ED Chest Pain Pathway

Clinical Summary

    Welcome

    This tool guides you through the Emergency Department Chest Pain Pathway. Click below to begin.

    Step 1: Patient Arrival & Initial ECG

    A patient presents to the ED with chest pain. An initial ECG is performed.

    Step 2: STEMI Evaluation

    Does the initial ECG meet STEMI criteria?

    Outcome: STEMI Positive

    Activate the STEMI protocol and follow the 2013 ACC/AHA STEMI Guidelines.

    Step 3: Evaluate for Non-STEMI Ischemic Changes

    Does the ECG show any of the following high-risk ischemic changes?

    High-Risk Ischemic Changes:
    • Transient ST changes (≥0.5 mm, horizontal or downsloping) during symptoms.
    • Marked symmetrical precordial T-wave inversion (≥2 mm).

    Action: High-Risk ECG Findings

    The patient has new or concerning ECG findings. The following immediate actions are required while proceeding with the evaluation.

    • Place patient in a monitored treatment space.
    • Obtain initial high-sensitivity troponin (hs-cTn).
    • Repeat ECG in 15-30 minutes (or with any change in symptoms).
    • Initiate standard evaluation and treatment (e.g., Aspirin).

    High-Risk Pathway: NSTE-ACS Evaluation

    The ECG is concerning. Are the patient's symptoms also suggestive of a NSTE-ACS?

    High-Risk Pathway: Hemodynamic Stability

    After initiating NSTE-ACS workup, first assess for hemodynamic instability. Does the patient have any signs of hemodynamic instability?

    Examples of Hemodynamic Instability:
    • Hypotension (Systolic BP < 90, MAP < 65)
    • Tachypnea (RR > 30)
    • Increased work of breathing (e.g., sweating, sitting up)

    High-Risk Pathway: Troponin Evaluation

    Is the high-sensitivity troponin (hs-cTn) elevated on the initial or 2-hour repeat draw?

    High-Risk Pathway: Final Safety Check

    Despite the initial high-risk ECG, the troponins are negative. Is the patient now clinically stable?

    Confirm ALL of the following are true:
    • Repeat ECG is unchanged or improved.
    • Chest pain is resolved.
    • 2-hour hs-cTn is negative/normal.

    Outcome: Consider Other Diagnoses

    Work up other causes of chest pain with ischemic ECG changes (PE, dissection, pericarditis, sepsis, etc.). This may require observation or admission.

    Outcome: High-Risk NSTE-ACS

    Patient is high-risk due to hemodynamic instability, elevated troponin, or ongoing signs/symptoms. Consult Cardiology fellow for recommendations, consideration of LHC/PCI, and subsequent admission.

    Step 4: Main Clinical Decision Pathway

    The patient has no STEMI and no other concerning ischemic ECG changes. They are a candidate for the main pathway using hs-cTn and the HEART Score.

    Step 4a: Symptom Onset

    Did symptoms start ≥ 3 hours before the initial hs-cTn was drawn?

    Single-Draw Pathway

    Is the initial hs-cTn < 3 ng/L?

    Step 4b: Evaluate hs-cTn Results

    Which criteria do the initial and 2-hour delta hs-cTn results meet?

    Myocardial Injury: Evaluate Cause

    The troponin is significantly elevated. Does the clinical picture suggest this is a primary Type 1 NSTEMI?

    Outcome: Consult Cardiology for NSTEMI

    Patient has findings concerning for a Type 1 NSTEMI. Consult Cardiology fellow for recommendations and admission.

    Outcome: Admit for Undifferentiated Injury

    Patient has undifferentiated myocardial injury not felt to be a primary Type 1 NSTEMI. Consult Medicine for admission and further workup.

    Step 4c: HEART Score Calculator

    Calculate the patient's HEART score to determine disposition for the Gray Zone.

    Total Score: 0

    Intermediate Risk Pathway (HEART 4-6)

    The patient has an Intermediate Risk HEART score. Engage in Shared Decision Making about the next steps.

    High Risk Pathway (HEART ≥7)

    The patient has a High Risk HEART score and requires either observation or admission.

    Step 5: Disposition Planning

    This patient requires further evaluation beyond the initial ED workup. Is an ED Observation unit available for this patient?

    Outcome: Low-Risk / Rapid Rule-Out Discharge

    Patient meets low-risk criteria. Discharge home with Primary Care (PDC) follow-up within 14 days.

    Final Discharge Considerations:
    • ED Clinical judgment (consider other etiologies)
    • Is chest pain improving or resolved?
    • Is a repeat 2 hour ECG unchanged?
    Documentation Reminder: A HEART score should be documented for all chest pain patients.

    Outcome: Discharge via Shared Decision

    Patient is intermediate-risk and a shared decision was made to discharge. Discharge home with Primary Care (PDC) follow-up within 7 days.

    Final Discharge Considerations:
    • ED Clinical judgment (consider other etiologies)
    • Is chest pain improving or resolved?
    • Is a repeat 2 hour ECG unchanged?

    Outcome: Place in ED Observation

    The patient meets criteria for observation status. Initiate the ED Observation protocol for further monitoring and/or non-invasive testing as per unit guidelines.

    Outcome: Admit to Medicine

    The patient requires inpatient admission. Consult the hospital medicine service for admission and further management.