Approach to patients with chest pain in ED

With more than 6 million emergency department visits annually in the US and reported 2% rate of missed diagnosis of ACS in discharged patients, the optimal management of ACS in the ED is an important dilemma faced by many clinicians. Risk stratification with accelerated diagnstic protocol (ADP) that is based upon history taking, physical exam, ECG, and troponin measurement is essential in the triage process. For patients who are at low to intermediate risk for short term events (death and MI), the first goal is to identify patients who can be safely discharg from the ED after an observational period. For achieving this goal Pre-discharge confirmatory tests such as stress test or CCTA is needed in some but not all patients. With the advent of high-sensitivity troponins (hsTn), that is game changer, the ability to rule out MI in the ED has improved. however the second goal of evaluation of patients with chest pain in ED is risk stratification for future events. although low to intermediate risk patients are generally at exceedingly low risk in terms of short-term death and MI, but low risk is not no risk. This second goal is addressed by BEACON (better evaluation of acute chest pain with coronary computed tomography angiography) trial .AUC endorsed by ACC/AHA for non-invasive tests in these patients is as follows : (test selection should be based upon the expertise, resources and experience of any given center) For patients suspected to NSTEMI/ACS with negative results of ECG and troponin, Exercise ECG with NPV > 99 % is an appropriate test .If initial diagnosis of NSTEMI/ACS is equivocal, either because ischemic symptoms were resolved several days before testing or because of equivocal initial troponin result or just because of single troponin rise without additional evidences of ACS, CCTA is appropriate .Another scenario with appropriateness for CCTA, is low/intermediate likelihood of initial diagnosis of NSTEMI/ACS either in those patients with TIMI risk score of 0, early hsTrop negative or in those with normal or non-ischemic findings on initial ECG and normal initial troponin .Three landmark trials that validated utilization of CCTA in ED, with its strength of high sensitivity and NPV of %99> are ACIRN (American College of Radiology Network) trial, CT-STAT trial that compared CCTA vs Nuclear imaging in terms of Time to diagnosis and Total ED costs, and ROMICAT || ( Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial. The strength of CCTA for detection high risk plaques is also discussed