Emergency Department Chest Pain Evaluation Pathway

Atraumatic Chest Pain in Hemodynamically

Stable Adult Patient

Shortness of breath OR
Upper abdominal pain OR
Upper back pain

History & Physical

ECG if indicated

PTX
CXR if indicated
Pneumonia

Further testing for dangerous

conditions not excluded by
history and physical

Aortic Perimyocarditis
Esophageal Rupture5 Acute Coronary Syndrome Pulmonary Embolism
Dissection Pericardial Effusion

CT Chest with oral &

+ Physician gestalt or
ADD Risk Score Cardiology Very High Risk / Active Ischemia Troponin
IV contrast score Echocardiography6
– (Wells or Geneva)

Moderate HEART Score Moderate

High Risk Low Risk High Risk
Risk4 Risk

Low Risk Moderate Risk High Risk

CT Aortic - Alternate
HEART 0-3
PERC
diagnosis
Angiography2 and Neg Trop HEART 4-6 HEART 7-10
confirmed?
at 0 and 3 hours1 +
Age-adjusted
+ D-dimer3

+
Treatment Admit to
CTPA or VQ
Observation or Admit for
Discharge with
if Neg Trop x 2, Inpatient
physician f/u
discharge with Cardiology
cardiology f/u
 Modified AHA Modified HEART Score PERC Score Wells Score Geneva Score
Aortic Dissection Detection Risk Score Patient Assessment High-Risk Symptoms Low-Risk Symptoms
Age ≥ 50 years Signs/symptoms of DVT 3 Age > 65 years 1
High-Risk Conditions High-Risk Pain Features High-Risk Exam Features History Middle or left sided pain Well localized pain
HR ≥ 100 bpm PE is #1 Dx or equally likely 3 Previous DVT/PE 3
Mostly high-risk symptoms 2 Heavy chest pain Sharp pain
SpO2 on room air ≤ 94% Heart rate > 100 bpm 1.5 Surgery/lower limb
Marfan Syndrome Chest, back, or abdominal Pulse deficit Mix of high and low-risk symptoms 1 Diaphoresis Non-exertional fracture in past month 2
Connective tissue disease pain described as abrupt in Systolic BP differential Symptoms relieved by nitrates No diaphoresis Unilateral leg swelling Immobilization ≥ 3 days or
Mostly low-risk symptoms 0 1.5 Active malignancy 2
onset, severe in intensity Hemoptysis surgery within 4 weeks
Family history aortic disease and ripping, tearing, sharp Focal neurologic deficit ECG Nausea or vomiting No nausea or vomiting Unilateral lower limb pain 3
Previous DVT/PE 1.5
Known aortic valve disease or stabbing in quality Hypotension/shock state Radiation of pain Recent surgery or trauma
New ischemic change 2 Hemoptysis Hemoptysis 2
Prior PE/DVT 1
Recent aortic manipulation Murmur of aortic Non-specific change 1 Exertional pain HR 75-94 bpm 3
insufficiency Malignancy within 6 months 1
Known thoracic aortic Exogenous hormone use
Normal 0 HR > 94 bpm 5
aneurysm
Age ECG New ischemic changes ECG Non-specific changes Pain on lower limb deep
If one or more criteria is present, patient is Low risk < 2 venous palpation + 4
≥65 years 2 Ischemic ST depression Repolarization abnormalities PERC-positive. If none of these 7 elements
are present and clinician’s pre-test Intermediate risk 2-6 unilateral edema
Low risk No high risk features, reassuring CXR 45-64 years 1 New ischemic T wave Non-specific T-wave changes
probability is <15%, patient is PERC-
< 45 years 0 Bundle branch blocks negative; no need for further workup, as High risk > 6 Low risk < 4
Intermediate risk 1 high risk feature or widened mediastinum on CXR <2% chance of pulmonary embolism.
Vascular Disease–Max 2 points7 Vascular Risk Factors Digoxin effect Intermediate risk 4-10
High risk 2 or more high risk features
Known CAD or Obesity (BMI ≥ 30) Pacemaker rhythms
High risk > 10
Prior Stroke or 2 Smoker within 90 days LVH
Notes Peripheral Artery Disease Diabetes currently being treated Early repolarization
1. Single troponin may be considered if symptoms > 6 hours 1st degree relative with ACS < age 55 Non-specific ST changes
If No Known Vascular Disease
2. TEE and MRI can be used to exclude aortic dissection in place of CT aorta ≥3 Vascular risk factors 2 Diagnosed or treated hypertension
1-2 Vascular risk factors 1 Hypercholesterolemia
3. For assays with cutoff of 500 FEUs, age-adjusted is age x 10; for assays with cutoff of 250 DDUs,
age-adjustment is age x 5 0 Vascular risk factors 0
4. Patients who are low risk for aortic dissection by Aortic Dissection Detection (ADD) score but have Troponin
widened mediastinum on CXR or other clinical features that concern the clinician should be
>0.12 ng/mL 2
considered for advanced imaging
.041-0.120 ng/mL 1
5. Patients with profuse vomiting preceding chest pain, esophageal disease, or recent esophageal
instrumentation should be considered for advanced chest imaging to exclude esophageal rupture 0-0.040 ng/mL 0

6. Patients with unexplained hypotension should have pericardial effusion excluded by sonography

7. Known atherosclerotic disease (CAD, PAD, CVA) garners 2 points; if no known disease, calculate
score according to vascular risk factors bradley shy • reuben strayer • emupdates.com/cp