Suspected Cardiac Chest Pain Guideline for patients presenting to ED
September 2, 2011
These guidelines have been updated from 2007 because we found that there were
intermediate patients that colleagues felt safe to discharge with stress test within 72
hours, but which the guideline suggested should have a negative stress test prior to
discharge. The new guideline draws a greater distinction between symptoms of classic
angina and chest pain symptoms indicative of other issues.
Classic Angina symptoms:
Location is anterior, radiating to the jaw or left arm.
Quality is dull, squeezing, or burning.
Duration is at least 5 minutes.
Associated symptoms include shortness of breath, nausea, and diaphoresis.
Symptoms worsen with exertion and improve with rest.
Chest pain symptoms indicative of other issues:
association of pain with eating or drinking, or
recumbent position (suggesting GERD), or
pain which is pleuritic (suggesting pulmonary disease), or
pain which is associated with motion of the rib cage (suggesting chest wall pain).
Intermediate patients requiring stress test before discharge from ED are suggested only
for patients with classic angina together with other risk characteristics.
The discussion about the revision has revealed some valuable insights:
1. The guidelines are clear for pts with typical angina and risk factors, and clear for
pts with chest pain (i.e. atypical angina) and without risk factors. The
recommendations are less clear for angina but without risk factors, or chest pain
and risk factors. This revision identifies this issue and suggests that clinical
judgment will inform whether patients are intermediate or low risk.
2. There are well-documented groups of patients who do not present with classic
angina symptoms, including women and diabetics. We have not attempted to
identify guidelines specific to each of these groups, but will rely on clinical
judgment to inform risk stratification of these patients
3. The reliability of a next day stress test is important to the decision to send a patient
home. In general the goal is for patients to leave the ED with a stress test
appointment for the next day. The Chiefs of Cardiology will pursue this. Similarly
our goal should be to provide the same service for patients needing nuclear
medicine testing. The Chiefs of Nuclear Medicine will pursue this.
These guidelines and statements are not intended to establish a protocol for all patients
with a particular condition. While the guidelines provide one approach to evaluating a
problem, clinical conditions may vary significantly from individual to individual. Therefore,
the clinician must exercise independent judgment and make decisions based upon the
Progress in the sensitivity of cardiac markers suggests that a single marker, 6 hours after
the onset of suspect symptoms, is appropriate. An acceptable alternative for some
patients (poor historian, suspicion high, etc), which may be considered by the attending
physician, is to draw two troponins: one on arrival and another one either 2 hours later or
6 hours after onset of symptoms (whichever one is later). Troponins obtained after 6 hours
can be obtained based upon a higher index of suspicion. Serial ECG may be
considered if there is return of Chest Pain while patient is in ED.
Stratification Patient Characteristics Disposition
High Risk if Increased risk of death: HBS consult at clinical
Yes to any discretion
Y N Transient ST-segment
Y N New (or presumed new) T-
wave inversions strongly
suggestive of critical LAD
lesion if anterior, and/or
Y N Pulmonary edema, new S3,
new MR murmur, or
hypotension with signs of
Y N New (or presumed new) LBBB,
Y N Sustained VT and/or
Y N Elevated Troponin at 6 hours
after onset of chest pain
High likelihood of CAD:
Accelerating tempo of ischemic
pain or other symptoms in the
past 48 hrs or symptoms
consistent with their angina,
Y N Prolonged (>20 min) chest
pain typical for myocardial
Y N Known angina with changes
Intermediate Patient Characteristics Dispositions
Yes to all
Y N Normal Troponin at 6 hours Stress test prior to
after onset of chest pain, and discharge from
Patient does not have high ED/CPU/HOO.
Y N risk characteristics, and [Consider nuc med if
Patient presents with clear inappropriate for stress
Y N symptoms of typical angina test due to physical
(use these as prompts as disability or baseline
individualizing this to a
(LBBB, LVH w/strain,
particular patient relies on
Afib, paced rhythm.
clinical judgment) Ensure the patient is
Location is anterior, NPO and the
radiating to the jaw or left appropriate
medications are held.
Quality is dull, squeezing, or
Duration is at least 5 minutes. test/Nuc med:
Associated symptoms Discharge home;
include shortness of breath, consider referral to
nausea, and diaphoresis. PCP. Consider HBS
Symptoms worsen with consult if stress test
exertion and improve with result appears
rest. inconsistent with
and any of the following significant risk factors,
CAD risk factors: history and
o Diabetes presentation.
o History of prior MI, Positive/Equivocal
Y N CABG, PTCA etc
stress test: consult
o Known other
with HBS or
disease elsewhere Cardiologist in
than CAD ED/CPU/HOO
o ≥ 2 other CAD risk
factors: HTN, +FH,
smoking, age (>65 for
men, >70 for women)
If there are no CAD risk factors, but
the symptomatic presentation
shows classic angina, then the pt
still qualifies as Intermediate.
There are well-documented groups of patients (eg women and diabetics) who do not present with
“typical” angina/chest pain symptoms. Some patients with other cardiac risk factors may also
present with atypical chest pain. Clinical judgment should supersede this guideline for these types
Low Risk if Patient Characteristics Dispositions
Yes to all Discharge Home with
Y N Chest pain not consistent with eConsult for stress test
classic angina, eg booked for 1-3 days (or
Y N Normal Troponin at 6 hours stress test prior to
discharge if slots are
after onset of chest pain.
available) and PCP
Y N Unremarkable cardiac exam
has dedicated slots for
Y N Normal ECG ED/CPU/HOO eConsults
for stress test, so that pts
can leave ED with
specific appointment. If
these slots have been
Cardiology will ensure
that all patients referred
by ED are given a stress
test appointment to be
seen in 1-3 days. [If
inappropriate for stress
test due to physical
disability or baseline
(LBBB, LVH w/strain, Afib,
paced rhythm), consider
nuclear medicine scan.
Ensure the patient is
NPO and the
medications are held.]
HBS consult at clinical
Excluded Patient history suggests non- Consider referral to PCP
cardiac, including: for follow-up. If CAD still a
o association of pain with consideration, consider
eating or drinking, or an outpatient stress test.
o recumbent position
(suggesting GERD), or
o pain which is pleuritic
o pain which is associated with
motion of the rib cage
(suggesting chest wall pain).