Part 9: Acute Coronary Syndromes
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 16_suppl_2 Linguagem: Inglês
10.1161/circulationaha.110.985549
ISSN1524-4539
AutoresRobert E. O’Connor, Leo Bossaert, Hans-Richard Arntz, Steven C. Brooks, Deborah Diercks, Gilson Soares Feitosa-Filho, Jerry P. Nolan, Terry L. Vanden Hoek, D. Walters, Aaron Wong, Michelle Welsford, Karen Woolfrey, William J. Brady, Teresa Camp-Rogers, Marc J. Claeys, Alan Craig, R. Denman, Judith Finn, Chris A. Ghaemmaghami, Ian Jacobs, Michael C. Kurz, Dawn Yin Lim, Steve Lin, Venu Menon, Patrick Meybohm, Peter T. Morley, Dirk H Mueller, Hiroshi Nonogi, Brian J. O’Neil, Joseph P. Ornato, Julian Owen, Valeria E. Rac, Hiromi Seo, Kimberly A. Skelding, Christian Spaulding, Nico R. Van de Veire, Hiroyuki Yokoyama,
Tópico(s)Heart Failure Treatment and Management
ResumoHomeCirculationVol. 122, No. 16_suppl_2Part 9: Acute Coronary Syndromes Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBPart 9: Acute Coronary Syndromes2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations Robert E. O'Connor, Leo Bossaert, Hans-Richard Arntz, Steven C. Brooks, Deborah Diercks, Gilson Feitosa-Filho, Jerry P. Nolan, Terry L. Vanden Hoek, Darren L. Walters, Aaron Wong, Michelle Welsford, Karen Woolfrey, Acute Coronary Syndrome Chapter Collaborators William J. Brady, Teresa R. Camp-Rogers, Marc J. Claeys, Alan M. Craig, Russell Denman, Judith Finn, Chris Ghaemmaghami, Ian Jacobs, Michael C. Kurz, Dawn Yin Lim, Steve Lin, Venu Menon, Patrick Meybohm, Peter T. Morley, Dirk Mueller, Hiroshi Nonogi, Brian J. O'Neil, Joseph P. Ornato, Julian J. Owen, Valeria Rac, Hiromi Seo, Kimberly A. Skelding, Christian Spaulding, Nico R. Van de Veire and Hiroyuki Yokoyama Robert E. O'ConnorRobert E. O'Connor , Leo BossaertLeo Bossaert , Hans-Richard ArntzHans-Richard Arntz , Steven C. BrooksSteven C. Brooks , Deborah DiercksDeborah Diercks , Gilson Feitosa-FilhoGilson Feitosa-Filho , Jerry P. NolanJerry P. Nolan , Terry L. Vanden HoekTerry L. Vanden Hoek , Darren L. WaltersDarren L. Walters , Aaron WongAaron Wong , Michelle WelsfordMichelle Welsford , Karen WoolfreyKaren Woolfrey , Acute Coronary Syndrome Chapter Collaborators , William J. BradyWilliam J. Brady , Teresa R. Camp-RogersTeresa R. Camp-Rogers , Marc J. ClaeysMarc J. Claeys , Alan M. CraigAlan M. Craig , Russell DenmanRussell Denman , Judith FinnJudith Finn , Chris GhaemmaghamiChris Ghaemmaghami , Ian JacobsIan Jacobs , Michael C. KurzMichael C. Kurz , Dawn Yin LimDawn Yin Lim , Steve LinSteve Lin , Venu MenonVenu Menon , Patrick MeybohmPatrick Meybohm , Peter T. MorleyPeter T. Morley , Dirk MuellerDirk Mueller , Hiroshi NonogiHiroshi Nonogi , Brian J. O'NeilBrian J. O'Neil , Joseph P. OrnatoJoseph P. Ornato , Julian J. OwenJulian J. Owen , Valeria RacValeria Rac , Hiromi SeoHiromi Seo , Kimberly A. SkeldingKimberly A. Skelding , Christian SpauldingChristian Spaulding , Nico R. Van de VeireNico R. Van de Veire and Hiroyuki YokoyamaHiroyuki Yokoyama Originally published19 Oct 2010https://doi.org/10.1161/CIRCULATIONAHA.110.985549Circulation. 2010;122:S422–S465Note From the Writing Group: Throughout this article, the reader will notice combinations of superscripted letters and numbers (eg, "Chest Pain Observation UnitsACS-005A"). These callouts are hyperlinked to evidence-based worksheets, which were used in the development of this article. An appendix of worksheets, applicable to this article, is located at the end of the text. The worksheets are available in PDF format and are open access.The International Liaison Committee on Resuscitation (ILCOR) ACS-MI Task Force included expert reviewers from Africa, Asia, Australia, Europe, North America, and South America. These experts reviewed 25 topics related to the acute initial management of acute coronary syndrome (ACS), which was further categorized as unstable angina, non–ST-elevation MI (UA/NSTEMI) and ST-elevation MI (STEMI). Topics were identified based on previous recommendations, emerging science, and clinical importance, using an iterative writing process involving all Task Force members. The Task Force reviewed the evidence specifically related to diagnosis and treatment of ACS in the out-of-hospital setting and the first hours of care in the in-hospital setting, typically in the emergency department (ED). The evidence review took place over several years, with ongoing refinement of recommendations being made as new evidence was published. The purpose of the review was to generate current, evidence-based treatment recommendations for healthcare providers who serve as the initial point of contact for patients with signs and symptoms suggestive of ACS.The following is a summary of the most important changes in recommendations for diagnosis and treatment of ACS since the last ILCOR review in 2005.1,2The history and physical examination, initial ECG, and initial serum biomarkers, even when used in combination, cannot be used to reliably exclude ACS in the prehospital and ED settings.In contrast, chest pain observation protocols are useful in identifying patients with suspected ACS and patients who require admission or may be referred for provocative testing for coronary artery disease (CAD) to identify reversible ischemia. Such strategies also reduce cost by reducing unnecessary hospital admissions and improve patient safety through more accurate identification of NSTEMI and STEMI.The acquisition of a prehospital 12-lead ECG is essential for identification of STEMI patients before hospital arrival and should be used in conjunction with pre-arrival hospital notification and concurrent activation of the catheter laboratory.Nonphysicians can be trained to independently interpret 12-lead ECGs for the purpose of identifying patients with STEMI, provided that appropriate and reliable STEMI criteria are used. This skill is of particular value in the prehospital setting where paramedics may independently identify STEMI, thus mitigating over-reliance on ECG transmission.Computer-assisted ECG interpretation can be used to increase diagnostic accuracy of STEMI diagnosis when used alone or in combination with ECG interpretation by a trained healthcare provider.STEMI systems of care can be implemented to improve the time to treatment. The following measures have been shown to reduce the time to primary percutaneous coronary intervention (PPCI): institutional commitment, use of a team-based approach, arranging single-call activation of the catheterization laboratory by the emergency physician or prehospital provider, requiring the catheterization laboratory to be ready in 20 minutes, having an experienced cardiologist always available, and providing real-time data feedback.Intravenous (IV) β-blockers should not be given routinely in the ED or prehospital setting, but may be useful in a subset of patients with hypertension or tachycardia in the setting of ACS.The routine use of high-flow supplemental oxygen in ACS is not recommended. Instead, oxygen administration should be guided by arterial oxygen saturation.Reinforce the need for time targets for reperfusion beginning from the time of first medical contact (FMC). The clinical circumstances that favor fibrinolysis and PCI are discussed, including the role of prehospital fibrinolytics.The prophylactic use of antiarrhythmics is discouraged.Angiography and percutaneous coronary intervention (PCI) may be considered in patients with out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC). It may also be acceptable to perform angiography in selected patients, despite the absence of ST-segment elevation on the ECG or prior clinical findings such as chest pain.Despite progress in diagnostic and therapeutic strategies, numerous knowledge gaps have been identified during the discussions. These gaps include: Much of the research concerning the care of the patient with ACS has been conducted on in-hospital populations rather than specifically in the ED or out-of-hospital settings. By definition, extending the conclusions from such research to the early ED management or the out-of-hospital setting requires extrapolation.Strategies for improving layperson recognition of ACS and shortening time to diagnosis in vulnerable populations.The value of emergency dispatcher-initiated bystander administration of aspirin.Accurate decision rules for the early identification of patients with and without ACS in the prehospital and the ED settings.Feasibility of widespread paramedic interpretation of prehospital 12-lead ECGs versus reliance on transmission or computer interpretation.Impact on mortality of systems of care strategies designed to expedite reperfusion.The role of reperfusion including PCI in post–cardiac arrest care following either prehospital or in-hospital cardiac arrest, in the presence or absence of STEMI.The sensitivity and specificity of newer biomarkers for the detection of ACS.Is high-dose oxygen harmful in the setting of ACS?What is the role of analgesia and anxiolysis in patients with ACS?Optimal timing of platelet inhibition and anticoagulation in the prehospital and ED setting.While the time goals for reperfusion begin with first medical contact, time from symptom onset may be preferred, yet precise identification of this time point has been elusive.The American Heart Association and the American College of Cardiology, the European Society of Cardiology, and others have developed comprehensive guidelines for the in-hospital management of patients with STEMI and UA/NSTEMI, and the reader is referred to these guidelines for more detailed recommendations regarding the care of patients with ACS.3–6 The ILCOR CoSTR statements are intended to supplement these other resources by having a specific focus on the initial evaluation and treatment in the prehospital and ED phases of care. It is envisioned that these CoSTR documents will be used to develop treatment guidelines to assist providers during the initial acute phase of care.The prognostic and diagnostic use of the signs and symptoms of ACS, cardiac markers, and 12-lead ECG can have enormous impact on the initial impression and management of patients with suspected ACS. As such, it is important to evaluate the sensitivity, specificity, and clinical impact of various diagnostic strategies in ACS through a comprehensive evidence-based process.The 12-lead ECG in the ED and out-of-hospital settings is central to the initial triage of patients with possible ACS. Neither signs and symptoms nor cardiac markers alone are sufficiently sensitive to diagnose AMI or ischemia in the prehospital setting or the first 4 to 6 hours in the ED.Diagnostic Tests in ACSRisk StratificationDemographic FactorsACS-002A, ACS-002BFor patients with ACS, we evaluated whether any specific demographic factors (eg, age, sex, race, weight) were associated with delayed treatment and classified these delays according to whether they occurred before or after hospital arrival.Consensus on SciencePrehospital Treatment Delay. Thirty-five studies (LOE P17,8; LOE P39–40) showed that demographic factors, such as older age,8,11,16,19–25,28–31,35–39,41 female gender,7,10–13,16,19,21,22,25,26,28–35,37,38,42 nonwhite race,7,8,14,15,19–21,27,30,38–40 low socioeconomic status,7–9,17,18,37,38,41 and living alone19,25,7 are independent factors for prehospital treatment delay (symptom-to-door time).Twenty studies indicated that old age, female gender, nonwhite race and/or living alone did not show any association with prehospital delay times (LOE P243; LOE P313,17,20,24,25,36,40,41,44–54).As many studies analyzed more than one demographic factor for prediction of treatment delay, and one factor may predict delay while another factor was not found to be independent for prediction of delay, 8 studies were mixed in identifying factors associated with treatment delays (LOE P2).13,17,20,24,25,36,40,41In-Hospital Treatment Delay. Nineteen studies (LOE P28; LOE P39,10,14,19,29,39,42,55–62; LOE 563–65) showed that demographic factors, such as older age,8,19,29,39,55–58,60,61,63), female gender,8,10,19,29,39,42,55–58,60–64 nonwhite race,8,14,19,39,55,58–60,63–65 low socioeconomic status,8,9 and living alone19 are independent factors for in-hospital treatment delay (door-to-balloon, door-to-needle, or door-to-reperfusion time).Five studies indicated that older age, female gender, nonwhite race and/or living alone did not show any association with in hospital delay times (LOE P3).48,49,54,62,66 Most data on the impact of demographic factors on delay to treatment for patients with ACS have been derived from studies in North America.Treatment RecommendationVarious patient-related factors impede seeking medical help rapidly, but also add to further in-hospital treatment delay; these factors include older age, racial and ethnic minorities, female gender, low socioeconomic status and residing alone. Providers should be trained to expeditiously identify patients with ACS irrespective of age, gender, socioeconomic status, or living arrangements.Accuracy of History and Physical Examination for Diagnosing ACSACS-011In patients with suspected ACS in various settings (eg, prehospital, emergency or in-hospital), do specific historical factors, physical examination findings, and test results, compared with normal, increase the accuracy of diagnosis ACS and MI?Consensus on Science: DiagnosisFourteen studies (LOE 267–70; LOE 371–80;) did not support the use of any clinical signs and symptoms independent of ECG, cardiac biomarkers, or other diagnostic tests to rule in or rule out ACS in prehospital or ED settings. Although some signs are more sensitive and specific than others, no sign or symptom evaluated exceeded 92% sensitivity in the higher LOE studies (most reported sensitivity of 35% to 38%) or 91% specificity (range 28% to 91%).Four LOE 1 studies71,81–83 and 32 studies (LOE 3 to 5)24,31,52,67–70,72–75,78,84–103 suggest that individual clinical signs and symptoms lack sufficient sensitivity and specificity to be used alone and independent of ECG, cardiac biomarkers, or other diagnostic tests to rule in or rule out ACS in prehospital or ED settings.Consensus on Science: Prognosis and Clinical ImpactIn 34 studies (LOE 171,83,92; LOE 224,67–70,84,87,94,95,100; LOE 331,52,72–74,76–79,82,85,86,89,90,93,96–99,101,104) a variety of signs and symptoms assisted in the diagnosis of ACS and had clinical impact (defined as triage and some treatment and investigational decisions) on the prehospital emergency management and risk assessment for coronary atherosclerosis and unstable syndromes.Three LOE 1 meta-analyses/systematic reviews71,82,83 and 28 studies LOE 3 to 524,31,52,67–70,72–75,84–87,89–95,97–101,103 suggest that some clinical signs (eg, chest pain that radiates to the left arm, radiates to the right shoulder, or radiates to both arms, patients presenting with chest pain and sweating, S3 or hypotension, sweating, and/or vomiting, a history of risk factors [in addition to known coronary heart disease], and some demographic characteristics such as age) assisted in the diagnosis of ACS and had clinical impact (defined as influencing triage and some treatment and investigational decisions) on the out-of-hospital emergency management and risk assessment for ACS. One LOE 5 study103 and extrapolations from 27 other studies LOE 3 to 5 studies24,31,52,67–70,72–75,84–87,89–95,97–101 suggested that there are symptom clusters related to demographic factors such as age, race, and sex. These symptom clusters may have an impact on clinical decision making (defined as influencing triage and some treatment and investigational decisions). One systematic review/meta-analysis (LOE 181) found the sign of tenderness to chest wall palpation useful in ruling out a diagnosis of AMI.Treatment RecommendationSigns and symptoms alone are neither sensitive nor specific and should not be used without other data for making the diagnosis of ACS. Signs and symptoms may be useful in combination with other important information (biomarkers, risk factors, ECG, and other diagnostic tests) in making triage and some treatment and investigational decisions for ACS in the out-of-hospital and ED setting.ACS and NitroglycerinACS-030A-1, ACS-030A-2In patients with suspected ACS/STEMI in the ED and prehospital settings, does the use of nitroglycerin, compared with no nitroglycerin, improve diagnosis of ACS/MI?Consensus on ScienceFive studies (LOE D368,78,105; LOE D4106,107) using reduction in pain after nitroglyercin administration as an end point, found that reduction of pain does not reliably identify presence of ACS.Treatment RecommendationsA reduction in chest pain following nitroglycerin administration may be unrelated to the presence or absence of ACS, and should not be used as a diagnostic test or strategy in the prehospital or ED setting.ED Interpretation of 12-Lead ECG for STEMI12-Lead ECGACS-014In patients with suspected ACS in various settings (eg, prehospital or emergency), does the use of prehospital or emergency 12-lead ECG, compared with standard diagnostic techniques, increase sensitivity and specificity of diagnosis of ACS/MI?Consensus on ScienceOne study showed that prehospital or emergency ECGs had a sensitivity of 76% and a specificity of 88% for diagnosing acute cardiac ischemia in patients with chest pain (LOE D1).108 For diagnosing AMI, prehospital ECG had a sensitivity of 68% and a specificity of 97%. Two studies indicated that diagnostic accuracy of the prehospital ECG can be improved by repeating the ECG on arrival in the ED and by serial measurement of cardiac markers (LOE D2).109,110 Two studies showed that computer-interpreted electrocardiograpy or field-transmitted electrocardiography can be applied if no adequate interpretation of the prehospital ECG is available on site (LOE D1111,112).Treatment RecommendationIn patients with suspected ACS, a 12-lead-ECG should be acquired and interpreted by prehospital or emergency providers as soon as possible after first patient contact. The interpretation should be used in conjunction with the clinical signs and presentation for diagnosis and triage, including destination decisions and activation of the cardiac catheterization laboratory. If interpretation of the prehospital ECG is not available on site, field-transmission of the ECG for expert interpretation may be reasonable.Diagnosis of STEMI by NonphysiciansACS-007BIn patients with suspected ACS in the prehospital, ED, or in-hospital settings, can nonphysicians (eg, paramedics and nurses) accurately diagnose STEMI when compared to physicians?Consensus on ScienceEight observational studies reported paramedics can diagnose STEMI in the prehospital setting without transmission of a 12-lead ECG for physician consultation (LOE D3113–115; LOE D4116–119; LOE D5120). The limited evidence available about paramedic false-negative diagnostic decisions, including decisions not to obtain a 12-lead ECG, may affect paramedics' true overall diagnostic accuracy.Eight observational studies reported that nurses can diagnose STEMI in the context of nurse-initiated fibrinolysis programs (LOE D3121; LOE D4116,122–124; LOE D5125–127). The literature largely describes the ability of nurses to avoid false-positive diagnosis in fibrinolysis programs without substantial evidence about false-negative decisions, which may affect true overall diagnostic accuracy.Treatment RecommendationsIt is reasonable for paramedics and nurses to identify STEMI on a 12-lead ECG independently as long there is a mandatory program of initial training and ongoing concurrent medical oversight of all ECG interpretations.Computer-Assisted ECG InterpretationACS-008AIn patients with suspected ACS, does the use of computer-assisted ECG interpretation, compared with standard diagnostic techniques (emergency physicians), increase accuracy of diagnosis (eg, of NSTEMI/STEMI)?Consensus on ScienceTwo studies found evidence of improved diagnostic accuracy with the use of computerized ECG interpretation (LOE D5).128,129 Eight studies either found no effect or equivocal effect of the use of computerized ECG interpretation on diagnostic accuracy (LOE 1111,130–132; LOE D5133–136). Two studies found evidence that the use of computerized ECG interpretation decreased diagnostic accuracy (LOE D1).137,138 Three studies showed computer ECG interpretation relating to ACS to be reliable (LOE D1137; LOE 1111,130). The "gold standard" used most commonly was expert "electrocardiographer" review, although four studies used validated clinical diagnosis as the gold standard (LOE 1130; LOE D1111; LOE D1131; LOE D5133). Two studies reported a higher specificity for the computer-interpretation (identifying true negatives), while the physicians had a higher sensitivity (identifying true positives) (LOE 1111; LOE D1131). Three studies found that computer interpretation had a greater influence on nonexpert subject performance in interpreting ECGs than it did on more expert interpretation (LOE D1137; LOE D5135; LOE D5133).Treatment RecommendationPrehospital ECG interpretation should be augmented with computer interpretation. Computer interpretation of the ECG may increase the specificity of diagnosis of STEMI, especially for clinicians less experienced in reading ECGs. The benefit of computer interpretation is dependent on accuracy, and therefore computer-assisted ECG interpretation should not replace, but may be used as an adjunct to, interpretation by an experienced clinician. The computer interpretation should be considered in the clinical context.Diagnostic and Prognostic Test Characteristics of Cardiac Biomarkers for ACSProtein Markers of Coronary IschemiaACS-013BIn patients with suspected ACS in various settings (eg, prehospital, emergency, or in-hospital), do abnormal protein markers compared with normal levels allow the clinician to accurately diagnose acute coronary ischemia?Consensus on ScienceEight studies supported cardiac troponin testing alone in the diagnosis of AMI, when serum testing was drawn at least 6 hours from time of symptom onset or ED presentation, or drawn serially (LOE D2139–141; LOE D3142; LOE D4143–146).No studies showed adequate sensitivity of cardiac troponin testing outside of the ED or short-stay cardiac unit (LOE 2147; LOE 4148–150) including the ICU (LOE 4).151 Four studies showed increased sensitivity of new sensitive troponin assays compared with conventional troponin assays and supported their use to diagnose AMI (LOE D2152,153; LOE D3154; LOE D4155). Nine studies supported multimarker testing (CK-MB, ischemia-modified albumin or myoglobin) in combination with cardiac troponin in the diagnosis of AMI (LOE D2139,141,153,156–158; LOE D4145,156,159).There were heterogeneous data on the use of troponin point-of-care testing (POCT) in the diagnosis of ACS: 5 studies supported the use of troponin POCT (LOE D2145; LOE D4145,160–163), and 5 studies opposed the use of troponin POCT in the ED and cardiac short-stay units (LOE D3164; LOE D4165–168). Two studies opposed the use of troponin POCT in the prehospital setting (LOE D4),148,149 and 1 opposed the use of troponin POCT in the outpatient clinic setting (LOE D2).147Treatment RecommendationsClinicians should take into account the timing of symptom onset, the sensitivity, precision, and institutional norms of the assay, and the release kinetics and clearance of the measured biomarker.All patients presenting to the ED with symptoms suspicious of cardiac ischemia should have cardiac biomarker testing as part of an initial evaluation. A cardiac-specific troponin is the preferred biomarker. For patients who present within 6 hours of symptom onset suggestive of cardiac ischemia with negative cardiac troponin initially, it is recommended that a troponin level be remeasured between 6 and 12 hours after symptom onset. It is reasonable to use highly sensitive cardiac troponin assays, defined as having a 10% coefficient of variation at the 99th percentile, to evaluate patients with symptoms suspicious of cardiac ischemia. Multimarker evaluation with CK-MB or myoglobin in conjunction with troponin in patients with symptoms suspicious of cardiac ischemia may be considered to improve the sensitivity of diagnosing AMI.There is no evidence to support the use of troponin POCT in isolation as a primary test in the prehospital setting to evaluate patients with symptoms suspicious of cardiac ischemia.There is insufficient evidence to support the use of myoglobin, brain natriuretic peptide (BNP), NT-proBNP, D-dimer, C-reactive protein, ischemia-modified albumin pregnancy-associated plasma protein A (PAPP-A), and/or interleukin-6 in isolation as primary tests to evaluate patients with symptoms suspicious for cardiac ischemia.Prognosis for Discharge Versus AdmissionACS-004BIn patients with suspected ACS, does the presence of any specific factors (eg, history, examination, ECG, and/or biomarkers) or combination into a specific clinical decision rule compared with standard care increase accuracy of prediction of prognosis (eg, decision rule for early discharge)?Consensus on Science StatementsThere are no randomized controlled studies addressing clinical decision rules for ACS in the prehospital or ED settings. Existing studies do not adequately address the question because they are heterogeneous (LOE P1).169 There is not a single published clinical decision rule which is adequate and appropriate for identifying ED chest pain patients who can be safely discharged home from the ED (LOE P1).169Younger patients with no history of previous ischemic heart disease, atypical presentations, negative serial biomarkers, and a nondiagnostic 12-lead ECGs have a very low short-term rate of adverse events. Five studies demonstrated that younger patients with no history of previous ischemic heart disease, atypical presentations, negative serial biomarkers, and nondiagnostic 12-lead ECGs have a very low short-term rate of adverse events (LOE P2).88,170–175 One study demonstrated that older patients are evaluated less effectively and the subset of older patients who can be safely discharged from the ED are less easily identified than younger patients (LOE P2).88Five studies demonstrated that the combined use of serial biomarkers and ECGs in selected patients (ie, low risk, sensation-free, and clinically stable) can assist in the identification of a subset of patients who can be safely discharged from the ED (LOE P2).88,170,171,174,175 This statement is not directly age-dependent, although older patients demonstrate higher rates of ACS diagnosis and adverse outcome.Nine studies demonstrated that scoring systems derived from in-patient populations (eg, TIMI Risk Score or Goldman Criteria) are not appropriate for ED use and do not assist in the identification of patients who can be safely discharged from the ED (LOE P1176,177; LOE P3178–184).Treatment RecommendationsNone of the currently reported clinical decision rules should be used to select ED chest pain patients who can be safely discharged from the ED. Patients <40 years of age with non-classical presentations and lacking significant past medical history, who have normal serial biomarkers and 12-lead ECGs, have a very low short-term event rate.Chest Pain Observation UnitsACS-005AIn patients with suspected ACS, does the use of chest pain observation units (CPUs), compared with not using them, increase accuracy of diagnosis and safely identify patients who require admission or specific management of CAD?CPUs have been developed to assess patients with chest pain and normal initial biomarkers and non-ischemic ECG. The elements that define a CPU vary depending on the characteristics of the individual organizations and the clinical context in which the unit is sited (eg, ED versus in-patient environment versus dedicated site).Components of the CPU are typically a protocol or pathway based care strategy, dedicated physical space/infrastructure and staffing, use of an accelerated risk-stratification protocol comprising Measurement of serial biomarkers of acute infarction (eg, troponin or CK-MB)Serial ECG or continuous ECG monitoringA period of observation (6 hours)Integration with more advanced diagnostic testing (eg, exercise stress test, myocardial perfusion scan)Consensus on ScienceEleven studies of patients with chest pain and normal initial biomarkers and nondiagnostic ECGs demonstrated that CPUs result in reduced length of stay, hospital admissions, quality of life measures, and healthcare costs (LOE 1).185–195 One large case-control multicenter study showed that care in CPUs did not reduce the proportion of patients with chest pain admitted to hospital and may have increased ED attendances when implemented across a healthcare system (LOE 2).196 Fifty-five studies from many healthcare settings demonstrate that CPUs enable evaluation of patients systematically, with a short length of stay, high diagnostic accuracy, and a low event rate at follow-up (LOE 4).197–246Treatment RecommendationsIn patients with suspicion for ACS, normal initial biomarkers and nonischemic ECG, chest pain (observation) protocols may be recommended as a safe and effective strategy for evaluating patients in the ED.Chest pain observation protocols should include a history and physical examination, a period of observation, serial electrocardiography, serial measurement of serum cardiac markers, and either an evaluation for anatomic coronary disease or for inducible myocardial ischemia at some point after AMI is excluded. These protocols may be used to improve accuracy in identifying patients requiring in-patient admission or further diagnostic testing, and those who may be discharged.Chest pain protocols may be recommended as a means to reduce length of stay, reduce hospital admissions, reduce healthcare costs, improve diagnostic accuracy, and improve quality of life. Since CPUs have not been shown to a reduce hospital admission rates, these protocols must be monitored so that they do not lead to overutilization of hospital resources. There is also no direct evidence demonstrating that CPUs or observation protocols reduce adverse cardiovascular outcomes, particularly mortality for patients presenting with possible ACS, normal serum cardiac biomarkers, and a nondiagnostic ECG.Imaging TechniquesImaging Techniques and DiagnosisACS-006-1A, ACS-006-1BIn
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