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    Non-ST Elevation Acute Coronary Syndromes (beta)

    Official guideline from the American College of Emergency Physicians.

    Summary by Eric Steinberg, DO, and Hyunjoo Lee, MD
    Strength
    Level A
    Level B
    Level C

    Risk Stratification

    Risk Stratification
    1. 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%.
    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
    1. 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
    1. 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
    1. 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
    1. 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.
    2. 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

    Therapy
    1. P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors may be given in the emergency department or delayed until cardiac catheterization.
    What do the icons mean?  
    Research PaperFesmire FM, Decker WW, Diercks DB, et al. American College of Emergency Physicians. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Non-ST-segment Elevation Acute Coronary Syndromes. Ann Emerg Med. 2006;48(3):270-301.