Suspected Cardiac Chest Pain Guideline for patients presenting to ED

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					Suspected Cardiac Chest Pain Guideline for patients presenting to ED
September 2, 2011

Why updated?
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
situation presented.

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
for Acute
High Risk if   Increased risk of death:       HBS consult at clinical
Yes to any                                    discretion
  Y     N       Transient ST-segment
                  changes, and/or
  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
                  cardiac ischemia
                  (BP<100mmHg), significant
                  bradycardia, significant
                  tachycardia, and/or
  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
                 ischemia, and/or
 Y    N         Known angina with changes
                 in symptoms.
            Intermediate Patient Characteristics           Dispositions
            Risk if
            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
                                                              ECG abnormalities
                            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
                                                                       Negative stress
                                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
of patients.
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
                                                         follow-up. Cardiology
                                                         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
                                                         allocated, then
                                                         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
                                                         ECG abnormalities
                                                         (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
                     (suggesting pulmonary
                     disease), or
                  o pain which is associated with
                     motion of the rib cage
                     (suggesting chest wall pain).

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