The management of the patient with chest pain in the emergency room
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Abstract
Managing chest pain is one of the greatest challenges in emergency departments worldwide. The symptom of chest pain constitutes the most frequent cause of emergency room visits (between 5-9%) and is one of the most common reasons for activating emergency medical services, with a high mortality rate (2-4%) in cases of missed diagnosis and improper discharge.
The goals of an appropriate pathway for patients with chest pain are to prevent both missed diagnoses or improper discharges, by early identification of patients with coronary-related chest pain (ACS), and promptly initiating appropriate treatment, or swiftly establishing a diagnosis of chest pain caused by another etiology.
The management of chest pain requires a integration and cooperation among all involved parties (physicians, cardiologists, triage nurses, nurses), including the patient (information/sharing of pathways, etc.).
This document aims to serve as a guide for managing non-traumatic chest pain in the Emergency Department (ED). The information provided in this review reflects the latest recommendations from the international literature and takes into account the diagnostic-therapeutic pathways shared among various operational units and regional networks dealing with cardiac emergencies.
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References
Takada JY, Roza LC, Ramos RB, Avakian SD, Ramires JA, Mansur Ade P. Emergency service admission time and in-hospital mortality in acute coronary syndrome. Arq Bras Cardiol. 2012 Feb;98(2):104-10.
Baptista R, Maricoto T, Monteiro S, Dias J, Gonçalves S, Febra H, Gil V. Practical approach to referral from primary health care to a cardiology hospital consultation in 2022. Rev Port Cardiol. 2023 Jun;42(6):557-578. 3. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluatelow-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol 2002; 40:251–256
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835–842
Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Report 2008;7:1-38.
Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-70
Antman EM, Wiviott SD, Murphy SA, Voitk J, Hasin Y, Widimsky P, Chandna H, Macias W, McCabe CH, Braunwald E. Early and late benefits of prasugrel in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a TRITON-TIMI 38 ((TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with Prasugrel-Thrombolysis In Myocardial Infarction) analysis. J Am Coll Cardiol 2008;51:2028–2033
Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.
Sharma V, Choudhury A, Basavarajaiah S, Rashid M, Yuan M, Jefferey D, Vanezis AP, Sall H, Smith WHT, Parasa R, Kelly P, Kinnaird T, Mamas MA. Chronic total occlusion in non-ST elevation myocardial infarction - A multi-centre observational study. Cardiovasc Revasc Med. 2024 Feb 14:S1553-8389(24)00049-6.
Zhang L, Zeng J, Huang H, Zhu Y, Peng K, Liu C, Luo F, Yang W, Wu M. Impact of chest pain center quality control indicators on mortality risk in ST-segment elevation myocardial infarction patients: a study based on Killip classification. Front Cardiovasc Med. 2024 Jan 3;10:1243436.
Abusharekh M, Kampf J, Dykun I, Souri K, Backmann V, Al-Rashid F, Jánosi RA, Totzeck M, Lawo T, Rassaf T, Mahabadi AA. Acute coronary occlusion with vs. without ST-elevation: impact on procedural outcomes and long-term all-cause mortality. Eur Heart J Qual Care Clin Outcomes. 2024 Jan 8:qcae003.
Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.
Lindskou TA, Andersen PJ, Christensen EF, Søvsø MB. More emergency patients presenting with chest pain. PLoS One. 2023 Mar 23;18(3):e0283454. doi: 10.1371/journal.pone.0283454.
Paciullo F, Giannandrea D, Gianfredi V, Borgognoni F, Verdecchia P, L'Angiocola PD, Monti M. Epidemiology of emergency calls for time-dependent acute illnesses during COVID-19 outbreak in Umbria region (Italy). Ann Ig. 2021 Mar-Apr;33(2):198-200.
Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8.
Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65.
Monti, M, Ruggieri, M. P, Vincentelli, G. M., Capuano, F., Pugliese, F. R. (2015). Cardiovascular risk factors in sub-Saharan Africa: a review. Italian Journal of Medicine, 9(4), 305–313.
Amin O, Howlett DC. Atypical chest pain in an older woman. BMJ. 2018 Feb 22;360:k345.
Beiser DG, Cifu AS, Paul J. Evaluation and Diagnosis of Chest Pain. JAMA. 2022 Jul 19;328(3):292-293.
Nilsson T, Lundberg G, Larsson D, Mokhtari A, Ekelund U. Emergency Department Chest Pain Patients With or Without Ongoing Pain: Characteristics, Outcome, and Diagnostic Value of the Electrocardiogram. J Emerg Med. 2020 Jun;58(6):874-881.
Sandoval Y, Apple FS, Mahler SA, Body R, Collinson PO, Jaffe AS; International Federation of Clinical Chemistry and Laboratory Medicine Committee on the Clinical Application of Cardiac Biomarkers. High-Sensitivity Cardiac Troponin and the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guidelines for the Evaluation and Diagnosis of Acute Chest Pain. Circulation. 2022 Aug 16;146(7):569-581.
Poldervaart JM, Langedijk M, Backus BE, Dekker IMC, Six AJ, Doevendans PA, Hoes AW, Reitsma JB. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017 Jan 15;227:656-661.
Paccamonti, E., Marchetti, R. and Monti M. 2023. The management of overcrowding in the emergency room: analysis of the phenomenon and operational strategies. Italian Journal of Prevention, Diagnostic and Therapeutic Medicine.2023; 6(2):35-39.
Di Tano G, Bonatti R. Il percorso del paziente con dolore toracico. G Ital Cardiol 2019;20(10 Suppl. 2):e4-e7
Saitta D, Hebbard G. Beyond the heart: Noncardiac chest pain. Aust J Gen Pract. 2022 Nov;51(11):849-854. doi: 10.31128/AJGP-06-22-6467
Crockford S. Calculated decisions: Aortic Dissection Detection Risk Score (ADD-RS). Emerg Med Pract. 2021 Dec 1;23(12):CD1-CD3.
Reti tempo-dipendenti di cui alla DGR 1421/2022. Riorganizzazione Rete regionale Cardiologica per l'emergenza -STEMI DELIBERAZIONE DELLA GIUNTA REGIONALE UMBRIA N. 170 SEDUTA DEL 28/02/2024
Bhatt DL, Lopes RD, Harrington RA. Diagnosis and Treatment of Acute Coronary Syndromes: A Review. JAMA. 2022 Feb 15;327(7):662-675.
Brami P, Fischer Q, Pham V, Seret G, Varenne O, Picard F. Evolution of Coronary Stent Platforms: A Brief Overview of Currently Used Drug-Eluting Stents. J Clin Med. 2023 Oct 24;12(21):6711.
Gharacholou SM, Larson BJ, Zuver CC, Wubben RJ, Gimelli G, Raval AN. Pre PCI hospital antithrombotic therapy for ST elevation myocardial infarction: striving for consensus. J Thromb Thrombolysis. 2012 Jul;34(1):20-30.