Chest pain
- Initial troponin ***
	- Continue to trend troponins to peak every 1-3 hrs for hsTn (3-6 hrs if conventional troponin assays)
- ECG: ***
	- If nondiagnostic, consider serial ECGs to detect potential ischemic changes including if CP recurs or clinical deterioration
- CXR to r/o other potential cardiac, pulmonary, and thoracic causes
- Optimize GDMT/anti-anginal therapy (if known CAD)
- Work-up to exclude other causes of CP

Chest Pain

Schema source

• Description of chest pain can be helpful¹
  • Anginal symptoms gradually build in intensity over a few minutes.
  • Triggers
    • physical exercise
    • emotional stress
  • Associated symptoms include dyspnea, palpitations, diaphoresis, lightheadedness, presyncope or syncope, upper abdominal pain, or heartburn unrelated to meals and nausea or vomiting ¹
  • ⚠️ Relief with nitroglycerin is not necessarily diagnostic of myocardial ischemia and should not be used as a diagnostic criterion.
  • 
• Differential diagnosis
  • Sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease (e.g., these symptoms usually occur with acute pericarditis) ¹
  • Sudden onset of ripping chest pain (with radiation to the upper or lower back) is unlikely to be anginal and is suspicious of an acute aortic syndrome (e.g., aortic dissection).¹
  • Ripping chest pain (“worse chest pain of my life”), especially when sudden in onset and occurring in a hypertensive patient, or with a known bicuspid aortic valve or aortic dilation, is suspicious of an acute aortic syndrome (e.g., aortic dissection).
  • Pain that can be localized to a very limited area and pain radiating to below the umbilicus or hip are unlikely related to myocardial ischemia.¹
  • Positional chest pain is usually nonischemic (e.g., musculoskeletal)¹
• Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents.¹
• ⚠️ Avoid the term ‘atypical chest pain’. Instead, use “cardiac,” “possible cardiac,” and “noncardiac” to describe the suspected cause of chest pain¹
• Anginal equivalents (e.g., new-onset/↑ DOE, nausea/vomiting, diaphoresis, unexplained fatigue, or syncope) may occur in those who are…
  • older (e.g., ≥75 years of age)
  • female
  • diabetes mellitus
  • renal dysfunction
  • dementia

Figure source: ²

Non-cardiac causes of chest pain

• Respiratory
  • Pulmonary Embolism
  • Pneumothorax/hemothorax
  • Pneumomediastinum
  • Pneumonia
  • Bronchitis
  • Pleural irritation
  • Malignancy
• GI
  • Cholecystitis
  • Pancreatitis
  • Hiatal hernia
  • Gastroesophageal reflux disease/gastritis/esophagitis
  • Peptic ulcer disease
  • Esophageal spasm
  • Dyspepsia
• MSK
  • Costochondritis
  • Chest wall trauma or inflammation
  • Herpes zoster (shingles)
  • Cervical radiculopathy
  • Breast disease
  • Rib fracture
  • Musculoskeletal injury/spasm
• Pain disorder
  • Panic disorder
  • Anxiety
  • Clinical depression
  • Somatization disorder
  • Hypochondria
• Other
  • Hyperventilation syndrome
  • Carbon monoxide poisoning
  • Sarcoidosis
  • Lead poisoning
  • Prolapsed intervertebral disc
  • Thoracic outlet syndrome
  • Adverse effect of certain medications (e.g., 5-fluorouracil)
  • Sickle cell crisis

Unstable angina

Class	Presentation
Rest angina	Angina occuring at rest and prolonged, usually > 20 minutes.
New-onset angina	New-onset angina of at least CCS class III severity.
Increasing angina	Previously diagnosed angina that has become distinctly more frequent, longer duration, or lower in threshold (i.e., increased by 1 or more CCS class to at least CCS class III severity)

Risk Scores for Patient Stratification

• Clinical Decision Pathways are useful to identify low risk patients for early discharge
  • Serial troponins in HEART Pathway, EDACS, ADAPT, etc
  • For example, if HEART score < 3 and normal evaluation patient may be able to be discharged and have outpatient eval.

	HEART Pathway	EDACS	ADAPT (mADAPT)	NOTR	2020 ESC/hs-cTn	2016 ESC/GRACE
Target population	Suspected ACS	Suspected ACS, CP >5 min, planned serial troponin	Suspected ACS, CP >5 min, planned observation	Suspected ACS, ECG, troponin ordered	Suspected ACS, stable	Suspected ACS, planned serial troponin
Target outcome	↑ ED discharge without increasing missed 30-d or 1-y MACE	↑ ED discharge rate without increasing missed 30-d MACE	↑ ED discharge rate without increasing missed 30-d MACE	↑ Low-risk classification without increasing missed 30-d MACE	Early detection of AMI; 30-d MACE	Early detection of AMI
Patients with primary outcome in study population, %	6–22	12	15	5–8	9.8	10–17
Troponin	cTn, hs-cTn	hs-cTn	cTn, hs-cTn	cTn, hs-cTn	hs-cTn	cTn, hs-cTn
Variables used	History ECG Age Risk factors Troponin (0, 3 h)	Age Sex Risk factors History Troponin (0, 2 h)	TIMI score 0-1 No ischemic ECG changes Troponin (0, 2 h)	Age Risk factors Previous AMI or CAD Troponin (0, 2 h)	History ECG hs-cTn (0, 1 or 2 h)	Age HR, SBP Serum Cr Cardiac arrest ECG Cardiac biomarker Killip class
![[Acute Coronary Syndromes (ACS)-20240923121531173.webp	758]]

HEART Score

• Helps determine who will benefit from hospital 🏥 admission
• Low (0-3), Medium (4-6), or High (7-10) Risk for 30-Day MACE

Cardiac Testing

Test selection should be based on patient risk and pre-test likelihood of CAD and may be influenced by site expertise and availability¹

¹ recommends using clinical decision pathways (CDPs) to categorize patients into low-, intermediate-, and high-risk.

Intermediate-risk Patients

Intermediate Risk and no known CAD

Figure source: Figure 9 of ¹

Intermediate Risk with known CAD

• High-risk CAD features include:
  • left main disease
  • proximal LAD disease
  • multivessel CAD
• Class 1 indication for invasive coronary angiography for a patient with intermediate-risk p/w acute chest pain with high-risk CAD. Figure source: Figure 10 of ¹

Selection of Stress Imaging versus CCTA

• Related:
  • Cardiac Stress Testing
  • Coronary Computed Tomography Angiography (CCTA)
  • Stress Imaging
    • Stress Echocardiography
    • Stress Cardiac MRI
    • Nuclear Stress: PET, SPECT

Footnotes

1. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Journal of the American College of Cardiology. 2021;78(22):e187-e285. doi:10.1016/j.jacc.2021.07.053 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹ ↩¹²

2. Twerenbold R, Boeddinghaus J, Nestelberger T, Wildi K, Rubini Gimenez M, Badertscher P, Mueller C. Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction. J Am Coll Cardiol. 2017 Aug 22;70(8):996-1012. doi: 10.1016/j.jacc.2017.07.718. PMID: 28818210. ↩