Skip to main content
SpringerLink
Log in

Emergency Department Disposition of Patients Presenting with Chest Pain

  • Chapter
  • First Online:
Short Stay Management of Chest Pain

Part of the book series: Contemporary Cardiology ((CONCARD))

  • 777 Accesses

Abstract

The disposition of patients with chest pain, concerning for acute coronary syndrome, presenting to the emergency department, is a challenge for emergency physicians. The creation of chest pain observation units had added another option, other than discharge or admission, for further evaluation of patients with chest pain. The key to rapid and safe evaluation and treatment is risk stratification. Most patients can be classified into high risk, intermediate risk, and low risk. High-risk patients are usually appropriate for admission to an inpatient cardiology service. Intermediate-risk patients can be admitted either to observation unit or inpatient service, but should receive further risk stratification during their hospital visit. Low-risk patients can be sent to an observation unit and should receive stress testing within 72 hours of presentation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 169.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 219.00
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Graff LG, Dallara J, Ross MA, Joseph AJ, Itzcovitz J, Andelman RP, Emerman C, Turbiner S, Espinosa JA, and Severance H. (1997) Impact on the Care of the Emergency Department Chest Pain Patient from the Chest Pain Evaluation Registry (CHEPER) study. Am J Cardiol 80, 563–568.

    Article  PubMed  CAS  Google Scholar 

  2. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffith JL, and Selker HP. (2000) Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department. N Engl J Med 342, 1163–1170.

    Article  PubMed  CAS  Google Scholar 

  3. Chase M, Robey JL, Zogby KE, Sease KL, Shofer FS, Hollander JE. (2006) Prospective Validation of the Thrombolysis in Myocardial Infarction Risk Score in the Emergency Department Chest Pain Population. Ann Emerg Med 48, 252–259.

    Article  PubMed  Google Scholar 

  4. Pollack CV Jr, Sites FD, Shofer FS, Sease KL, Hollander JE. (2006) Application of the TIMI Risk Score for Unstable Angina and non-ST Elevation Acute Coronary Syndrome to an Unselected Emergency Department Chest Pain Population. Acad Emerg Med 13, 12–18.

    Article  Google Scholar 

  5. Jaffery Z, Hudson MP, Jacobsen G, Nowak R, McCord J. (2007) Modified Thrombolysis in Myocardial Infarction (TIMI) Risk Score to Risk Stratify Patients in the Emergency Department with Possible Acute Coronary Syndrome. J Thromb Thrombolysis 24, 137–144.

    Article  PubMed  Google Scholar 

  6. Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, Goodman SG, Granger CB, Steg PG, Gore JM, Budaj A, Avezum A, Flater MD, Fox KA; GRACE Investigators. (2004) A Validated Prediction Model for all Forms of Acute Coronary Syndrome: Estimating the Risk of 6-month Postdischarge Death in an International Registry. JAMA 291, 2727–2733.

    Google Scholar 

  7. Lyon R, Morris AC, Caesar D, Gray S, Gray A. (2007) Chest Pain Presenting to the Emergency Department—to stratify risk with GRACE or TIMI. Resuscitation 74, 90–93.

    Article  PubMed  Google Scholar 

  8. Ramsay G, Podogrodzka M, McClure C, Fox KA. (2007) Risk Prediction in Patients Presenting with Suspected Cardiac Pain: The GRACE and TIMI Risk Scores Versus Clinical Evaluation. QJM 100, 11–18.

    Article  PubMed  CAS  Google Scholar 

  9. Boersma E, Pieper KS, Steyerberg EW, Wilcox RG, Chang WC, Lee KL, Akkerhuis KM, Harrington RA, Deckers JW, Armstrong PW, Lincoff AM, Califf RM, Topol EJ, Simoons ML. (2000) Predictors of Outcome in Patients with Acute Coronary Syndromes Without Persistent ST-Segment Elevation. Results from an International Trial of 9461 Patients. The PURSUIT Investigators. Circulation 101, 2557–2567.

    CAS  Google Scholar 

  10. King SB et al. (2008) 2007 focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention, Writing on Behalf of the 2005 Writing Committee. Circulation 117, 261–295.

    Article  PubMed  Google Scholar 

  11. Antman EM et al. (2008) 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the Canadian Cardiovascular Society Endorsed by the American Academy of Family Physicians : 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 117, 296–329.

    Article  PubMed  Google Scholar 

  12. Zalenski RJ, Rydman RJ, Sloan EP, Hahn KH, Cooke D, Fagan J, Fligner DJ, Hessions W, Justis D, Kampe LM, Shah S, Tucker J, Zwicke D. (1997) Value of Posterior and Right Ventricular Leads in Comparison to the Standard 12-Lead Electrocardiogram in Evaluation of ST-Segment Elevation in Suspected Acute Myocardial Infarction. Am J Cardiol 79, 1579–1585.

    Article  PubMed  CAS  Google Scholar 

  13. Matetzky S, Freimark D, Chouraqui P, Rabinowitz B, Rath S, Kaplinsky E, Hod H. (1998) Significance of ST Segment Elevations in Posterior Chest Leads (V7–V9) in Patients with Acute Inferior Myocardial Infarction; Application for Thrombolytic Therapy. J Am Coll Cardiol 31, 506–511.

    Article  PubMed  CAS  Google Scholar 

  14. Matetzky S, Freimark D, Feinberg MS, Novikov I, Rath S, Rabinowitz B, Kaplinsky E, Hod H. (1999) Acute Myocardial Infarction with Isolated ST-Segment Elevation in Posterior Chest Leads V7–V9: “Hidden” ST-Segment Elevations Revealing Acute Posterior Infarction. J Am Coll Cardiol 34, 748–753.

    Article  PubMed  CAS  Google Scholar 

  15. Haines DE, Raabe DS, Gundel WD, Wackers FJ. (1983) Anatomic and Prognostic Significance of New T-Wave Inversion in Unstable Angina. Am J Cardiol 52, 14–18.

    Article  PubMed  CAS  Google Scholar 

  16. Renkin J, Wijns W, Ladha Z, Col J. (1990) Reversal of Segmental Hypokinesis by Coronary Angioplasty in Patients with Unstable Angina, Persistent T Wave Inversion, and Left Anterior Descending Coronary Artery Stenosis. Additional Evidence for Myocardial Stunning in Humans. Circulation 82, 913–921.

    PubMed  CAS  Google Scholar 

  17. Grines C, Patel A, Zijlstra F, Weaver WD, Granger C, Simes RJ; PCAT Collaborators. (2003) Primary Coronary Angioplasty Compared with Intravenous Thrombolytic Therapy for Acute Myocardial Infarction: Six-Month Follow UP and Analysis of Individual Patient Data from Randomized Trials. Am Heart J 145, 47–57.

    Google Scholar 

  18. Dalby M, Bouzamondo A, Lechat P, and Montalescot G. (2003) Transfer for Primary Angioplasty Versus Immediate Thrombolysis in Acute Myocardial Infarction: A Meta-Analysis. Circulation 108, 1809–1814.

    Article  PubMed  CAS  Google Scholar 

  19. Hochman JS, Sleeper LA, Webb JG, Dzavik V, Buller CE, Aylward P, Col J, White HD. (2006) Early Revascularization and Long-Term Survival in Cardiogenic Shock Complicating Acute Myocardial Infarction. JAMA 295, 2522–2525.

    Article  Google Scholar 

  20. Hochman JS, Sleeper LA, White HD, Dzavik V, Wong SC, Menon V, Webb JG, Steingart R, Picard MH, Menegus MA, Boland J, Sanborn T, Buller CE, Modur S, Forman R, Desvigne-Nickens P, Jacobs AK, Slater JN, LeJemtel TH. (2001) One-Year Survival Following Early Revascularization for Cardiogenic Shock. JAMA 285, 190–192.

    Article  PubMed  CAS  Google Scholar 

  21. Anderson JL et al. (2007) ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force of on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 116, 803–877.

    Article  Google Scholar 

  22. Pitta SR, Grzybowski M, Welch RD, Frederick PD, Wahl R, Zalenski RJ. (2005) ST-Segment Depression on the Initial Electrocardiogram in Acute Myocardial Infarction-Prognostic Significance and it’s Effect on Short-Term Mortality: A report from the National Registry of Myocardial Infarction (NRMI-2, 3, 4). Am J Cardiol 95, 843–848.

    Article  PubMed  Google Scholar 

  23. Slater DK, Hlatky MA, Mark DB, Harrell FE Jr, Pryor DB, Califf RM. (1987) Outcome in Suspected Acute Myocardial Infarction with Normal or Minimally Abnormal Admission Electrocardiographic Findings. Am J Cardiol 60, 766–770.

    Article  PubMed  CAS  Google Scholar 

  24. Rao SV, Ohman EM, Granger CB, Armstrong PW, Gibler WB, Christenson RH, Hasselblad V, Stebbins A, McNulty S, Newby LK. (2003) Prognostic Value of Isolated Troponin Elevation Across the Spectrum of Chest Pain Syndromes. Am J Cardiol 91, 936–940.

    Article  PubMed  CAS  Google Scholar 

  25. Babuin L, Vasile VC, Rio Perez JA, Alegria JR, Chai HS, Afessa B, Jaffe AS. (2008) Elevated Cardiac Troponin is an Independent Risk Factor for Short-and Long-Term Mortality in Medical Intensive Care Unit Patients. Crit Care Med 36, 759–765.

    Google Scholar 

  26. Brekke PH, Omland T, Holmedal SH, Smith P, Soyseth V. (2008) Troponin T Elevation and Long-Term Mortality After Chronic Obstructive Pulmonary Disease Exacerbation. Eur Respir J 31, 563–570.

    Article  PubMed  CAS  Google Scholar 

  27. Roe MT, Chen AY, Mehta RH, Li Y, Brindis RG, Smith SC Jr, Rumsfeld JS, Gibler WB, Ohman EM, Peterson ED. (2007) Influence of Inpatient Service Specialty on Care Processes and Outcomes for Patients with Non ST-Segment Elevation Acute Coronary Syndromes. Circulation 116, 1153–1161.

    Article  PubMed  Google Scholar 

  28. Chan MY, Becker RC, Harrington RA, Peterson ED, Armstrong PW, White H, Fox KA, Ohman EM, Roe MT. (2008) Noninvasive, Medical Management for Non-ST-Elevation Acute Coronary Syndromes. Am Heart J 155, 397–407.

    Article  PubMed  Google Scholar 

  29. Zia MI, Goodman SG, Peterson ED, Mulgund J, Chen AY, Langer A, Tan M, Ohman EM, Gibler WB, Pollack CV Jr, Roe MT. (2007) Paradoxical Use of Invasive Cardiac Procedures for Patients with Non-ST Segment Elevation Myocardial Infarction: An International Perspective from the CRUSADE Initiative and the Canadian ACS Registries I and II. Can J Cardiol 23, 1073–1079.

    PubMed  Google Scholar 

  30. Cannon CP, McCabe CH, Stone PH, Rogers WJ, Schactman M, Thompson BW, Pearce DJ, Diver DJ, Kells C, Feldman T, Williams M, Gibson RS, Kronenberg MW, Ganz LI, Anderson HV, Braunwald E. (1997) The Electrocardiogram Predicts One-Year Outcome of Patients with Unstable Angina and Non-Q Wave Myocardial Infarction: Results of the TIMI Registry ECG Ancillary Study. J Am Coll Cardiol 30, 133–140.

    Article  PubMed  CAS  Google Scholar 

  31. Goodacre S, Nicholl J, Dixon S, Cross E, Angelini K, Arnold J, Revill S, Locker T, Capewell S, Quinney D, Campbess S, Morris F. (2004) Randomized Controlled Trial and Economic Evaluation of a Chest Pain Observation Unit Compared with Routine Care. BMJ 328, 254.

    Article  PubMed  Google Scholar 

  32. Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow L, Das K, Kampe LM, Dickover B, McDermott MF, Hart A, Straus HE, Murphy DG, Rao R. (1997) Costs of an Emergency Department-Based Accelerated Diagnostic Protocol vs Hospitalization in Patients with Chest Pain: A randomized Controlled Trial. JAMA 278, 1701–1702.

    Article  Google Scholar 

  33. Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, Kopecky SL, Allen M, Allison TG, Gibbons RJ, Gabriel SE, for the Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. (1998) A Clinical Trial of A Chest-Pain Observation Unit for patients with Unstable Angina. N Engl J Med 339, 1882–1888.

    Article  PubMed  CAS  Google Scholar 

  34. Aroney CN, Dunlevie HL, Bett JHN. (2003) Use of an Accelerated Chest Pain Assessment Protocol in Patients at Intermediate Risk of Adverse Cardiac Events. MJA 178, 370–374.

    PubMed  Google Scholar 

  35. Steele R, McNaughton T, McConahy M, Lam J. (2006) Chest Pain in Emergency Department Patients: If the Pain is Relieved by Nitroglycerin, is it More Likely to be Cardiac Chest Pain? CJEM 8, 164–169.

    PubMed  Google Scholar 

  36. Swap CJ, Nagurney JT. (2005) Value and Limitations of Chest Pain History in the Evaluation of Patients with Suspected Acute Coronary Syndromes. JAMA 294, 2623–2629.

    Article  PubMed  CAS  Google Scholar 

  37. Chan GW, Sites FD, Shofer FS, Hollander JE. (2003) Impact of Stress Testing on 30-Day Cardiovascular Outcomes for Low-Risk Patients with Chest Pain Admitted to Floor Telemetry Beds. Am J Emerg Med 21, 282–287.

    Article  PubMed  Google Scholar 

  38. Meyer MC, Mooney RP, Sekera AK. (2006) A Critical Pathway for Patients with Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 47, 435.e1–e3.

    PubMed  Google Scholar 

  39. Amsterdam EA, Kirk JD, Diercks DB, Turnipseed SD, Lewis WR. (2004) Early Exercise Testing for Risk Stratification of Low-Risk Patients in Chest Pain Centers. Crit Pathw Cardiol 3, 114–120.

    PubMed  Google Scholar 

  40. Richards D, Meshkat N, Chu J, Eva K, Worster A. (2007) Emergency Department Compliance with Follow-Up for Outpatient Exercise Stress Testing: A Randomized Controlled Trial. CJEM 9, 435–440.

    PubMed  Google Scholar 

  41. Davis C, VanRiper S, Longstreet J, Moscucci M. (1997) Vascular Complications of Coronary Interventions. Heart Lung 26, 118–127.

    Article  PubMed  CAS  Google Scholar 

  42. Hollander JE, Robey JL, Chase MR, Brown AM, Zogby KE, Shofer FS. (2007) Relationship Between a Clear-Cut Alternative Noncardiac diagnosis and 30-Day Outcome in Emergency Department Patients with Chest Pain. Acad Emerg Med 14, 210–215.

    Article  PubMed  Google Scholar 

  43. Miller CD, Lindsell CJ, Khandelwal S, Chandra A, Pollack CV, Tiffany BR, Hollander JE, Gibler WB, Hoekstra JW. (2004) Is the Initial Diagnostic Impression of “Noncardiac Chest Pain” Adequate to Exclude Cardiac Disease? Ann Emerg Med 44, 565–574.

    Article  PubMed  Google Scholar 

  44. Hess EP, Wells GA, Jaffe A, Stiell IG. (2008) A Study to Derive a Clinical Decision Rule for Triage of Emergency Department Patients with Chest Pain: Design and Methodology. BMC 8.

    Google Scholar 

  45. Giannoglou GD, Antoniadis AP, Chatzizisis YS, Damvopoulou E, Parcharidis GE, Louridas GE. (2008) Sex-Related Differences in the Angiographic Results of 14,500 Cases Referred for Suspected Coronary Artery Disease. Coron Artery Dis 19, 9–14.

    Article  PubMed  Google Scholar 

  46. Patel H, Rosengren A, Ekman I. (2004) Symptoms in Acute Coronary Syndromes: Does Sex Make a Difference? Am Heart J. 148, 27–33.

    Article  PubMed  Google Scholar 

  47. DeVon HA, Ryan CJ, Ochs AL, Shapiro M. (2008) Symptoms Across the Continuum of Acute Coronary Syndromes: Differences Between Women and Men. Am J Crit Care 17, 14–24.

    PubMed  Google Scholar 

  48. Kaul P, Chang WC, Westerhout CM, Graham MM, Armstrong PW. (2007) Differences in Admission Rates and Outcomes Between Men and Women Presenting to Emergency Departments with Coronary Syndromes. CMAJ 177, 1193–1199.

    Article  PubMed  Google Scholar 

  49. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SI, Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiolol 2002 Jul 17; 40(2): 251–256.

    Article  Google Scholar 

  50. Fava S, Azzopardi J, Agius-Muscat H. (1997) Outcome of Unstable Angina in Patients with Diabetes Mellitus. Diabet Med 14, 209–213.

    Article  PubMed  CAS  Google Scholar 

  51. Pitsavos C, Kourlaba G, Panagiotakos DB, Stefanadis C. (2007) Characteristics and In-Hospital Mortality of Diabetics and Nondiabetics with Acute Coronary Syndrome; the GREECS Study. Clin Cardiol 30, 239–244.

    Article  PubMed  Google Scholar 

  52. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, Vand de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman M. (2007) Acute Coronary Care in the Elderly, Part I: Non-ST-Segment-Elevation Acute Coronary Syndromes: A Scientific Statement for Healthcare Professionals From the American Heart Association Council on Clinical Cardiology: In Collaboration With the Society of Geriatric Cardiology. Circulation 115, 2549–2569.

    Article  PubMed  Google Scholar 

  53. Avezum A, Makdisse M, Spencer F, Gore JM, Fox KA, Montalescot G, Eagle KA, White K, Mehta RH, Knobel E, Collet JP; GRACE Investigators. (2005) Impact of Age on Management and Outcome of Acute Coronary Syndrome: Observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J 149, 67–73.

    Google Scholar 

  54. Devlin G, Gore JM, Elliott J, Wijesinghe N, Eagle KA, Avezum A, Huang W, Brieger D; for the GRACE Investigators. (2008) Management and 6-Month Outcomes in Elderly and Very Elderly Patients with High-Risk Non-ST-Elevation Acute Coronary Syndromes: The Global Registry of Acute Coronary Events. Eur Heart J. April 2 (Epub-accessed April 8, 2008).

    Google Scholar 

  55. Weber JE, Shofer FS, Larkin GL, Kalaria AS, Hollander JE. (2003) Validation of a Brief Observation Period for Patients with Cocaine-Associated Chest Pain. N Engl J Med 348, 510–517.

    Article  PubMed  Google Scholar 

  56. Turnipseed SD, Richards JR, Kirk JD, Diercks DB, Amsterdam EA. (2003) Frequency of Acute Coronary Syndrome in Patients Presenting to the Emergency Department with Chest Pain After Methamphetamine Use. J Emerg Med 24, 369–373.

    Article  PubMed  Google Scholar 

  57. Diercks DB, Kirk JD, Turnipseed SD, Amsterdam EA. (2007) Evaluation of Patients with Methamphetamine-and Cocaine-Related Chest Pain in a Chest Pain Observation Unit. Crit Pathw Cardiol 6, 161–164.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, University of California, Davis Medical Center, Sacramento, CA, USA

    MD Kelly Owen

  2. Department of Emergency Medicine, University of California, Davis Medical Center, 2315 Stockton Boulevard, PSSB 2100, Sacramento, CA 95661, USA

    Deborah B. Diercks

Authors
  1. MD Kelly Owen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deborah B. Diercks
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Deborah B. Diercks .

Editor information

Editors and Affiliations

    Rights and permissions

    Reprints and permissions

    Copyright information

    © 2009 Humana Press, a part of Springer Science+Business Media, LLC

    About this chapter

    Cite this chapter

    Owen, K., Diercks, D.B. (2009). Emergency Department Disposition of Patients Presenting with Chest Pain. In: Cannon, C., Peacock, W. (eds) Short Stay Management of Chest Pain. Contemporary Cardiology. Humana Press. https://doi.org/10.1007/978-1-60327-948-2_9

    Download citation

    • DOI: https://doi.org/10.1007/978-1-60327-948-2_9

    • Published:

    • Publisher Name: Humana Press

    • Print ISBN: 978-1-60327-947-5

    • Online ISBN: 978-1-60327-948-2

    • eBook Packages: MedicineMedicine (R0)

    Publish with us

    Policies and ethics

    Search

    Navigation