What is the approach to rule out Acute Coronary Syndrome (ACS) in a patient with chest pain requiring hospital admission and a History and Physical (H&P) using DotPhrase?

From the Guidelines

For a chest pain admission H&P dotphrase to rule out acute coronary syndrome (ACS), I recommend using a structured template that includes chief complaint, history of present illness, risk factors, past medical history, medications, physical exam findings, initial diagnostic results, and assessment/plan, as outlined in the most recent guidelines 1. The dotphrase should begin with "Patient admitted for evaluation of chest pain concerning for possible ACS."

• Include detailed characterization of the pain (onset, quality, radiation, severity, exacerbating/alleviating factors), associated symptoms (dyspnea, diaphoresis, nausea), and timing.
• Document cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, family history) and prior cardiac history.
• Include initial ECG findings, troponin results, and other relevant labs, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. The physical exam should focus on vital signs, cardiac and pulmonary exams. The assessment/plan should outline the ACS rule-out protocol, which includes:
• Serial cardiac troponin I or T levels at presentation and 3 to 6 hours after symptom onset, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.
• Antiplatelet therapy, such as aspirin 325mg loading dose, then 81mg daily.
• Consideration of additional anticoagulation, such as heparin.
• Plans for further cardiac testing if indicated, such as stress test or cardiac catheterization, as outlined in the 2020 ESC guidelines 1. This structured approach ensures comprehensive documentation while facilitating efficient evaluation of patients presenting with chest pain that may represent ACS, and is supported by the most recent and highest quality evidence 1.

From the Research

Approach to Rule Out Acute Coronary Syndrome (ACS)

The approach to rule out ACS in a patient with chest pain requiring hospital admission involves a combination of clinical assessment, electrocardiogram (ECG) findings, and risk scores.

• The initial assessment should include a thorough History and Physical (H&P) to identify key symptoms and risk factors, such as chest discomfort, substernal pain, and radiation to the arms or jaw 2.
• The ECG is a crucial diagnostic tool, with findings such as ST-segment depression, ST elevation, T-wave inversion, or presence of Q waves suggesting ACS 2, 3.
• Risk scores, such as the HEART score or TIMI score, can be used to stratify patients into low, intermediate, or high risk for ACS 3, 4.
• The HEART score, which incorporates the first cardiac troponin, has been shown to provide more diagnostic information than the initial history, physical examination, and ECG alone 3.
• A modified HEART risk score has been validated in chest pain patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and may complement MACE risk assessment and patient triage in the emergency department 4.

Key Findings and Risk Factors

• Prior abnormal stress test, peripheral arterial disease, and pain radiation to both arms are clinical findings and risk factors most suggestive of ACS 3.
• ST-segment depression and any evidence of ischemia on the ECG are useful findings for diagnosing ACS 3.
• Elevated troponin levels without ST-segment elevation on electrocardiography suggest non-ST-segment elevation ACS 2.

Management and Referral

• Patients with suspected ACS should receive urgent referral for definitive risk stratification and management, including coronary angiography with percutaneous or surgical revascularization, dual antiplatelet therapy, and parenteral anticoagulation 5, 2.
• Hospital-based risk stratification and management should be guided by the patient's risk score and clinical presentation 5.