Restricted accessReview articleFirst published online 2020-2
Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association
This paper provides an update on the European Society of Cardiology task force report on the management of chest pain. Its main purpose is to provide an update on the decision algorithms and diagnostic pathways to be used in the emergency department for the assessment and triage of patients with chest pain symptoms suggestive of acute coronary syndromes.
ErhardtLHerlitzJBossaertL, et al. Task force on the management of chest pain. Eur Heart J2002; 23: 1153–1176.
2.
BeyguiFCastrenMBrunettiND, et al. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. Eur Heart J Acute Cardiovasc Care2015; 2048872615604119.
3.
AchenbachSMarwanMRopersD, et al. Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram-triggered high-pitch spiral acquisition. Eur Heart J2010; 31: 340–346.
4.
IbanezBJamesSAgewallS, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the Management of Acute Myocardial Infarction in Patients Presenting with ST-segment Elevation of the European Society of Cardiology (ESC). Eur Heart J2018; 39: 119–177.
5.
RoffiMPatronoCColletJ-P, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J2016; 37: 267–315.
6.
KonstantinidesSVTorbickiAAgnelliG, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Endorsed by the European Respiratory Society (ERS). Eur Heart J2014; 35: 3033–3073.
7.
ErbelRAboyansVBoileauC, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult: the Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J2014; 35: 2873–2926.
8.
Regitz-ZagrosekVOertelt-PrigioneSPrescottE, et al. Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes. Eur Heart J2016; 37: 24–34.
9.
TemplinCGhadriJRDiekmannJ, et al. Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med2015; 373: 929–938.
10.
AdlamDAlfonsoFMaasA, et al.; European Society of Cardiology, Acute Cardiovascular Care Association, SCAD Study Group. A position paper on spontaneous coronary artery dissection. Eur Heart J2018; 39: 3353–3368.
GoodacreSCrossEArnoldJ, et al. The health care burden of acute chest pain. Heart2005; 91: 229–230.
13.
Martínez-SellésMBuenoHSacristánA, et al. Chest pain in the emergency department: incidence, clinical characteristics, and risk stratification. Revista Española de Cardiología (English edn)2008; 61: 953–959.
14.
BhuiyaFPittsSMcCaigL.Emergency department visits for chest pain and abdominal pain: United States, 1999–2008. NCHS Data Brief2010; 43: 1–8.
15.
MöckelMSearleJMullerR, et al. Chief complaints in medical emergencies: do they relate to underlying disease and outcome? The Charité Emergency Medicine Study (CHARITEM). Eur J Emerg Med2013; 20: 103–108.
16.
EkelundUAkbarzadehMKhoshnoodA, et al. Likelihood of acute coronary syndrome in emergency department chest pain patients varies with time of presentation. BMC Research Notes2012; 5: 420.
17.
BjørnsenLPNaess-PleymLEDaleJ, et al. Description of chest pain patients in a Norwegian emergency department. Scand Cardiovasc J2019; 53: 28–34.
18.
PopeJHAufderheideTPRuthazerR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med2000; 342: 1163–1170.
19.
ClaeysMJAhrensISinnaeveP, et al. The organization of chest pain units: position statement of the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care2017; 6: 203–211.
20.
HollanderJEThanMMuellerC. State-of-the-art evaluation of emergency department patients presenting with potential acute coronary syndromes. Circulation2016; 134: 547–564.
21.
ChangAMFischmanDLHollanderJE. Evaluation of chest pain and acute coronary syndromes. Cardiol Clin2018; 36: 1–12.
22.
ThanMCullenLAldousS, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT Trial. J Am Coll Cardiol2012; 59: 2091–2098.
23.
ThanMFlawsDSandersS, et al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas2014; 26: 34–44.
24.
FlawsDThanMScheuermeyerFX, et al. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Emerg Med J2016; 33: 618–625.
25.
ThanMPPickeringJWAldousSJ, et al. Effectiveness of EDACS versus ADAPT accelerated diagnostic pathways for chest pain: a pragmatic randomized controlled trial embedded within practice. Ann Emerg Med2016; 68: 93–102.e1.
26.
SixAJBackusBEKelderJC. Chest pain in the emergency room: value of the HEART score. Neth Heart J2008; 16: 191–196.
27.
BackusBESixAJKelderJC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol2013; 168: 2153–2158.
28.
SantiLFarinaGGramenziA, et al. The HEART score with high-sensitive troponin T at presentation: ruling out patients with chest pain in the emergency room. Intern Emerg Med2017; 12: 357–364.
29.
CarltonEWKhattabAGreavesK. Identifying patients suitable for discharge after a single-presentation high-sensitivity troponin result: a comparison of five established risk scores and two high-sensitivity assays. Ann Emerg Med2015; 66: 635–645.e1.
30.
MahlerSAHiestandBCGoffDCJ, et al. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events?Crit Pathw Cardiol2011; 10: 128–133.
31.
MahlerSARileyRFHiestandBC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes2015; 8: 195–203.
32.
de HoogVCLimSHBankIE, et al. HEART score performance in Asian and Caucasian patients presenting to the emergency department with suspected acute coronary syndrome. Eur Heart J Acute Cardiovasc Care2018, 7: 591–560.
33.
Van Den BergPBodyR. The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care2018; 7: 111–119.
34.
CarltonEWCullenLThanM, et al. A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin. Heart2015; 101: 1041–1046.
35.
O’NeillLSmithKCurrieP, et al. Nurse-led Early Triage (NET) study of chest pain patients: a long term evaluation study of a service development aimed at improving the management of patients with non-ST-elevation acute coronary syndromes. Eur J Cardiovasc Nursing2014; 13: 253–260.
36.
RocheTEGardnerGJackL. The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study. BMC Health Serv Res2017; 17: 445.
37.
CarltonEWKhattabAGreavesK. Beyond triage: the diagnostic accuracy of emergency department nursing staff risk assessment in patients with suspected acute coronary syndromes. Emerg Med J2016; 33: 99–104.
38.
LeeTHGoldmanL. Evaluation of the patient with acute chest pain. N Engl J Med2000; 342: 1187–1195.
39.
ForestRSShoferFSSeaseKL, et al. Assessment of the standardized reporting guidelines ECG classification system: the presenting ECG predicts 30-day outcomes. Ann Emerg Med2004; 44: 206–212.
40.
KontosMCRobertsBDTatumJL, et al. Mortality based on the presenting electrocardiogram in patients with myocardial infarction in the troponin era. Am J Emerg Med2009; 27: 146–152.
41.
KontosMCDiercksDBKirkJD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc2010; 85: 284–299.
42.
KnowlmanTGreensladeJHParsonageW, et al. The association of electrocardiographic abnormalities and acute coronary syndrome in emergency patients with chest pain. Acad Emerg Med2017; 24: 344–352.
43.
ThygesenKAlpertJSJaffeAS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J2019; 40: 237–269.
44.
FoxKAADabbousOHGoldbergRJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ2006; 333: 1091.
45.
ThygesenKAlpertJSWhiteHD, et al.; on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J2007; 28: 2525–2538.
46.
ThygesenKAlpertJSJaffeAS, et al. Third universal definition of myocardial infarction. Eur Heart J2012; 33: 2551–2567.
47.
MairJLindahlBHammarstenO, et al. How is cardiac troponin released from injured myocardium?Eur Heart J Acute Cardiovasc Care2018; 7: 553–560.
48.
ReichlinTHochholzerWBassettiS, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med2009; 361: 858–867.
49.
TwerenboldRBoeddinghausJNestelbergerT, et al. Clinical use of high-sensitivity cardiac troponin in patients with suspected myocardial infarction. J Am Coll Cardiol2017; 70: 996–1012.
50.
MuellerC. Biomarkers and acute coronary syndromes: an update. Eur Heart J2014; 35: 552–556.
51.
MöckelMGiannitsisEMuellerC, et al. Rule-in of acute myocardial infarction: focus on troponin. Eur Heart J Acute Cardiovasc Care2017; 6: 212–217.
52.
MuellerCGiannitsisEMöckelM, et al. Rapid rule out of acute myocardial infarction: novel biomarker-based strategies. Eur Heart J: Acute Cardiovasc Care2017; 6: 218–222.
53.
KellerTZellerTPeetzD, et al. Sensitive troponin I assay in early diagnosis of acute myocardial infarction. N Engl J Med2009; 361: 868–877.
54.
WildiKNellesBTwerenboldR, et al. Safety and efficacy of the 0 h/3 h protocol for rapid rule out of myocardial infarction. Am Heart J2016; 181: 16–25.
55.
Rubini GimenezMTwerenboldRJaegerC, et al. One-hour rule-in and rule-out of acute myocardial infarction using high-sensitivity cardiac troponin I. Am J Med2015; 128: 861–870.e4.
56.
ReichlinTTwerenboldRWildiK, et al. Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ2015; 187: E243–E252.
57.
ReichlinTSchindlerCDrexlerB, et al. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med2012; 172: 1211–1218.
58.
MuellerCGiannitsisEChristM, et al. Multicenter evaluation of a 0-hour/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T. Ann Emerg Med2016; 68: 76–87.e4.
59.
TwerenboldRNeumannJTSörensenNA, et al. Prospective validation of the 0/1-h algorithm for early diagnosis of myocardial infarction. J Am Coll Cardiol2018; 72: 620–632.
60.
BoeddinghausJTwerenboldRNestelbergerT, et al. Clinical validation of a novel high-sensitivity cardiac troponin I assay for early diagnosis of acute myocardial infarction. Clin Chem2018; 64: 1347–1360.
61.
Rubini GiménezMHoellerRReichlinT, et al. Rapid rule out of acute myocardial infarction using undetectable levels of high-sensitivity cardiac troponin. Int J Cardiol2013; 168: 3896–3901.
62.
ThelinJMelanderOÖhlinB. Early rule-out of acute coronary syndrome using undetectable levels of high sensitivity troponin T. Eur Heart J Acute Cardiovasc Care2015; 4: 403–409.
63.
BodyRMuellerCGiannitsisE, et al. The use of very low concentrations of high-sensitivity troponin T to rule out acute myocardial infarction using a single blood test. Acad Emerg Med2016; 23: 1004–1013.
64.
MokhtariALindahlBSmithJG, et al. Diagnostic accuracy of high-sensitivity cardiac troponin T at presentation combined with history and ECG for ruling out major adverse cardiac events. Ann Emerg Med2016; 68: 649–658.e3.
65.
LjungLReichardCHagermanP, et al. Sensitivity of undetectable level of high-sensitivity troponin T at presentation in a large non-ST-segment elevation myocardial infarction cohort of early presenters. Int J Cardiol2019; 284: 6–11.
66.
PickeringJWYoungJMGeorgePM, et al. Validity of a novel point-of-care troponin assay for single-test rule-out of acute myocardial infarction. JAMA Cardiol2018; 1(3): 1108–1111.
67.
MairJLindahlBMüllerC, et al. What to do when you question cardiac troponin values. Eur Heart J Acute Cardiovasc Care2018; 7: 577–586.
68.
YanATYanRTKennellyBM, et al. Relationship of ST elevation in lead aVR with angiographic findings and outcome in non-ST elevation acute coronary syndromes. Am Heart J2007; 154: 71–78.
69.
BadertscherPBoeddinghausJTwerenboldR, et al. Direct comparison of the 0/1h and 0/3h algorithms for early rule-out of acute myocardial infarction. Circulation2018; 137: 2536–2538.
70.
TwerenboldRCostabelJPNestelbergerT, et al. Outcome of applying the ESC 0/1-hour algorithm in patients with suspected myocardial infarction. J Am Coll Cardiol2019; 74: 483–494.
71.
BoeddinghausJNestelbergerTTwerenboldR, et al. Direct comparison of 4 very early rule-out strategies for acute myocardial infarction using high-sensitivity cardiac troponin I. Circulation2017; 135: 1597–1611.
72.
LancellottiPPriceSEdvardsenT, et al. The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association. Eur Heart J Acute Cardiovasc Care2015; 4: 3–5.
73.
BuengerRE. Five thousand acute care/emergency department chest radiographs: comparison of requisitions with radiographic findings. J Emerg Med1988; 6: 197–202.
74.
BudoffMJDoweDJollisJG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) Trial. J Am Coll Cardiol2008; 52: 1724–1732.
75.
MeijboomWBMeijsMFLSchuijfJD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol2008; 52: 2135–2144.
76.
GoldsteinJAChinnaiyanKMAbidovA, et al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) Trial. J Am Coll Cardiol2011; 58: 1414–1422.
77.
HoffmannUTruongQASchoenfeldDA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med2012; 367: 299–308.
78.
LittHIGatsonisCSnyderB, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med2012; 366: 1393–1403.
79.
HultenEPickettCBittencourtMS, 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 Cardiol2013; 61: 880–892.
80.
DedicALubbersMMSchaapJ, et al. Coronary CT angiography for suspected ACS in the era of high-sensitivity troponins. Randomized Multicenter Study. J Am Coll Cardiol2016; 67: 16–26.
81.
FerencikMHoffmannUBambergF, et al. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. Eur Heart J2016; 37: 2397–2405.
82.
GallagherMJRaffGL. Use of multislice CT for the evaluation of emergency room patients with chest pain: the so-called “Triple rule-out”. Catheter Cardiovasc Interv2008; 71: 92–99.
83.
BurrisACBouraJARaffGL, et al. Triple rule out versus coronary CT angiography in patients with acute chest pain. J Am Coll Cardiol Imag2015; 8: 817–825.
84.
RicciFAquilaniRRadicoF, et al. Role and importance of ultrasound lung comets in acute cardiac care. Eur Heart J Acute Cardiovasc Care2015; 4: 103–112.
85.
AmsterdamEAKirkJDBluemkeDA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation2010; 122: 1756–1776.
86.
AmsterdamEAWengerNKBrindisRG, et al. 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol2014; 64: e139–e228.
87.
SafaviKCLiS-XDharmarajanK, et al. Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes. JAMA Intern Med2014; 174: 546–553.
88.
FoyAJLiuGDavidsonWRJr, et al. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Intern Med2015; 175: 428–436.
89.
ReinhardtSWLinC-JNovakE, et al. Noninvasive cardiac testing vs clinical evaluation alone in acute chest pain: a secondary analysis of the ROMICAT-II Randomized Clinical Trial. JAMA Intern Med2018; 178: 212–219.
90.
HowellSJPrasadPVipparlaNS, et al. Usefulness of predischarge cardiac testing in low risk women and men for safe, rapid discharge from a chest pain unit. Am J Cardiol2019; 123: 1772–1775.
91.
MahlerSALenoirKMWellsBJ, et al. Safely identifying emergency department patients with acute chest pain for early discharge. Circulation2018; 138: 2456–2468.
