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ED Chest Pain Algorithm

ED Chest Pain Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular, Related


Patient Presentation:
Chest Pain or Anginal Equivalent
with Concern for ACS
Definitive
NSTE-ACS or
Unstable Angina
STEMI
STEMI
Activation
Clinical
Concern for
NSTE-ACS?
Admit to CVM
for Medical
Management
Refer to UW Health
NSTE-ACS Medical
Therapy Algorithm
Coronary CTA or Stress Test
ED Provider Preference
(AHA Class Iia, LOE B)
Inclusion
Criteria met?
Perform CCTA
(AHA Class Iia, LOE B)
Use ED Order Set
Stress Lab
open?
CCTA
Result:
High risk/
Severe stenosis
Result:
Equivocal risk/
Moderate stenosis
Result:
Low risk/No or
Mild stenosis
Discharge
Follow-up
with PCP
Admit to CVM
ED Provider Preference
12-lead ECG (within 10 min of arrival) (AHA Class I, LOE C)
1
st
Troponin Lab (draw upon arrival) (AHA Class I, LOE A)
UW Health ED Chest Pain Algorithm
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.
2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of
Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
3. Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary
syndrome. J Am Coll Cardiol. 2013;62(14):1242-1249.
4. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.
2
nd
Troponin
(draw 2hrs. after onset of
symptoms)*
Change in
troponin?
Stress Test
Yes
Order Stress Test**
(AHA Class IIa, LOE A,B)
ED Management
(outside guideline scope)
No
Admit to appropriate
Medical Service for
Stress Testing***
(AHA Class IIa, LOE B)
Consider for OP Stress
Testing and Discharge
- Patient Low Risk?
- Patient Agreeable?
- PCP?
Yes
No
YesNo
CCTA Inclusion Criteria:
ξ During available hours
ξ Age < 60 yrs.
ξ No history of CAD
ξ HR < threshold or no contraindications to
beta blockade
ξ ECG with NSR, no ischemia, no arrhythmia
ξ No allergy to iodinated contrast
ξ Can hold breath for 15 seconds
ξ eGFR > 60
ξ Not taking PDE-5 inhibitor drugs (i.e., 24
hrs. since sildenafil/vardenafil dose, or 48
hrs. since tadalafil dose) (AHA Class III, LOE B)
Last Revised: 04/2015
Contact CCKM for revisions.
UW Health Management of Non-ST Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory Clinical Practice Guideline
*UW Health uses troponin lab with higher sensitivity.
3,4
**Stress test type will be determined by the Stress Test Lab
staff using the UW Health Stress Testing (from ED) Algorithm.
***Patients may be transferred from TAC to CSC on Fri./Sat.
1
st
Troponin
positive?
Yes
No
Yes
No
NOTE: Consider
Contraindications for
Stress Testing
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org