What is the protocol for ruling out Acute Coronary Syndrome (ACS) in a patient with chest pain requiring admission?

From the Guidelines

The protocol for ruling out Acute Coronary Syndrome (ACS) in a patient with chest pain requiring admission should include a structured assessment and management plan, as outlined in the 2020 ESC guidelines for the management of acute coronary syndromes 1. This approach should begin with a thorough evaluation of the patient's presenting symptoms, including onset, duration, character, radiation, and associated symptoms, as well as vital signs, risk factors, and initial ECG and troponin results. Key elements of the management plan include:

• Initial aspirin 325mg loading dose, with additional antiplatelet therapy if indicated (e.g., clopidogrel 300-600mg or ticagrelor 180mg loading dose) 1
• Anticoagulation if appropriate (e.g., heparin drip or enoxaparin 1mg/kg BID) 1
• Symptom management with nitroglycerin, beta-blockers, and pain control as needed
• Serial troponins (typically q3-6h x3) and repeat ECGs to monitor for signs of ischemia or infarction 1
• Stress testing or cardiac catheterization if indicated, based on the patient's risk profile and clinical presentation 1 The goal of this approach is to rapidly identify patients with ACS and initiate evidence-based treatment, while also safely discharging patients with low-risk chest pain and minimizing unnecessary hospital admissions. It is also important to note that the use of troponin assays, in combination with clinical risk stratification tools, can help improve the accuracy of ACS diagnosis and identify patients with very low risk of major adverse cardiac events (MACE) 1.

From the Research

Protocol for Ruling Out Acute Coronary Syndrome (ACS)

The protocol for ruling out ACS in a patient with chest pain requiring admission involves several steps:

• Immediate electrocardiography (within 10 minutes of presentation) to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 2
• High-sensitivity troponin measurements to evaluate for NSTEMI 2
• Use of risk scores such as the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) risk scores to diagnose ACS 3
• Consideration of clinical findings and risk factors, such as prior abnormal stress test, peripheral arterial disease, and pain radiation to both arms 3
• Electrocardiogram findings, such as ST-segment depression and any evidence of ischemia, can also be useful in diagnosing ACS 3

Management of ACS

The management of ACS involves:

• Rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes for STEMI 2
• Fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration) if PCI within 120 minutes is not possible 2
• Prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours for high-risk patients with NSTE-ACS without contraindications 2
• Initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy 4

Importance of Early Diagnosis and Treatment

Early diagnosis and treatment of ACS are crucial to reduce mortality and improve outcomes 2, 5, 6, 4

• Delay in diagnosis and treatment can lead to increased morbidity and mortality 2, 5, 6, 4
• The use of risk scores and clinical findings can help identify patients at high risk of ACS and guide management decisions 3