ED Chest Pain Evaluation Pathway

full pathway as png and pdf

This pathway was agreed upon by a hospital consortium; it is completely unsubstantiated by science and is only intended to serve as a supplement to your otherwise excellent clinical judgment.

Strengths: it reminds you to consider the 7 dangerous causes of chest pain, not just ACS. It’s pretty straightforward and based on well-validated decision tools.*

Weaknesses: chest pain is a complex problem that cannot be reduced to a pathway, even a pathway designed by smart, good-looking people. Don’t turn your brain off when using this or any other decision tool. Decision tools don’t take care of patients, you do.

credits: bradley shy, marc probst, nick genes and the HIC consortium.


*except the ADD score, which is not well validated and remains controversial. Nobody knows who needs a scan for dissection. Make sure you scan the patients who have very suggestive presentations, even though the vast majority of them will not have dissection. Think about dissection when patients have features in the score. Understand that you will eventually miss dissection because sometimes it presents in crazy atypical ways, and that if you try to catch very atypical dissections you will do more harm than good by overuse of CT.



Here is my list of features that, in patients with chest pain or back pain, indicate CT aortography:

risk factors
connective tissue disease
prior aortic procedure
aortic diseases
bicuspid aortic valve
hypertensive conditions (cocaine, pheo)

pain features
radiating posteriorly

+1 features
neuro symptoms
extremity malperfusion

pulse deficit/BP differential >20
neuro deficit
murmur of AI

widened mediastinum on CXR

Diagnosis of myocarditis, endocarditis, pericarditis / Pericarditis PV Card w Rx

Brady’s group offers a nice review in this month’s AmJEM.

Key excerpts:

“Clinical factors suggesting a diagnosis of myocarditis in individuals with ST-segment and T-wave abnormalities include a younger patient age (younger than 40 years), complaint of recent viral illness, slowly evolving ECG changes involving more than one vascular distribution, and diffuse?rather than focal?wall motion abnormalities on echocardiogram.”

“In a study of 137 patients with endocarditis diagnosed via the Duke criteria, 50% had AV block and 61% had intraventricular block, with overlap between the 2 groups.”

Punja et al, Electrocardiographic manifestations of cardiac infectious-inflammatory disorders. American Journal of Emergency Medicine (2010) 28, 364-377.