State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

Circulation. 2016 Aug 16;134(7):547-64. doi: 10.1161/CIRCULATIONAHA.116.021886.


It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.

Keywords: acute coronary syndrome; chest pain; coronary computerized tomographic angiography; emergency service, hospital; risk assessment; troponin.

Publication types

  • Review

MeSH terms

  • Acute Coronary Syndrome / diagnostic imaging*
  • Acute Coronary Syndrome / epidemiology
  • Acute Coronary Syndrome / therapy*
  • Chest Pain / diagnostic imaging
  • Chest Pain / epidemiology
  • Chest Pain / therapy
  • Coronary Angiography / methods
  • Coronary Angiography / standards
  • Diagnosis, Differential*
  • Electrocardiography / methods
  • Electrocardiography / standards
  • Emergency Service, Hospital / standards*
  • Humans
  • Tomography, X-Ray Computed / methods
  • Tomography, X-Ray Computed / standards