Chest Pain Assessment in the ED

Resources
DDx
Serious/do not miss
Acute coronary syndrome (ACS)
Aortic dissection
Pulmonary embolus
 
Common
Pneumothorax
Pmeumonia
Pericarditis
Abdominal- oesophagitis, cholecsystitis
 
Unusual
Oesophageal rupture
 
Assessment
 
History- is very important in assessing chest pain, and is helpful in risk stratification of patients. RIsk stratification plays an important role in determining disposition of the patient.
 
High risk:
  • Repetitive or prolonged chest pain (>10 mins)
  • Elevated troponin
  • ECG changes
  • Haemodynamic compromise with SBP< 90, cool peripheries
  • Kilip class 1> heart failure
  • New onset mitral regurgitation
  • Ventricular tachycardia
  • Syncope
  • LVEF < 40%
  • PCI in the last 6 months
  • Diabetes and chronic renal failure eGFR < 60 ml/min with typical ACS symptoms

Intermediate risk
  • chest pain in last 48 hours that occurred at rest or was repetitive or prolonged, but now resolved
  • age > 65 years
  • prior AMI
  • 2 or more risk factors (hypertension/family history/smoker/hyperlipidemia)
  • Diabetes and chronic renal failure eGFR < 60 ml/min with atypical ACS symptoms
 
Low risk
  • Patients with chest pain without high risk or intermediate risk features.

High risk are likely to require CCU admission or admission with telemetry monitoring and therefore should be discussed early with the cardiology team.
Intermediate risk patients warrant a stress test (either a myocardial perfusion scan or exercise stress test prior to discharge); at TPCH this is done via CPAS or admission for cardiology for serial troponins.
 
​And the low risk patients are ones that you would probably discharge home following a negative troponin and no repeated symptoms with GP follow up. At TPCH, there is the pathway to organise this PRIOR to discharge via the Accelerated Diagnostic Protocol (ADP) pathway.
 
Examination
Examination in patients with chest pain can often be unremarkable, unless there are signs of heart failure.
 
Investigation
ECG- all patients with active chest pain need an ECG done within 10 mins, as serious causes of chest pain (ie STEMIs) are diagnosed only with ECG and these patients require urgent reperfusion therapy. Serial ECGs are essential for all patients with ongoing chest pain to identify any dynamic changes.
Emergency Medicine - Cadogan & Brown

Rosen's Emergency Medicine