• Chest pain is one of the most common presentations to the emergency department (ED) and approximately 10 – 15% of such patients will have an acute coronary syndrome. (ACS; either acute myocardial infarction or unstable angina).
• This approach applies to:
  • stable patients
  • suspected ACS only and cannot be used to rule out other causes such as pulmonary embolus or aortic dissection
  • patients with no other clear cause for their pain.
• Stable patients have the following features: normal vital signs, no evidence of ischemia on EKG, (no ST elevations or depressions, and no T wave inversions) no ongoing pain in the ED, and negative troponin(s).
• Stable patients do not require cardiac monitoring while awaiting serial troponins.
• 20-30% of these patients do not need further testing. We can determine who can go home within 2-3 hours and who can go home after within 6 hours. The result is increased patient satisfaction, decreased ED crowding, and a reduction in unnecessary testing.

• Patients who are under 50 with no prior ACS or nitrate use, and who have normal EKGs and troponin at 2 hours, can be safely discharged home with no follow-up testing.
• Patients over 50 with no prior ACS or nitrate use, a normal EKG and negative troponin at 2 hours AND who have pain reproducible with direct palpation, can also be safely discharged home with no follow-up testing.
• Patients with an elevated troponin or abnormal EKG and no other cause for their pain should be referred for further investigation.
• Patients who do not fall into the above categories should undergo ED observation with sequential investigations (EKGs and troponins) over 6 hours. If all investigations are normal, they should have outpatient follow-up with a cardiologist or internist within two weeks. Ideally, the emergency physician can arrange ancillary outpatient investigations within 48 hours to be followed by a cardiologist or internist in a similar time frame.
• Patients should be encouraged to take ASA and return if their pain recurs.

Vancouver Chest Pain Rule

• Exercise stress tests (EST) are functional investigations that have ~70% sensitivity and specificity for ACS. Patients must have normal resting EKGs and be able to walk for 12 minutes.
• Myocardial perfusion scanning is a functional test with similar sensitivity and specificity as EST for ACS. However, patients with diffuse disease may be false-negatives.

1. Management of Low Risk Chest Pain in the ED

   
   

1. Scheuermeyer FX, Innes G, Grafstein E, et al. Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain Ann Emerg Med 2012;59;256-264

   
   

2. Scheuermeyer FX, Wong H, Yu E, et al. Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain. CJEM 2014;16(2):106-119

   
   

3. https://www.mdcalc.com/vancouver-chest-pain-rule

   
   

4. Twerenbold R, et al. Effect of the FDA Regulatory Approach on the 0/1-h Algorithm for Rapid Diagnosis of MI. Am Coll Cardiol 2017; 70:1532-1534

   
   

5. Morrow D. Clinician’s Guide to Early Rule-Out Strategies With High-Sensitivity Cardiac Troponin. 2017;135:1612-1616