Friday, September 4, 2015

Approach to Potential Ischemic Chest Pain in the Emergency Department

This is a lecture for my residents that I have done since the early 90's, and update every 3 years.  There is a lot of new data in the last few years, especially on high sensitivity troponin and on risk scores (e.g. HEART score, EDACS score etc.) and on Accelerated Diagnostic Protocols which use both risk scores and contemporary or high sensitivity troponin.

But there is also new data on chest pain characteristics.

High sensitivity troponin is not here in the U.S. yet, but I cannot believe that it will be long before approval, so you have to know this stuff!

There is no chief complaint that we see more than chest pain (or other symptoms of potential ACS).  Most do not have a clear initial diagnosis.  This is what I discuss here.

The lecture is detailed, but it is what every emergency physician should know.  I believe it is not more, not less.

It is 68 minutes, and designed so that you can pause at any moment to review the data in more detail.  There are references throughout in case you need to delve even further.

Thanks to Scott Joing for recording this.  Scott is our tech wizard and fine emergency physician, and co-editor of Ma and Mateer's standard EM ultrasound textbook.  He is the creator of

Also thanks to my incredibly bright and knowledgeable research partners, Fred Apple and Yader Sandoval,  and the Cardiac Biomarkers Research Lab at Hennepin and Minneapolis Medical Research Foundation.

Yader Sandoval ( made some great comments on CTCA:

The CT part was interesting.  However, as you pointed out, it all depends on what technology you are using and the experience you have. I can tell you that the listed contraindications are day-to-day cases at Minneapolis Heart Institute (Abbott Northwestern Hospital), where there is the most up to date scanner. At ANW they do ~ 20 CTs per day (many from ED or observation unit) and they very frequently do CT among patients with prior stents, CABG, Atrial Fib, PACs, and PVCs. Moreover (not yet available but likely soon introduced); CT Fractional Flow Reserve will likely shift practice also: CT will not only tell you whether there's a moderate lesion, but will also be able to assess whether there's hemodynamic significance or not (just as invasive FFR).


  1. Just an amazing compendium of everything you need to know when evaluating patients with chest pain in the emergency department! Thank you so much for putting this together.

    Minor point that just caught my eye: The top ECG at the 1:07:30 mark was performed at half-voltage. While there are still changes on the second ECG, that technical error is still a huge problem because it can attenuate otherwise apparent ST or T-wave abnormalities.

  2. Thank you Dr Smith! Very well done and immediately applicable to clinical practice while easy to comprehend.

  3. Thank you Dr Smith! Well done, easily understood, and readily applicable to practice. Plan to share with my Paramedic colleagues and EDMD's.

  4. EDACS score sounds really interesting and useful. I don't remember if you mentioned it, but do you know if EDACS score has been externally validated?

    1. Yes, but unpublished. It will be out soon. Those Aussies and New Zealanders are getting very productive.

  5. What is the idea of getting calcium score rather than proceed directly to CTCA , as CAC score is low sensitivity and specificity than CTCA ?

    1. There are variable practices dependent on the radiologist and reading cardiologist.


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