Figure 6
Management of chest pain within the emergency department. TTE: transthoracic echocardiography. *If chest pain onset is more than 3 hours.
Source publication
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 synd...
Contexts in source publication
Context 1
... In the HEART pathway implementation trial, patients with a HEART score of 3 or less in whom an ACS was excluded by serial troponin testing could be safely discharged without further testing. 91 Based on these studies it is proposed to limit pre-discharge exercise testing and cardiac imaging to patients with a HEART score greater than 3 ( Figure 6). ...
Context 2
... the new hs-cTn-based diagnostic algorithms obviate the use of clinical risk stratification scores, it is proposed to add a HEART score of 3 or less as an additional criterion for the decision on early discharge as this score predicts a very low MACE risk during early follow-up. The small group of patients in whom the diagnosis is unclear should remain in the ED, CPU or observation units until further ECG monitoring, repeated hs-cTn measurement, bedside echocardiography and additional CCTA or ischaemia testing allows us to clarify the diagnosis ( Figure 6). ...
Similar publications
Background
The ideal high-sensitivity troponin (hsTn) cutoff for identifying those at low risk of 30 days events is debated; however, the 99th percentile overall or gender-specific upper reference limit (URL) is most commonly used. The magnitude of risk and the best management strategy for those with low-level hsTn elevation hasn’t been extensively...
Citations
... The use of chest pain assessment tools, such as the PQRST (precipitating or palliative factors, quality, region or radiation, severity, timing), is recommended to gather information about the patient's pain and to help facilitate an effective management plan (Kucia and Jones 2022). Of patients admitted to hospital with chest pain, around 25% will be diagnosed with an acute coronary syndrome, which is associated with a twofold increase in 30-day mortality if undetected (Stepinska et al 2020). Acute coronary syndrome is an umbrella term that encompasses unstable angina, non-ST elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) (Malecki-Ketchell 2022). ...
... For instance, the NEWS2 in patients with cardiovascular diseases is suboptimal to predict deterioration early [9]. 1 2 1 1 The mortality risks and need for hospital admission associated with the initial presenting complaint in a standardised national data set have not been previously reported. Chest pain might sound dangerous to an external observer due to concerns about the possibility of myocardial infarction, though many emergency physicians will recognise that there are a lot of people with chest pain whose risk of death is very low [10]. Likewise, generalised weakness is a nonspecific symptom that may be encountered in a large number of medical and psychiatric disorders [11] which anecdotally may be associated with a higher risk of death and hospital admission. ...
Background: Early identification of patients at higher risk of death and hospital admission is an important problem in Emergency Departments (ED). Most triage scales were developed before current electronic healthcare records were developed. The implementation of a national Emergency Care Data Set (ECDS) allows for the standardised recording of presenting complaints and the use of Electronic Patient Records (EPR) offers the potential for automated triage. The mortality risk and need for hospital admission associated with the different presenting complaints in a standardised national data set has not been previously reported. This study aimed to quantify the risks of death and hospitalisation from presenting complaints. This would be valuable in developing automated triage tools and decision support software.
Methods: We conducted an observational retrospective cohort study on patients who visited a single ED in 2021. The presenting complaints related to subsequent attendances were excluded. This patient list was then manually matched with a routinely collected list of deaths. All deaths that occurred within 30 days of attendance were included.
Results: Data was collected from 84,999 patients, of which 1,159 people died within 30 days of attendance. The mortality rate was the highest in cardiac arrest [32 (78.1%)], cardiac arrest due to trauma [2(50%)] and respiratory arrest [3(50%)]. Drowsy [17(12%)], hypothermia [3(13%)] and cyanosis [1(10%)] were also high-risk categories. Chest pain [34(0.6%)] was not a high-risk presenting complaint.
Conclusion: The initial presenting complaint in ECDS may be useful to identify people at higher and lower risk of death. This information is useful for building automated triage models.
... Chest pain can be caused by a wide range of diseases from life-threatening conditions such as acute coronary syndrome (ACS), aortic dissection, pulmonary embolism or pericardial effusion, to more benign and harmless entities [4,5], making it a diagnostic challenge for emergency physicians. Ultimately, only 5.1% of all chest pain visits are diagnosed with acute coronary syndrome [5], but a missed diagnosis can be clinically devastating with high impact on morbidity and mortality [6,7]. ...
Background
Chest pain is responsible for millions of visits to the emergency department (ED) annually. Cardiac ultrasound can detect ischemic changes, but varying accuracy estimates have been reported in previous studies. We synthetized the available evidence to yield more precise estimates of the accuracy of cardiac ultrasound for acute myocardial ischemia in patients with chest pain in the ED and to assess the effect of different clinical characteristics on test accuracy.
Methods
A systematic search for studies assessing the diagnostic accuracy of cardiac ultrasound for myocardial ischemia in the ED was conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Web of Science, two trial registries and supplementary methods, from inception to December 6th, 2022. Prospective cohort, cross-sectional, case–control studies and randomized controlled trials (RCTs) that included data on diagnostic accuracy were included. Risk of bias was assessed with the QUADAS-2 tool and a bivariate hierarchical model was used for meta-analysis with paired Forest and SROC plots used to present the results. Subgroup analyses was conducted on clinically relevant factors.
Results
Twenty-nine studies were included, with 5043 patients. The overall summary sensitivity was 79.3% (95%CI 69.0–86.8%) and specificity was 87.3% (95%CI 79.9–92.2%), with substantial heterogeneity. Subgroup analyses showed increased sensitivity in studies where ultrasound was conducted at ED admission and increased specificity in studies that excluded patients with previous heart disease, when the target condition was acute coronary syndrome, or when final chart review was used as the reference standard. There was very low certainty in the results based on serious risk of bias and indirectness in most studies.
Conclusions
Cardiac ultrasound may have a potential role in the diagnostic pathway of myocardial ischemia in the ED; however, a pooled accuracy must be interpreted cautiously given substantial heterogeneity and that important patient and test characteristics affect its diagnostic performance.
Protocol Registration : PROSPERO (CRD42023392058).
... The second phase entails the standard diagnostic procedures that are required for any patient experiencing chest pain, including an electrocardiogram (ECG), a chest X-ray and laboratory testing for biomarkers [14,20]. This is a crucial step in the diagnostic procedure that allows differentiation between the two most common serious illnesses that cause chest pain: pulmonary embolism and acute coronary syndrome (ACS). ...
... This is a crucial step in the diagnostic procedure that allows differentiation between the two most common serious illnesses that cause chest pain: pulmonary embolism and acute coronary syndrome (ACS). ACS can be diagnosed with great sensitivity when troponin levels and ECG are combined [20]. Chest pain originating from the heart, such as in myocardial infarction, can be distinguished with an ECG. ...
This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an “aorta code”. Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in “aortic centres” improves long-term outcomes and decreases mortality rates.
... 21 Angina-like pain due to right ventricular ischemia may also be observed in patients with central pulmonary artery occlusion. 22 Therefore, in patients presenting with chest pain, in addition to cardiovascular diseases such as acute coronary syndrome and aortic dissection, APE should also be considered in the differential diagnosis. ...
Objective The aim of this study was to evaluate the relationship between symptoms and short-term mortality in geriatric patients presenting to the emergency department with acute pulmonary embolism.
Materials and Methods This retrospective cohort study was conducted to evaluate the data of geriatric patients admitted to the emergency department between September 01, 2022, and March 01, 2023. The study population comprised patients who presented with acute pulmonary embolism signs and symptoms. Demographic data, vital parameters, and symptoms were noted.
Results Of the 176 patients included in the final analysis, 55 (31.2%) were female. The median of age was 76 (25th–75th percentile: 72–82.5) years. The most common symptoms were dyspnea (61.9%), fatigue (27.2%), and syncope (23.8%). There was no statistically significant difference between the survivor and nonsurvivor groups in terms of symptoms (p-values for dyspnea, syncope, chest pain, back pain, hemoptysis, extremity pain, and fatigue: 0.804, 0.765, 0.154, 0.543, 0.675, 0.342, and 0.943, respectively) (chi-squared test).
Conclusion In patients presenting to the emergency department with acute pulmonary embolism, clinicians should not prioritize based on symptoms but should evaluate patients according to clinical severity scores.
... Although chest pain accounts for approximately 10% of noninjury-related visits to the emergency department, less than half of these patients receive a definite diagnosis of cardiac chest pain. [1] The rest are usually discharged without a definitive diagnosis, and their pain is labeled as noncardiac chest pain (NCCP). [2] The prevalence of NCCP may reach 70%. ...
Objectives
This study aimed to compare the effects of trigger point injections and stretching exercises in patients with noncardiac chest pain (NCCP) associated with myofascial pain syndrome.
Patients and methods
This prospective randomized controlled trial included 50 patients with noncardiac chest pain and trigger points in the pectoralis muscles between October 2019 and June 2020. The patients were randomly assigned to receive trigger point injections into the pectoralis muscles and exercise (n=25; 15 males, 10 females; mean age: 42.8±9.2 years; range, 25 to 57 years) or only perform exercise (n=25; 11 males, 14 females; mean age: 41.8±11.2 years; range, 18 to 60 years). The primary outcome was pain intensity at the first month and three months after the first treatment session, measured using the Visual Analog Scale from 0 to 100. The secondary outcome was the Nottingham Health Profile score.
Results
Treatment with stretching exercises and trigger point injection resulted in significant pain reduction compared to stretching exercises alone, and the reduction was persistent at the three-month follow-up (p<0.001). A between-group comparison showed no significant difference in the Nottingham Health Profile (p=0.522). Complications related to the procedure or severe adverse events attributable to treatment were not reported.
Conclusion
Trigger point injection combined with stretching exercises is an efficient treatment for noncardiac chest pain related to myofascial pain syndrome compared to exercise treatment alone.
... Since the US Food and Drug Administration (FDA) approved the use of hs-cTn assays in 2017, the integration of high-sensitivity troponin assays into clinical decision-making algorithms has been variable, and very institution-specific [39]. Differences in how these assays are used by providers and institutions can be based upon a variety of factors, including differences in the triage process, when ECGs are obtained, how clinical decision scores for chest pain are used, and whether providers are comfortable with the level of evidence suggesting the ability of hs-cTn assays to rule out AMI with a single blood draw [11,40,41]. Whether a rule-out can be achieved upon presentation, 1 h, 2 h, or 3 h after initial presentation is still commonly debated within hospital systems [11]. ...
Purpose of Review
This paper will review the published literature on the implementation of high-sensitivity troponin in the diagnosis and treatment of myocardial infarction, with a special focus on accelerated diagnostic protocols used in the emergency department and other acute care settings.
Recent Findings
Since the FDA approval of high-sensitivity troponin assays in 2017, US healthcare systems have begun creating accelerated diagnostic protocols for emergency departments. Standardization of the assay can improve patient outcomes and the efficiency of emergency rooms nationwide.
Summary
This paper summarizes the historical use of the standard troponin assay and the significance of the high-sensitivity troponin assay as used in acute care settings. Implementation of the high-sensitivity troponin is discussed, demonstrating common assays used, clinical considerations, and previously reported accelerated diagnostic pathways. These aspects are aligned with current guidelines in the use of high-sensitivity troponin to emphasize the need for standardization of use within the US healthcare system.
... We are perhaps most comfortable using troponin testing in ischemic conditions such as acute myocardial infarction, but there remain many acute or chronic conditions in which detectable levels of cardiac troponins are present, though its interpretation is less clear. In aortic stenosis, hypertrophic cardiomyopathy, longstanding hypertension/hypertensive emergencies, acute aortic syndromes, and acute heart failure, we suspect that detectable troponin is a harbinger of risk [1]. Other conditions than myocardial infarction that are associated with elevated cardiac troponins include tachyarrhythmias, cardiac trauma, cardiac procedures (percutaneous coronary intervention, coronary artery bypass grafting, cardioversion, and endomyocardial biopsy), critical illness, sepsis, burns, Takotsubo syndrome (stress cardiomyopathy), coronary artery spasm, myocarditis (also related to COVID-19 or its vaccines) [2], pulmonary embolism, renal failure, rhabdomyolysis, endurance exercise, acute cerebrovascular accidents, and hypo-and hyperthyroidism [1]. ...
... In aortic stenosis, hypertrophic cardiomyopathy, longstanding hypertension/hypertensive emergencies, acute aortic syndromes, and acute heart failure, we suspect that detectable troponin is a harbinger of risk [1]. Other conditions than myocardial infarction that are associated with elevated cardiac troponins include tachyarrhythmias, cardiac trauma, cardiac procedures (percutaneous coronary intervention, coronary artery bypass grafting, cardioversion, and endomyocardial biopsy), critical illness, sepsis, burns, Takotsubo syndrome (stress cardiomyopathy), coronary artery spasm, myocarditis (also related to COVID-19 or its vaccines) [2], pulmonary embolism, renal failure, rhabdomyolysis, endurance exercise, acute cerebrovascular accidents, and hypo-and hyperthyroidism [1]. It has been postulated to be a sign of severe ventricular remodeling or very elevated left ventricular filling pressures to the point of microvascular ischemia and cardiomyocyte injury. ...
... The elements and weights of HEAR score can be found in Figure 2. Calculations of HEART and EDACS scores and procedures of 0 h/1 h hs-cTnT algorithm, HEART pathway, and EDACS-ADP have been previously described [20,21] and are also given in Table 1 and Supplemental Materials. ...
... The elements and weights of HEAR score can be found in Figure 2. Calculations of HEART and EDACS scores and procedures of 0 h/1 h hs-cTnT algorithm, HEART pathway, and EDACS-ADP have been previously described [20,21] and are also given in Table 1 and Supplemental Materials. HEART consists of five elements: history, ECG, age, risk factors, and troponin; each item is given a score of 0 to 2, yielding a total score of 0 to 10. ...
... Patients with a history of coronary artery disease (CAD), AMI, PCI, or CABG accounted for 24.7%, 5.4%, 14.0%, and 0.5%, respectively. As for clinical risk assessment, NSTEMI patients showed remarkably higher HEAR, HEART, and EDACS scores with a median HEAR of Diagnostics 2023, 13, 3217 6 of 14 5 (IQR: 4-7), a median HEART of 7 (IQR: [6][7][8], and a median EDACS of 18 (IQR: [14][15][16][17][18][19][20][21]. Initial 0 h hs-cTnT level was significantly higher in NSTEMI patients (119 [47-354] vs. 11 [7][8][9][10][11][12][13][14][15][16], p < 0.001) and rose in accordance with HEAR scores (r = 0.345, p < 0.001) ( Figure 3A). ...
The study aims to develop a decision pathway based on HEAR score and 0 h high-sensitivity cardiac troponin T (hs-cTnT) to safely avoid a second troponin test for suspected non-ST elevation myocardial infarction (NSTEMI) in emergency departments. A HEAR score consists of history, electrocardiogram, age, and risk factors. A HEAR pathway is established using a Bayesian approach based on a predefined safety threshold of NSTEMI prevalence in the rule-out group. In total, 7131 patients were retrospectively enrolled, 582 (8.2%) with index visit NSTEMI and 940 (13.2%) with 180-day major adverse cardiovascular events (MACE). For patients with a low-risk HEAR score (0 to 2) and low 0 h hs-cTnT (<14 ng/L), the HEAR pathway recommends early discharge without further testing. After the HEAR pathway had been applied to rule out NSTEMI, the negative predictive value of index visit NSTEMI was 100.0% (95% CI, 99.8% to 100.0%) and false-negative rate of 180-day MACE was 0.40% (95% CI, 0.18% to 0.87%). Compared with the 0 h hs-cTnT < limit of detection (LoD) strategy (<5 ng/L), the HEAR pathway could correctly reclassify 1298 patients without MACE as low risk and lead to a 18.2% decrease (95% CI, 17.4–19.1%) in the need for a second troponin test. The HEAR pathway may lead to a substantial and safe reduction in repeated troponin test for emergency department patients with suspected NSTEMI.
... The The current study showed that although not at a stasti- (20). According to the results of a questionnaire related to chest pain applied to 1029 emergency medicine physicians, cardiac pain was seen to be overlooked at the rate of 1% because of the focus on major cardiac events (21). ...
Objective: Chest pain is one of the potential symptoms of acute coronary syndrome and is the second most common emergency worldwide. Acute coronary syndrome tends to be seen in patients aged
