UW Medicine ED Chest Pain Pathway

UWMC ED Chest Pain Pathway

STEMI or Sudden Death

History

Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognizes symptoms. Low risk features of chest pain include: well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.

Slightly suspicious

Moderately suspicious

Highly suspicious

EKG

• 1 point: No ST depression but LBBB, LVH, repolarization changes (ex: digoxin)
• 2 points: ST depression/elevation not due to LBBB, LVH, or digoxin

Normal

Non-specific repolarization disturbance

Significant ST depression

Age

<45

45-60

>60

Risk factors

• HTN • hypercholesterolemia • DM • obesity (BMI >30 kg/m²) • smoking (current, or smoking cessation ≤3 mo) • positive family history (parent or sibling with CVD before age 65) • atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease

No known risk factors

1-2 risk factors

≥3 risk factors or history of atherosclerotic disease

Initial troponin

Less than 0.04 ng/mL (normal)

0.04 to 0.08 ng/mL (1-2x normal)

Greater than 0.08 ng/mL (> 2x normal)

0 points

HEART Pathway Score

Low risk

0.9–1.7% 30-day MACE
Repeat troponin at 3 hours and if negative, discharge home with outpatient follow-up.

^♥Based on
• Backus BE, Six AJ, Kelder JC, et al. Chest pain in the emergency room: a multicenter validation of the HEART Score., Crit Pathw Cardiol 2010.
• Mahler et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge., Circ Cardiovasc Qual Outcomes 2015.

Admit to Cardiology

Disclaimer: This is an educational tool to supplement the cardiac imaging ordering process and does not replace clinical judgment or supersede established management protocols.

UWMC ED Chest Pain Pathway

Age (yrs)

Gender

Chest Pain

Diabetes

Dyslipidaemia

Hypertension

Current or Past Smoker

Risk of CAD:

Heart rate

Systolic blood pressure

CHF

Diuretic usage

Creatinine

Renal failure

ST-segment deviation

Elevated troponin

Cardiac arrest at admission

In-hospital risk of event:

Enter Pathway

^†Based on Genders et al. Prediction model to estimate presence of coronary artery disease, BMJ 2012.

^‡ Based on GRACE (the Global Registry of Acute Coronary Events), an international observational program of outcomes for patients who were hospitalized with an ACS in the 10 years from 1999.

Return to Heart Score Calculation

Low/Intermediate Risk – Additional risk stratification appropriate

High likelihood CAD

Iodine contrast allergy

Atrial Fibrillation

Can walk on treadmill

Bronchospastic lung disease

Heart block

Left bundle branch block

Recommended Test:

Alternative Tests:

Coronary CTA

Exercise SPECT (NM Cardiac Stress Perfusion)

Exercise Stress Echocardiogram

Dobutamine Stress Echocardiogram

Vasodilator SPECT (NM Cardiac Stress Perfusion)

Cardiology Consult

Return to risk calculation Copy patient summary to clipboard

Perform Cardiac CT Angiography

Cardiac CT Interpretation and Management

No CT Stenosis (CAD-RADS 0)

ACS highly unlikely
▸ No further evaluation of ACS is required.
▸ Consider other etiologies.

1-50% CT Stenosis (CAD-RADS 1-2)

ACS unlikely
▸ Consider evaluation of non-ACS etiology, if normal troponin and no ECG changes.
▸ Consider referral for outpatient follow-up for preventive therapy and risk factor modification.
▸ If clinical suspicion of ACS is high or if high-risk plaque features are noted, consider hospital admission with cardiology consultation.

> 50% CT Stenosis (CAD-RADS 3-5)

ACS likely
▸ Consider hospital admission with cardiology consultation.
Admit to Cardiology

Return to low risk stratification