Evaluating patients with chest pain in the emergency department
Fernanda Bellolio1, Michael Gottlieb2, Richard Body3
1Mayo Clinic, Minnesota, USA.
Insights
Accurately identifying cardiac chest pain is vital. High-sensitivity cardiac troponins (hs-cTn) aid diagnosis, but clinical context and risk assessment are key for managing acute coronary syndrome.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- Chest pain evaluation is critical due to high cardiovascular disease mortality.
- Cardiac biomarkers, including high-sensitivity cardiac troponins (hs-cTn), are essential for diagnosing acute myocardial infarction.
- Elevated hs-cTn levels can occur without acute myocardial infarction, necessitating careful clinical interpretation.
Purpose of the Study:
- To emphasize the importance of integrating hs-cTn levels into clinical decision-making for chest pain patients.
- To promote the use of structured risk assessments and evidence-based protocols for acute coronary syndrome.
- To guide the appropriate use of cardiac imaging and further testing for intermediate-to-high risk patients.
Main Methods:
- Review of current diagnostic approaches for chest pain.
- Emphasis on structured risk stratification protocols.
- Integration of hs-cTn interpretation within clinical decision pathways.
Main Results:
- hs-cTn assays improve the detection and exclusion of myocardial injury.
- Clinical judgment is crucial to differentiate myocardial infarction from other causes of hs-cTn elevation.
- Structured risk assessments aid in identifying patients who may benefit from further cardiac investigations.
Conclusions:
- Clinicians must integrate hs-cTn results with clinical presentation and risk assessment for accurate diagnosis.
- Routine use of clinical decision pathways in emergency departments is recommended for chest pain evaluation.
- Patient involvement in decision-making regarding further testing is essential.
Abstract:
Identifying patients with chest pain that is of cardiac origin is crucial owing to the high mortality and morbidity of cardiovascular diseases. History, electrocardiogram, and cardiac biomarkers are the core elements of the assessment. High sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers for diagnosing acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. However, elevations in hs-cTn can occur in patients who are not experiencing acute myocardial infarction. Therefore, it is important for clinicians to recognize how to integrate hs-cTn levels into their clinical decision making process. Structured risk assessments, using evidence based diagnostic protocols, should be employed to estimate the risk of acute coronary syndrome and adverse events in patients with chest pain. Clinical decision pathways should be used routinely in emergency departments. Patients at intermediate or high risk of obstructive coronary artery disease might benefit from cardiac imaging and further testing. Patients should be involved in decision making, with information provided about risks, radiation exposure, costs, and alternative options to facilitate informed decision making.
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