Skip to main content
SpringerLink
Log in

Evaluation and Management of Chest Pain and Acute Coronary Syndrome (ACS) in the Emergency Department

  • Chapter
  • First Online:
Cardiology Consult Manual

  • 1308 Accesses

Abstract

Presentations with chest pain to the emergency department are common. The differential for these patients includes a wide range of diagnoses from the benign to the life-threatening and the common to the rare, spanning across multiple different organ systems. One of the most important diagnoses for emergency practitioners to recognize and treat is acute coronary syndrome, which is both serious and relatively common. However, these presentations are not always classic or straightforward. This requires practitioners to conduct a careful evaluation and risk stratification of these patients while also considering alternative dangerous diagnoses (e.g., acute coronary syndromes, aortic dissection, or pulmonary embolism). This section strives to provide some of the key aspects of the evaluation and management of patients presenting with acute undifferentiated chest pain.

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 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
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. Hsia RY, Hale Z, Tabas JA. A national study of the prevalence of life-threatening diagnoses in patients with chest pain. JAMA Intern Med. 2016;176(7):1029–32.

    Article  PubMed  Google Scholar 

  2. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2016 update. Circulation. 2016;133(4):e38–e360.

    Article  PubMed  Google Scholar 

  3. Kumar A, Cannon CP, editors. Acute coronary syndromes: diagnosis and management, part I. In: Mayo Clinic Proceedings, Elsevier; 2009.

    Google Scholar 

  4. Eslick G, Coulshed D, Talley N. The burden of illness of non-cardiac chest pain. Aliment Pharmacol Ther. 2002;16(7):1217–23.

    Article  CAS  PubMed  Google Scholar 

  5. Han JH, Lindsell CJ, Storrow AB, Luber S, Hoekstra JW, Hollander JE, et al. The role of cardiac risk factor burden in diagnosing acute coronary syndromes in the emergency department setting. Ann Emerg Med. 2007;49(2):145–52, 152.e1.

    Article  PubMed  Google Scholar 

  6. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283(7):897–903.

    Article  CAS  PubMed  Google Scholar 

  7. Feier C. Chest Pain. The Chief Complaint. Hermosa Beach: 5150 Publishing; 2014. p. 19–30.

    Google Scholar 

  8. Hollander JE, Chase M. Evaluation of the adult with chest pain in the emergency department. In: UpToDate [Internet]. Waltham, MA: UpToDate; 2017.

    Google Scholar 

  9. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–9.

    Article  CAS  PubMed  Google Scholar 

  10. Body R, Carley S, Wibberley C, McDowell G, Ferguson J, Mackway-Jones K. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010;81(3):281–6.

    Article  PubMed  Google Scholar 

  11. Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review. JAMA. 2015;314(18):1955–65.

    Article  CAS  PubMed  Google Scholar 

  12. McGee S. Simplifying likelihood ratios. J Gen Intern Med. 2002;17(8):647–50.

    Article  PubMed Central  Google Scholar 

  13. Chandran S, Watkins J, Abdul-Aziz A, Shafat M, Calvert PA, Bowles KM, et al. Inflammatory differences in plaque erosion and rupture in patients with ST-segment elevation myocardial infarction. J Am Heart Assoc. 2017;6(5):e005868.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. N Engl J Med. 1996;334(8):481–7.

    Article  CAS  PubMed  Google Scholar 

  15. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012;60(6):766–76.

    Article  PubMed  Google Scholar 

  16. Cai Q, Mehta N, Sgarbossa EB, Pinski SL, Wagner GS, Califf RM, et al. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? Am Heart J. 2013;166(3):409–13.

    Article  PubMed  Google Scholar 

  17. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens’ syndrome. Am J Emerg Med. 2002;20(7):638–43.

    Article  PubMed  Google Scholar 

  18. Havakuk O, Rezkalla SH, Kloner RA. The Cardiovascular Effects of Cocaine. J Am Coll Cardiol. 2017;70(1):101–13.

    Article  CAS  PubMed  Google Scholar 

  19. McCord J, Jneid H, Hollander J, de Lemos J, Cercek B, Hsue P, et al., American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008;117(14):1897–907.

    Google Scholar 

  20. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(23):e179–347.

    Article  PubMed  Google Scholar 

  21. Pollack CV Jr, Sites FD, Shofer FS, Sease KL, Hollander JE. 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. 2006;13(1):13–8.

    Article  PubMed  Google Scholar 

  22. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast EG, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010;9(3):164–9.

    Article  PubMed  Google Scholar 

  24. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153–8.

    Article  CAS  PubMed  Google Scholar 

  25. Wu AH, Valdes R Jr, Apple FS, Gornet T, Stone MA, Mayfield-Stokes S, et al. Cardiac troponin-T immunoassay for diagnosis of acute myocardial infarction. Clin Chem. 1994;40(6):900–7.

    PubMed  CAS  Google Scholar 

  26. Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. Circulation. 2014:CIR 0000000000000134.

    Google Scholar 

  27. Phend C. Next Generation Troponin Test Cleared by FDA. Medpage Today [Internet]. 2017 February 12, 2017. Available from: http://www.medpagetoday.com/cardiology/myocardialinfarction/62620.

  28. deFilippi CR, Herzog CA. Interpreting cardiac biomarkers in the setting of chronic kidney disease. Clin Chem. 2017;63(1):59–65.

    Article  CAS  PubMed  Google Scholar 

  29. Raff GL, Hoffmann U, Udelson JE. Trials of Imaging Use in the Emergency Department for Acute Chest Pain. J Am Coll Cardiol Img. 2017;10(3):338–49.

    Article  Google Scholar 

  30. Arbab-Zadeh A. Stress testing and non-invasive coronary angiography in patients with suspected coronary artery disease: time for a new paradigm. Heart Int. 2012;7(1):e2.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Gibbons RJ. Chest pain triage in the ED: is CT coronary angiography the answer? J Nucl Cardiol. 2012;19(3):404–6.

    Article  PubMed  Google Scholar 

  32. Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195–203.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Mahler SA, Hiestand BC, Goff DC Jr, Hoekstra JW, Miller CD. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol. 2011;10(3):128–33.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, et al. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol. 2013;168(2):795–802.

    Article  PubMed  Google Scholar 

  35. Valadkhani S, Jalili M, Hesari E, Mirfazaelian H. Validation of the North American Chest Pain Rule in Prediction of Very Low-Risk Chest Pain; a Diagnostic Accuracy Study. Emergency. 2017;5(1):e11.

    PubMed  PubMed Central  Google Scholar 

  36. Than M, Aldous S, Lord SJ, Goodacre S, Frampton CM, Troughton R, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51–8.

    Article  PubMed  Google Scholar 

  37. Randomised Trial of Intravenous Streptokinase, Oral Aspirin, Both, or Neither Among 17,187 Cases of Suspected Acute Myocardial Infarction: ISIS-2 Lancet. 1988;332(8607):349–60.

    Google Scholar 

  38. Zeymer U. Oral antiplatelet therapy in acute coronary syndromes: recent developments. Cardiol Ther. 2013;2(1):47–56.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Kubica J, Kubica A, Jilma B, Adamski P, Hobl EL, Navarese EP, et al. Impact of morphine on antiplatelet effects of oral P2Y12 receptor inhibitors. Int J Cardiol. 2016;215:201–8.

    Article  PubMed  Google Scholar 

  40. Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143–50.

    Article  CAS  PubMed  Google Scholar 

  41. Hollander JE, Sites FD, Pollack CV, Shofer FS. Lack of utility of telemetry monitoring for identification of cardiac death and life-threatening ventricular dysrhythmias in low-risk patients with chest pain. Ann Emerg Med. 2004;43(1):71–6.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Rochester Medical Center/Emergency Medicine, Rochester, NY, USA

    Maria Finke & Dylan Norton

  2. Division of Cardiology, University of Rochester Medical Center, Rochester, NY, USA

    John Gassler

Authors
  1. Maria Finke
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dylan Norton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John Gassler
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dylan Norton .

Editor information

Editors and Affiliations

  1. School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA

    Hanna Z. Mieszczanska

  2. Division of Cardiovascular Medicine-EP section, SUNY Downstate Medical Center, Brooklyn, NY, USA

    Adam S. Budzikowski

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Finke, M., Norton, D., Gassler, J. (2018). Evaluation and Management of Chest Pain and Acute Coronary Syndrome (ACS) in the Emergency Department. In: Mieszczanska, H., Budzikowski, A. (eds) Cardiology Consult Manual. Springer, Cham. https://doi.org/10.1007/978-3-319-89725-7_2

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-89725-7_2

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-89724-0

  • Online ISBN: 978-3-319-89725-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation