Chest Pain

Cardiology‎ > ‎

CHEST PAIN evaluation for ACS

Acute coronary syndromes BMJ 2015

Typical CP or ACS : Go to ACS for further management of the patient Needs further risk stratification with Stress Test +- ECHO and is managed with initial conservative approach (needs anti-coagulation)
Non-anginal or atypical chest pain:

For this group of patient one should be able to group the patient into one of this criteria.

Non-anginal CP (often with low risk factors) that does not warrant any further cardiac risk stratification (eg. GERD, Pneumonia etc). No need to do TIMI or GRACE or any sort of risk stratification.
Atypical CP and sometime Non-anginal chest pain in high risk patient often warrants further risk stratification with biomarkers, and often with stress test especially in a patient with established CAD (no need of anti-coagulation)
When atypical chest pain, especially in a patinent with established CAD, one can use the Appendix table below for further risk stratification. If high or intermediate risk, then needs to be managed like ACS. If low risk further risk stratification with stress test is warranted.

CP Evaluation Goals:

Identify if patient falls into any of the life threatening categories that demands appropriate further work up

If concerning for coronary artery disease, one should be able to group the patient into one of the following 6 groups

1. Chronic Stable Angina (controlled on medication) that does not warrant any further cardiac risk stratification
2. Non-anginal CP (often with low risk factors) that does not warrant any further cardiac risk stratification (eg. GERD, Pneumonia etc)
3. Atypical CP and sometime Non-anginal chest pain in high risk patient that warrants further risk stratification with biomarkers and often with stress test (no need of anti-coagulation)
4. Typical CP or UA or NSTEMI that needs further risk stratification with Stress Test +- ECHO and is managed with initial conservative approach (needs anti-coagulation)
5. Patient in 4 that needs early invasive strategy for risk stratification (needs anti-coagulation)
6. Patient with STEMI that needs to go for Cath now

Risk stratification for patient with UA in a patient with previous diagnosis of CAD. This will represent what we typically see in ER.

Understand High-Risk Coronary Lesions after doing following tests. These typically need further risk stratification with Cath.

Stress induced large perfusion defect (particularly anterior)
Stress induced multiple perfusion defects of moderate size
Large fixed perfusion defect with LV dilatation or increased lung update
Stress induced moderate perfusion defect with LV dilation or increased lung update (contrast from above point, which is prestress vs this point which is under stress)
ECHO wall motion abnormality (>2 segments) at low dose of dobutamine or at HR <120
Stress ECHO consistent with extensive ischemia