Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary Syndromes

Official 2018 guideline from the American College of Emergency Physicians.

These guideline summaries are shared for educational purposes only and are not intended to direct patient care. For detail on the specific recommendations and information about the evidence considered by the guideline developer, we encourage you to go to the original guideline statement cited below.

Strength

Risk Stratification

In adult patients without evidence of ST-elevation acute coronary syndrome, the History, electrocardiogram [ECG], Age, Risk factors, Troponin (HEART) score can be used as a clinical prediction instrument for risk stratification. A low score (≤3) predicts a 30-day major adverse cardiac event miss rate within a range of 0% to 2%.

In adult patients without evidence of ST-elevation acute coronary syndrome, other risk-stratification tools, such as Thrombolysis in Myocardial Infarction (TIMI), can be used to predict a rate of 30-day major adverse cardiac event.

Diagnosis

Conventional Troponin Testing

In adult patients with suspected acute non–ST-elevation acute coronary syndrome, conventional troponin testing at 0 and 3 hours among low-risk acute coronary syndrome patients (defined by HEART score 0 to 3) can predict an acceptable low rate of 30-day major adverse cardiac events.

High-Sensitivity Troponin

A single high-sensitivity troponin result below the level of detection on arrival to the emergency department, or negative serial high-sensitivity troponin result at 0 and 2 hours is predictive of a low rate of major adverse cardiac events.

Accelerated Diagnostic Pathway

In adult patients with suspected acute non–ST-elevation acute coronary syndrome who are determined to be low risk based on validated accelerated diagnostic pathways that include a nonischemic electrocardiogram (ECG) result and negative serial high-sensitivity troponin testing results both at presentation and at 2 hours can predict a low rate of 30-day major adverse cardiac events allowing for an accelerated discharge pathway from the emergency department.

Further Diagnostic Testing

Do not routinely use further diagnostic testing (coronary computed tomography [CT] angiography, stress testing, myocardial perfusion imaging) prior to discharge in low-risk patients in whom acute myocardial infarction has been ruled out to reduce 30-day major adverse cardiac events.

Arrange follow-up in 1 to 2 weeks for low-risk patients in whom myocardial infarction has been ruled out. If no follow-up is available, consider further testing or observation prior to discharge (consensus recommendation).

Therapy

P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors may be given in the emergency department or delayed until cardiac catheterization.

Literature

Original/Primary Reference

Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown MD. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients with Suspected Non-ST-Elevation Acute Coronary Syndromes. Ann Emerg Med. 2018;72(5):e65-e106.

What do the ratings mean?

Level A

Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).

Level B

Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).

Level C

Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.