physician can arrange ancillary outpatient investigations within 48 hours to be followed by a cardiologist or internist in a similar time frame.
    • Patients should be encouraged to take ASA and return if their pain recurs.

    Vancouver Chest Pain Rule

    Outpatient Investigations

    • Exercise stress tests (EST) are functional investigations that have ~70% sensitivity and specificity for ACS. Patients must have normal resting EKGs and be able to walk for 12 minutes.
    • Myocardial perfusion scanning is a functional test with similar sensitivity and specificity as EST for ACS. However, patients with diffuse disease may be false-negatives.

    Quality Of Evidence?


    There are validated studies for both the 2 – hour and 6 – hour decision aids. Although the specifics are slightly different, this approach is similar to those in other settings. (see Than M, et al. Lancet. 2011; 377: 1077 – 1084)

    The 0/1-h early rule-out algorithm for ACS using high-sensitivity troponin has been prospectively validated with a NPV of 99.9% (see Twerenbold R, et al. Am Coll Cardiol 2017)


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