This Expert Consensus Decision Pathway by the American College of Cardiology provides structure around the evaluation of chest pain in the emergency department (ED) through formulating recommendations incorporating evidence, expert opinion, guidelines, and critical appraisal of clinical decision pathways (CDPs). Of note, the document does not address the management of patients with definite acute coronary syndrome (ACS). Pathways described are centered around the use of high-sensitivity cardiac troponin assays and are not appropriate for use with older-generation assays. The following are 10 key points to remember from this important document:

1. The electrocardiogram (ECG) remains the best initial test for chest pain evaluation because it is rapid, inexpensive, and provides critical diagnostic and prognostic information. Serial ECGs over short intervals should be performed in patients with a high suspicion of ACS. Patients with nonischemic ECGs are eligible for entering a CDP.
2. Emergent transthoracic echocardiography for assessment of wall motion should be considered for patients with suspected ACS but a nondiagnostic ECG.
3. High-sensitivity troponin assays should be used in conjunction with rapid CDPs. These pathways allow safe exclusion (“rule out”) of myocardial infarction (MI) within 1-2 hours for the majority of ED chest pain patients, facilitating rapid disposition and discharge of low-risk patients.
4. High-sensitivity troponin levels represent a continuum of risk—no detectable level can be considered entirely “normal,” and the higher the level, the more likely it is related to ACS. Serial high-sensitivity troponin measurements—rather than the use of 99th percentile thresholds—are essential to confirm the diagnosis of MI.
5. False-positive and false-negative troponin assay results are rare but can occur. False-positives may be secondary to sample handling, instrument malfunction, assay interference, and macro-troponin complexes. False-negative values can occur as a result of assay interference from ingested substances such as biotin.
6. Various CDPs using high-sensitivity troponin measurements have been studied, including 0 hours, 0/1, 0/2, 0/3 hours, and the High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS) protocol, each with certain advantages and disadvantages. A recent meta-analysis demonstrated that the 0/3-hour approach is inferior to the others and should not be used.
7. These protocols reduced ED length of stay and increased the proportion of ruled out and dispositioned home compensated with traditional approaches. Approximately two thirds of patients with chest pain will be ruled out, and one quarter of patients will be categorized as intermediate risk using the 0/1-hour, 0/2-hour, or High-STEACS protocols.
8. Patients determined to be at intermediate risk require additional observation and frequently additional noninvasive testing. The choice of noninvasive testing should include patient factors, results of prior testing, test availability, timeliness of test reporting, and institutional expertise. Noninvasive testing is not required for most low-risk patients who rule out early with the rapid CDPs.
9. When available, coronary computed tomography angiography should be considered as the preferred noninvasive test for patients without known coronary artery disease presenting with chest pain and who are at intermediate risk.
10. Patients classified as high risk by the CDP should be categorized as having type 1 or 2 MI or acute versus chronic myocardial injury, with management targeting the precipitating cause of myocardial injury and clinical presentation.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Statins, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Angina, Stable, Arrhythmias, Cardiac, Biotin, Chest Pain, Consensus, Computed Tomography Angiography, Coronary Angiography, Coronary Artery Disease, Cytidine Diphosphate, Diagnostic Imaging, Echocardiography, Electrocardiography, Emergency Medicine, Emergency Service, Hospital, Heart Failure, Hemodynamics, Length of Stay, Myocardial Infarction, Patient Care, Patient Care Team, Patient Discharge, Risk, Secondary Prevention, ST Elevation Myocardial Infarction, Tomography, Troponin I, Troponin T

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