Consensus Recommendations on Diagnostic Approach to Chest Pain in the Emergency Department

by Joseph Esherick, M.D., FAAFP, FHM

Target Audience: Emergency clinicians

Background: A multidisciplinary group of emergency physicians, radiologists, cardiologists, and others has developed appropriateness criteria for the use of imaging to help inform clinicians for four clinical scenarios presenting as chest pain in the ED.

Key Points:

  • Adults presenting to the ED with chest pain should all undergo a thorough H&P and frequently a 12-lead ECG, chest x-ray and cardiac biomarker testing.   If the diagnosis is obvious with this basic testing, then management should proceed based on standard evidence-based guidelines (e.g., guidelines for ST-elevation myocardial infarction [STEMI], or pneumothorax, or community-acquired pneumonia, etc)

 

  • Other patients will generally fall into four categories:
    • Suspected non–STEMI/Acute Coronary Syndrome (ACS):
      •  If cardiac biomarkers are elevated, cardiac catheterization (non-emergent) should be considered.
      • If biomarker results are equivocal or normal, the choices for a diagnostic work-up include:
        • computed tomography (CT) coronary angiography
        • dobutamine stress echocardiography
        • cardiovascular magnetic resonance (MR)
        • single-photon emission CT
        • Myocardial perfusion study
    • Suspected Pulmonary Embolism (PE):
      • Risk stratification is essential to determine pretest probability
      • Patients with a low- or intermediate pretest probability and normal D-dimer need no imaging
      • Patients with a high pretest probability should not have a D-dimer drawn
      • For patients with elevated d-dimer values or high risk, CT pulmonary angiography or ventilation-perfusion scan is appropriate.
      • Pregnant patients with symptoms of deep venous thrombosis should undergo compression ultrasounds first, which may preclude other imaging.
    • Suspected Acute Aortic Syndromes (AAS):
      • In unstable patients, CT aortography is appropriate.
      • In stable patients, possible diagnostic imaging options include:
        • CT aortography
        • MR aortography
        • transesophageal echocardiography
    • No Clear Leading Diagnosis:
      • If the overall likelihood of ACS, PE, or AAS is low, “triple-rule-out” CT angiography is not appropriate.

Reference:  Rybicki FJ et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: A joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016 Jan 16; [e-pub].