ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain

Abstract

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

Keywords: Acute coronary syndromes; Chest pain; Differential diagnosis; Emergency department.

Figure 1

Unusual ECG abnormalities during acute myocardial ischaemia. (A) Critical stenosis in the left main of the left coronary artery; (B) marked elevation of ST segment >5mm in leads V1–V2 with left bundle branch block and during chest pain; (C) significant abnormalities during chest pain under pace-maker rhythm.

Figure 2

Interpretation of elevated troponin values.

Figure 3

Selection of patient undergoing cardiac troponin assay in ED.

Figure 4

Decision-making on the basis of 12-lead ECG.

Figure 5

High sensitivity troponin algorithm 0 h/3 h.

Figure 6

In-hospital pathway through ED (A).

Figure 7

In-hospital pathway through ED (B).