ACC pathway offers guidance on managing patients presenting to the ED with chest pain
The American College of Cardiology (ACC) assessed the available clinical decision pathways for chest pain and advised on the use of high-sensitivity cardiac troponin to avoid unnecessary testing in patients at low risk for acute coronary syndrome.
A new consensus pathway from the American College of Cardiology (ACC) provided guidance on the evaluation of chest pain in the ED.
The pathway came out of a 2020 roundtable organized by the ACC to discuss optimal approaches to the evaluation and management of acute chest pain in the ED, with a specific focus on the implementation of protocols using high-sensitivity cardiac troponin (hs-cTN) levels. Representatives of emergency medicine, cardiology, hospital medicine, internal medicine, and various other stakeholders were included. The resulting pathway was published by the Journal of the American College of Cardiology on Oct. 11.
The pathway is designed to parallel the usual course of assessing patients in the ED with symptoms requiring evaluation for possible acute coronary syndrome (ACS) and to facilitate rapid disposition and limit unnecessary testing among low-risk patients. Among other guidance, it provides critical appraisal of the available clinical decision pathways (CDPs) for these patients.
According to the pathway, patients ruled out based on one of the recommended hs-cTn-based CDPs can generally be discharged directly from the ED without additional testing. In contrast, patients with substantially elevated initial hs-cTn values or those who have significant dynamic changes over one to three hours are assigned to the abnormal/high-risk category and should be further classified according to the Universal Definition of Myocardial Infarction (MI) into type 1 or 2 MI or acute or chronic nonischemic cardiac injury. High-risk patients should usually be admitted, the pathway said. Patients who are intermediate risk according to a CDP should undergo repeat hs-cTn measurements at three to six hours and risk assessment with a recommended score (HEART or EDACS). Noninvasive testing should be considered for the intermediate-risk group unless low-risk features are identified or such testing has been performed recently, the pathway recommended.
“Implementation of accelerated CDPs has the potential to further reduce ED length of stay and increase the proportion of patients who are eligible for rapid ED discharge and do not routinely require additional diagnostic testing, without compromising patient safety,” but a CDP “should be viewed as a tool to augment rather than replace the clinical judgment of the care team,” the pathway notes. “A systematic approach—both at the level of the institution and the individual patient—is essential to achieve optimal outcomes for patients presenting with chest pain to the ED.”
