Beth Israel Deaconess Emergency Department Chest Pain Guidelines

I.CMED Admission Criteria and Management

  1. Admission Criteria
  2. ST segment changes with positive enzymes
  3. Unequivocal history for unstable angina (with EKG changes and/or risk factors)
  4. Exertional angina (with EKG changes and/or risk factors)
  5. Chest Pain or Anginal Equivalent with 4 or more high risk features (see legend)

b. Management

  1. EKG performed and read within 10 minutes of arrival
  2. ASA 325 mg (preferably 4 baby ASA)
  3. Sub-lingual nitroglycerin x 3 prn CP. This may be followed by nitropaste or IV NTG.
  4. Lopressor 5 mg IV x 3 q 5 min. if HR > 75 bpm. Follow with 25-50 mg oral Lopressor.
  5. Morphine if CP persists. Cardiac consultation in the Emergency Department if anginal symptoms do not resolve.
  6. Heparin if EKG and/or symptoms are highly suggestive of ischemia.
  7. Strongly consider GP IIB/IIIA receptor antagonist (e.g. Eptifibatide) if positive biomarkers and/or ST segment depression and high clinical suspicion for ongoing acute coronary syndrome.

II.Medicine Admission Criteria and Management

  1. Admission Criteria
  2. Chest Pain with </= high risk features and must NOT have ST segment changes or positive enzymes. Patients MAY have non-diagnostic EKG changes such as TWI if negative enzymes.
  3. Atypical chest pain with no ST changes and negative cardiac enzymes that meet CDU exclusion criteria.
  1. Management
  2. EKG performed and read within 10 minutes of arrival
  3. ASA 325 mg (preferably 4 baby ASA)
  4. Sub-lingual nitroglycerin x 3 prn CP. This may be followed by nitropaste or IV NTG.
  5. Lopressor 5 mg IV (may repeat if CP persists, high clinical suspicion and HR > 75 bpm) Follow with 25-50 mg oral Lopressor.
  6. Morphine if CP persists.

III.Clinical Decision Unit Admission Criteria and Management

  1. Admission Criteria
  2. Chest Pain with </= 3 high risk features and absence of ST segment changes or positive enzymes

Note: patients may have non-diagnostic EKG changes; i.e. TWI and still be CDU admits as long as they have negative enzymes and do not meet other CMED admission criteria.

Note: patients with TnT between .01 and 0.1 may be admitted to the CDU, however, they should have serial troponins drawn. If troponin is increasing, obtain cardiology consult and admit to hospital. If unchanged or decreasing, stress prior to discharge.

Note: Cocaine related chest pain should be observed in the ED proper.

  1. Management
  2. Aspirin 325 mg
  3. Consider SL nitroglycerin.
  4. CPK/TnT at 0 and 6 hours
  5. EKG at 0 and 6 hours
  6. Exercise/MIBI w/ or w/o imaging (see box)
  7. Cardiology consult (optional)
  1. CDU Exclusion Criteria
  2. AMI or unstable angina
  3. New LBBB
  4. Transient or fixed ST elevations
  5. Dynamic T wave changes
  6. ST depressions
  7. Abnormal cardiac enzymes
  1. Imaging Stress Tests are reserved for patients with LBBB, LVH, paced rhythms, digoxin therapy, >1mm of ST depression, and pre-excitation syndromes.
  • Predictors of 2 day MIBI studies or when warning patients (so they are willing to stay) that they may be in obs for 2 days.
  • 2-day cut offs:
  • 225 pounds for women
  • 275 pounds for men.
  • Not needed if stress images are normal or unchanged regardless of weight
  • For lower weight individuals we use a low-dose for the rest study and then a normal dose for the stress study. That way we can do both studies the same day. However, for larger patients the low-dose study is too noisy. That is particularly true for the attenuation correction images that are particularly important in the larger patients. For larger patients we use the normal dose for both rest and stress studies, but then we have to wait a day until the first dose has decayed.
  • One further complication is that if the stress portion of the study is perfectly normal, then they don't do the rest portion.
  • Bottom line: For women > 225 pounds of men > 275 pounds it is likely they will need a two day study. Rarely, they will be able to say the stress study is completely normal, and not do the rest portion.
  • NOTE: Patients that meet CMED admission criteria in the setting of a major primary non-cardiac diagnosis may either be admitted to CMED or a non-Farr 3 floor with a mandatory cardiology consult.