emDocs - June 12, 2020 - By Helman A. Originally published at EM Cases.
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"Take home points for low risk chest pain and high sensitivity troponins
- Missed ACS is more often a result of a failure to consider the diagnosis in patients with atypical symptoms rather than a failure to interpret troponin or use a clinical decision tool properly.
- Classic cardiac risk factors may be more useful in shifting pretest probability for ACS in younger patients; ask about non-traditional risk factors in young patients.
- A single undetectable hs-troponin after 3 hours of symptom onset or a delta 2-hr hs-troponin T <4ng/L plus normal serial ECGs and a HEART score of 0-3 rules out acute MI and lowers 30-day MACE to well below 1%, a threshold below which admission and/or ancillary testing may cause more harm than benefit.
- An absolute change in hs-troponin is recommended rather than relative percentage change to rule in acute MI
- The HEART pathway is the best clinical decision tool for ED low risk chest pain patients but has several limitations that are important to understand when applying the tool
- Ancillary testing including stress testing and CCTA in low risk chest pain patients should not be done routinely during/after an ED visit"