Chest Pain
Chest Pain
Chest pain or other symptoms potentially consistent with anginal pain
ACS ruled out in main ED (see chest pain pathway for main ED)
Anticipated CDU length of stay of less than 18 hours
Initial labs (CBC/CMP/troponin +/-coags) resulted
hsTroponin must < 500 and unchanged (rise or fall < 20%) on serial troponins resulted during ED evaluation
Other important causes of chest pain (dissection, PE etc) considered and ruled out (either clinically or with testing)
Alternate emergent diagnosis as likely as obstructive coronary disease (trauma/PE/dissection/tamponade, etc)
History concerning for ACS with refractory pain in ED despite maximal medical management
Dynamic ischemic ECG changes
Troponin > 500 or changed (rise or fall >; 20%) on serial troponin
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.)
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 SL
If a patient has not had coronary evaluation (cardiac cath, stress test or coronary CTA) in the last 12 months, consider further testing to rule out obstructive coronary disease
For most patients the best test is a Coronary CTA. These are available M-F until 5 pm.
For patients who have a HR > 70 despite IV Metoprolol or who have a contrast allergy, a traditional treadmill or adenosine study is an acceptable alternative
Disposition
Stable and Normal Vital Signs
Resolved Symptoms
ACS or acute infarction ruled out with 0, 3, and 6 hour troponins and serial ECGs without dynamic ischemic changes
Follow-Up Obtained – Cardiology/Primary Care
No Critical Findings on CCTA or Stress test (or stress test not deemed necessary per protocol)
Development of abnormal Vital Signs
Symptoms of ACS with refractory pain despite medical management
Troponin >500 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