Chest Pain: Low Risk ‘Rule-Out’ Pathways

Authors: Stephen W Goodacre, Jason M Kendall / Editors: Michael Perry, Tajek B Hassan / Reviewer: Philip Delbridge / Code: A1 / Published: 28/02/2022

Before commencing this session you should:

  • Understand the pathophysiology of acute coronary syndrome
  • Be able to interpret a 12-lead ECG
  • Understand how diagnostic tests work, in terms of sensitivity, specificity and likelihood ratios
  • Complete the Learning Zone session on Chest Pain Syndromes

Description:

This session addresses the clinical assessment and management of patients with low risk chest pain, specifically the identification of patients with acute coronary syndrome.

After completing this session you will be able to:

  • Define low risk chest pain, describe patient characteristics and outline the diagnostic challenge
  • Identify clinical features that are useful for ruling in, or ruling out, a diagnosis of acute myocardial infarction (AMI)
  • Outline the diagnostic value of electrocardiography, biochemical cardiac markers and provocative exercise testing
  • Describe other common diagnoses in a patient with low risk chest pain
  • Determine which patients require further investigation to rule in, or rule out, coronary artery disease once an Acute Coronary Syndrome has been excluded
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References:

  1. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005 Nov 23;294(20):2623-9.
  2. Goodacre SW, Angelini K, Arnold J, Revill S & Morris F. Clinical predictors of acute coronary syndrome in patients with undifferentiated chest pain. Q J Med 2003;96:893-898.
  3. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998 Oct 14;280(14):1256-63.
  4. Balk EM, Ioannidis JP, Salem D, Chew PW, Lau J. Accuracy of biomarkers to diagnose acute cardiac ischemia in the emergency department: a meta-analysis. Ann Emerg Med. 2001 May;37(5):478-94.
  5. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med. 1996 Oct 31;335(18):1342-9.
  6. McCord J, Nowak RM, McCullough PA, et al. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I. Circulation. 2001 Sep 25;104(13):1483-8.
  7. Mitchell AM, Brown MD, Menown IB, Kline JA. Novel protein markers of acute coronary syndrome complications in low-risk outpatients: a systematic review of potential use in the emergency department. Clin Chem. 2005 Nov;51(11):2005-12.
  8. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000 Aug 16;284(7):835-42.
  9. Fox KA, Dabbous OH, Goldberg RJ, Pieper KS, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006 Nov 25;333(7578):1091.
  10. Goodacre S, Nicholl J, Dixon S, Cross E, et al. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004;328:254-7.
  11. Morrow DA, Cannon CP, Jesse RL, Newby LK, et al. National Academy of Clinical Biochemistry. National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines: clinical characteristics and utilization of biochemical markers in acute coronary syndromes. Clin Chem. 2007 Apr;53(4):552-74.
  12. National Institute of Health and Clinical Excellence. Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis. NICE Guideline [CG95], London, March 2010. 

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