Chest Pain

Question 1

CDU Admission Criteria

Answer 1

• History of chest pain or other symptoms potentially consistent with anginal pain, s/p initial ED evaluation using ACS HEART PATHWAY (HEART score <7)
• Anticipated CDU length of stay of less than 18 hours
• Adequate follow-up and social support anticipated at time of discharge
• Initial labs (CBC/CMP/troponin +/-coags) returned
• Troponin must be < 0.50 ng/mL and unchanged (rise or fall > 20%) when serial troponins resulted during ED evaluation
• If Troponin is >0.05 ng/mL, this must be at the patient’s known baseline or below.

Question 2

CDU Exclusion Criteria

Answer 2

• Alternate emergent diagnosis as likely as ACS (trauma/PE/dissection/tamponade, etc)
• History concerning for ACS with refractory pain in ED despite maximal medical management
• Dynamic ischemic ECG changes
• Troponin > 0.50 ng/mL or changed (rise or fall > 20%) if serial troponins resulted during ED evaluation
• Hemodynamic/Electrical instability or severe systemic illness
• Recent positive stress test without cath/angiography performed
• Unable to perform activities of daily living (ie walking, self bathing, etc.)
• History concerning for unstable angina

Question 3

CDU Intervention: Medications

Answer 3

• Cardiac monitoring
• Troponin and ECG at Q 3 hours x 3 (time: 0, 3 and 6 hours)
• Obtain repeat ECG PRN with change in symptoms and/or at time of repeat troponin
• Aspirin 325 mg chewed x1, if not allergic or already taken
• Clopidogrel (Plavix) 300 mg po x1, if aspirin allergic
• Nitropaste to chest wall 6 hours or nitroglycerin 0.4 & SQ Q5 min PRN x3
• Morphine prn

Question 4

CDU Intervention: catheterization/stress test

Answer 4

• If last cardiac catheterization was < 12 months and CLEAN (angiographically non-obstructive CAD)  rule out ACS with serial troponins and discharge with close follow up (cardiology within 3 days) if negative and symptoms have resolved. Repeat stress testing is only necessary when patient is thought to benefit from further testing at providers discretion.
• If last cardiac catheterization >12 months  serial troponins and stress test
• If last stress test <6 months and normal  rule out ACS with serial troponins and discharge with close follow up (cardiology within 3 days) when negative and symptoms have resolved. Repeat stress testing is only necessary when patient is thought to benefit from further testing at providers discretion.
• If last stress test >6 months repeat stress test
• Note: Can perform stress test on a patient after 2 SERIAL TROPONINS if chest pain >3 hours PTA.
• Cardiology consult as needed.

Question 5

Disposition: Home

Answer 5

ALL criteria must be met
• Stable and Normal Vital Signs
• Resolved Symptoms
• ACS ruled out infarction with 0, 3, and 6 hour troponins and serial ECGs without dynamic ischemic changes
• Follow-Up Obtained – Cardiology/Primary Care
• Normal Stress test (or stress test not deemed necessary per protocol)

Question 6

Disposition: Hospital

Answer 6

Hospitalize if patient has ANY criteria
• Development of abnormal Vital Signs
• Symptoms of ACS with refractory pain despite medical management
• Troponin > 0.50 ng/mL or changed (rise or fall > 20%) with serial troponins
• Dynamic ischemic ECG changes
• Does not or will not meet discharge criteria after 18 hours of treatment

Question 7

Pathway 1: (no stress test required, deferred to follow up provider)

Answer 7

• Low risk HEART score with negative serial troponins/ECGs and resolution of symptoms concerning for ischemia after observation
• Moderate risk HEART score with negative serial troponins/ECGs and resolution of symptoms concerning for ischemia after observation, PLUS a stress test (<6 months) or cardiac catheterization (<12 months) that is reassuring.

Question 8

Pathway 2: (routine treadmill)

Answer 8

• Low/Moderate risk heart score with negative serial troponins/ECGs and resolution of symptoms concerning for ischemia
• Physically able to perform treadmill test e.g. Bruce protocol at least 85% maximal predicated HR
• ECG MUST be normal e.g. no abnormal conduction/LBBB, paced rhythms, T- wave inversions, S-T changes, LVH with strain, WPW, etc.
• Simple, and cheapest test, very good for young and otherwise healthy patients

Question 9

Pathway 3: (stress echo (exercise or pharmacological))

Answer 9

• Low/Moderate risk heart score with negative serial troponins/ECGs and resolution of symptoms concerning for ischemia
• If patient is not able to exercise choose a pharmacological stress
• Consider nuclear imaging in morbidly obese/COPD/emphysema patients where it may be technically difficult to obtain sufficient echo images
Do not order echo and proceed to nuclear imaging study if patient has:
1. Prior echo showing resting wall motion abnormalities
2. Prior large infarct or multivessel disease
3. Dilated cardiomyopathy
4. Cardiac surgery

Question 10

Pathway 4: (Nuclear imaging (exercise or pharmacological))

Answer 10

• One of the below listed radiotracers are injected into a vein and photos are taken with a gamma camera before and after stress to assess cardiac function (per nuclear med)
o Thallium
o Technetium Tc99m-sestamibi (Cardiolite)
o Technetium Tc99m-tetrofosmin (Myoview)

Question 11

Cardiology consultations

Answer 11

At provider’s discretion or with positive troponin (>0.50 ng/mL or rise/fall >20%), dynamic ischemic ECG changes, and abnormal stress test results.

Question 12

HEART Score: History

Answer 12

Highly suspicious 2
Moderately suspicious 1
Slightly suspicious 0

Question 13

HEART Score: ECG

Answer 13

Significant ST depression 2
Nonspecific repolarization disturbance 1
Normal 0

Question 14

HEART Score: Age

Answer 14

≥65 years 2
45-65 years 1
<45 years 0

Question 15

HEART Score: Risk factors

Answer 15

≥3 risk factors or history of atherosclerotic disease 2
1 or 2 risk factors 1
No risk factors known 0

Question 16

HEART Score: Troponin

Answer 16

> 2x normal limit 2
1-2x normal limit 1
≤normal limit 0

Question 17

Risk Factors include…

Answer 17

High blood pressure
High cholesterol
High levels of C-reactive protein (CRP), a marker of inflammation
Diabetes
Obesity
Sleep apnea
Smoking and other tobacco use
A family history of early heart disease
Lack of exercise
An unhealthy diet

Question 18

HEART Score risk stratification

Answer 18

Low Risk: 0-3
Moderate risk: 4-6
High risk: 7-10