ACS in the ED: Should They Stay or Go?
- Eric Steinberg
- May 4
- 3 min read
Clinical Scenario
A 55 year old woman with a history of hypertension and diabetes presents with chest pain for two hours. She describes it as a dull, burning and pressure-like pain in the middle of her chest that does not radiate. She denies any associated symptoms.
She is well-appearing with a normal cardiac, pulmonary, abdominal, extremity, and neurologic exam. Her EKG is normal sinus rhythm without ischemic changes.
After receiving Aspirin, Pepcid and Maalox, she states, “my husband made me come here, and my pain is completely gone… Can I go home now?”
Why Do We Have Clinical Decision Rules for Suspected Acute Coronary Syndrome in the ED?
Between 6-9 million patients present to the ED for chest pain annually.
Objectively risk-stratifying these patients may help guide management and optimize resource utilization, resulting in shorter hospital and ED stays for low risk patients, and earlier interventions for moderate- and high-risk patients.
Summary
Both HEART and EDACS are best utilized for identifying patients with suspected ACS who are at low risk for MACE. HEART Score is specifically designed for patients presenting with chest pain, whereas EDACS can be applied to a broader patient population with various symptoms suspicious for ACS, including those with chest pain.
Both HEART Pathway and EDACS-ADP can be applied using high-sensitivity troponin, resulting in a decreased number of low risk patients and rate of MACE.
Tool Comparison: HEART Score/Pathway vs. EDACS/EDACS-ADP
Purpose | Predicts 6-week risk of major adverse cardiac events (MACE).** Risk-stratifies patients into low, moderate, and high-risk groups. | Identifies patients who are at low risk of MACE***. |
Ease of Use | Requires input in five categories: History | EKG | Age | Risk factors | Troponin | Requires age, sex, and four specific symptoms and signs. May be perceived as more complex. |
Cardiac Enzymes | Requires one single troponin upon arrival. Most widely validated tool for regular-sensitivity troponin, though, has also been recently studied using high-sensitivity (hs) troponin. Using hs troponin significantly reduces the number of low risk patients, as well as MACE rate. | |
Distinguishing Factor(s) | Designed for risk stratification. All scores of 0-3 in the study were discharged and all scores >3 were admitted. | Included any symptoms (not just chest pain!) >5 minutes that the attending thought were worth working up for possible ACS. This is a broader definition than other studies. Does not require EKG or enzymes to ID low-risk patients. |
Performance | Most widely-validated. Similar negative predictive value to EDACS. | Well-validated. Similar negative predictive value to HEART. |
Accelerated Diagnostic Pathway (ADP) | HEART Pathway is an ADP to ID those safe for discharge at 3 hours. Requires a repeat, negative troponin at 3 hours to predict safe discharge. May be used with both regular- and high-sensitivity troponin. | |
*Unlike TIMI Risk Index or GRACE, these scores are designed to predict the likelihood of ACS in the patient presenting to the emergency department with acute chest pain. TIMI and GRACE are used to risk stratify patients who have been already-diagnosed with ACS.
**MACE (HEART Score) (Major Adverse Cardiac Event) was defined as all-cause mortality, myocardial infarction, or coronary revascularization.
***MACE (EDACS) - ST-elevation or non-ST-elevation MI, emergency revascularization, death from cardiovascular causes, ventricular arrhythmia, cardiac arrest, cardiogenic shock, high-grade AV block. | ||
Case Resolution
You explain to your patient that based on her history, risk factors, and physical exam, you recommend keeping her in the department for serial cardiac enzyme testing. She had two negative troponin tests at 0 and 3 hours, remained symptom-free, and has an appointment scheduled with her cardiologist tomorrow.