CHEST PAIN GUIDELINE

  Introduction:

The timely assessment, investigation and treatment for a patient presenting to 

the Emergency Department with atraumatic chest pain remains a challenge. 

The consequence of failing to promptly diagnose an ST elevation myocardial 

infarction is grave for the patient, delaying lifesaving and muscle saving 

treatment. In addition failure to recognise an atypical or evolving cardiac event 

by the triage nurse and clinicians may contribute to irreversible cardiac injury 

and even death. Similarly, patients with non ST elevation acute coronary 

syndromes are at increased risk of progression to ST elevation MI. However, 

perhaps up to 9 in 10 presentations with chest pain will not have an acute

cardiac cause and this presents an operational burden to ensure that there is 

time and space to risk assess all patients presenting with chest pain 

appropriately.

With the establishment of the Cardiac Assessment Unit (CAU), and to ensure 

that the NICE guidance NICE CG95 (last updated 2016): Chest pain of 

recent onset: assessment and diagnosis, specifically section 1.2 People 

presenting with acute chest pain, is fully complied with, the previous chest 

pain pathway document has been reviewed. It now provides some changes, 

which will help manage patients with possible acute coronary syndrome

ensuring that they rapidly and safely reach the correct specialty team as they 

present with atraumatic, non-pleuritic chest pain at the Emergency 

Department. Likewise, clinical teams must appreciate other possible life 

threatening causes of chest pain and hence early management and 

appropriate specialty referral.

Patients presenting to ED with chest pain, need prompt (within 10 minutes) 

ECG and risk assessment to facilitate appropriate escalation to either CAU, 

CCU/resuscitation room (and or transfer to tertiary centre), or referral to 

alternate specialty or discharge home.

The NICE guidance specifies each patient requires an ECG to be performed 

and interpreted within 10 minutes of arrival (and repeated every 15 minutes as 

required), along with a prompt clinical assessment, including assessment of 

the chest pain for cardiac features, timing of the last chest pain, a past 

medical history of confirmed CAD, risk factors for CAD and clinical 

assessment for haemodynamic instability including heart failure. 

The burden of this is well recognised and has driven the development and 

validation of several different risk assessment scores. Many of these have 

required a serum troponin estimation (or other cardiac enzyme marker) which

potentially delays this risk assessment for up to 6 hours. 

The EDACS accelerated diagnostic protocol (EDACS-ADP) study included 

patients with any symptoms lasting longer than 5 minutes that the attending 

physician thought were worth working up for possible acute coronary 

syndromes (ACS). This is a broader definition than other studies, such as the 

Vancouver Chest Pain Score, which only included chest pain patients.

Front Door Chest Pain Guideline v1 July 2020 Page 3 of 10

Why Use EDACS-ADP

Patients requiring serial blood testing (serial troponin markers, typically at 0 

and 6 hours, to rule out myocardial infarction) and further risk stratification 

require an extended ED evaluation or hospital admission, leading to 

crowding, bed allocation problems, and exposure of patients to side effects 

of increased testing. The study authors were able to find a group of low-risk 

patients (~45%) who could be safely discharged from the ED after 2 

biomarkers just 2 hours apart, along with ECG, history, and physical 

examination. 

When to Use EDACS-ADP

Use in patients with chest pain or other anginal symptoms but now pain-free

requiring evaluation for possible ACS, who may potentially be at low risk and 

appropriate for early discharge from the ED. 

The goal of these rules is to identify a low-risk population of patients who 

need less testing than other higher-risk patients. As a rule-out calculator, the 

EDACS is good at identifying who is relatively safe to go home (highly sensitive), but not good at identifying who does have the disease (not terribly 

specific). The fairly extreme goal of ≥ 99% sensitivity was achieved in the 

study (see the Evidence Appraisal section below). 

• The score was initially created without electrocardiogram (ECG) or 

biomarkers. These were added into the EDACS-ADP, which includes an ECG 

and troponin at 0 hours and at 2 hours. 

• The score was internally validated in the original paper, but has not yet been 

externally validated. 

Advice 

Barring other concerning features for ACS or other life-threatening causes of 

chest pain (pneumothorax, pulmonary embolism, cardiac tamponade, aortic 

dissection, oesophageal rupture, etc), patients who meet the low-risk criteria 

can be considered for discharge after negative 0-hour and 2-hour troponin 

testing, with close follow-up by a primary care physician. 

It is vital to remember that EDACS is not to be used where there is 

ongoing chest pain, haemodynamic instability, dynamic ECG changes 

or ST elevation or other clear evidence of high risk ACS. These patients 

should be fast tracked immediately to the cardiology team and CCU

Patients who do not meet the low-risk criteria cannot be ruled out using the 

EDACS or EDACS-ADP. As a rule-out calculator, the EDACS does not 

provide definitive guidance for treatment of patients who fail the rule, so 

physicians should use best judgment and follow other evidence-based chest 

pain guidelines. 

Critical Actions 

Patients deemed to be at low risk are safe for discharge to early outpatient 

follow-up investigation, or to proceed to earlier inpatient testing. For patients 

who are not at low risk, physicians should use best judgment, as this rule-out 

calculator was not designed to “rule in” patients with ACS. Physicians cannot 

use the EDACS to rule out ACS entirely.

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Front Door Chest Pain Guideline v1 July 2020 Page 5 of 10

Patient disposition based on risk assessment (without the result of Troponin) at 

triage (Observation & ECG within 10 minutes of registration) and initial 

assessment carried out by ED clinician (RAT):

ST elevation/new LBBB:

 Place patient in resuscitation room and follow STEMI pathway. Call CAT/ 

Cardiology nurse 8am- 8pm, Medical registrar 8pm-8am. Ensure patient is 

offered appropriate antiplatelet therapy (see STEMI pathway), opiate pain 

relief, GTN, oxygen and is on a monitor.

No ST Elevation

 If ECG shows dynamic ECG changes (for example ST depression, T wave 

inversion, new Q waves) or patient has a normal ECG with ongoing pain,

haemodynamic instability, left ventricular failure or shock, place patient in 

resuscitation room, monitor and offer dual antiplatelet therapy, nitrates, and 

opioid pain relief. Monitor oxygen saturations and offer oxygen if clinically 

indicated. Call CAT team/cardiology registrar 8am-8pm, medical registrar 

8pm-8am to assess and facilitate immediate transfer to CCU. (during times

of capacity difficulties on CCU the site team will need to prioritise transfer of 

non-acute, or general medical patients from CCU to medical wards as an 

emergency)

 Pain free patients with known coronary artery disease or patients with

histories highly suspicious of ACS in the history (eg EDACS moderate to high 

risk/ crescendo chest pain/ unstable angina pain/ rest pain), patient to be 

referred to CCU/ cardiology via CAT (8am-8pm) or medical registrar (8pm8am). Place on cardiac monitor, ensure on aspirin 300mg unless there is clear 

evidence of allergy and offered appropriate analgesia. Ensure regular repeat 

of ECGs (upto every 60 minutes and if the pain/symptoms return)

 Patients with >5 minutes of chest pain at rest in the last 12 hours who are now 

pain free and without ECG changes, ongoing pain or haemodynamic 

instability should be clinically assessed and have EDACS score calculated

(Low risk). Whilst CAU is open these patients should be transferred to CAU 

and managed via their pathway under the cardiac assessment team. OOHs 

patients should be managed on AMU. Repeat ECG within 60 minutes or 

immediately if pain recurs.

 Admit patient to CAU via CAT. CAT will take cardiac blood tests if necessary,

and escalate patients to CCU/AMU via matron/ medical/cardiology registrar/ 

consultant if there is no space capacity in CAU. If CAT nurses are unable to 

see patient within 30 minutes of referral, they should escalate patients to 

medical/cardiology registrar/ consultant. After 8pm, low risk patients to be 

referred to AMU

Front Door Chest Pain Guideline v1 July 2020 Page 6 of 10

 CCU will accept patients clerked by CAT nurses and thus avoiding delays in 

transfer from ED waiting for medical clerking.

 Patients with ongoing chest pain and/or haemodynamic instability should be 

discussed urgently with cardiology registrar (even if there are no ECG 

changes)

 Referred patients do not need to have chest X-ray done prior to transfer to CAU, but 

this investigation can be requested in the ED and performed once patients on their 

transfer way to CAU or thereafter, once patient has been provided with a CCU bed. 

However, the X-ray request will have the same urgency as if the patient was in ED.

Non Cardiac Chest Pain (Pleurisy, musculo-skeletal etc)

ED will manage non cardiac chest pain and refer appropriately to AEC/ med 

reg if deemed necessary. 

Patients assessed by CAU and CAT nurses deemed non-cardiac can be 

referred by them to AEC (if ambulatory, 8am-7pm) or Med Reg outside these 

hours, if they feel that the patient require further medical input/ management.

*Alternate diagnoses that must be considered (list is not exhaustive):

o Pulmonary Embolus

o Aortic dissection

o Pneumothorax

o Oesophageal rupture

o Gastrointestinal causes eg Pancreatitis

o Refer to trust guideline for Pulmonary Embolism (small to moderate) 

Diagnosis and Management 

http://thehub/c/documents/policies/Documents/Management%20o

f%20Small%20to%20Moderate%20PE%20guideline.pdf for use of 

D-Dimer.

o Patients are examined by ED if pain is non- pleuritic and discharged if 

deemed low risk of cardiac event or other significant pathologies ruled 

out.

o If Hs-cTnT level deemed necessary and is taken within 3 hours onset 

of symptoms, a second Hs-cTnT should be taken at least 3 hours after 

the onset of symptoms