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Review
. 2024 Aug 22;25(8):302.
doi: 10.31083/j.rcm2508302. eCollection 2024 Aug.

How to Approach Patients with Acute Chest Pain

Kenji Inoue  1 , Tohru Minamino  2
Affiliations
Review

How to Approach Patients with Acute Chest Pain

Kenji Inoue et al. Rev Cardiovasc Med. .

Abstract

Acute coronary syndrome (ACS) is associated with high mortality rates. Although the goal was to achieve a missed diagnosis rate of < 1%, the actual data showed a rate of > 2%. Chest pain diagnosis has remained unchanged over the years and is based on medical interviews and electrocardiograms (ECG), with biomarkers playing complementary roles. We aimed to summarize the key points of medical interviews, ECG clinics, use of biomarkers, and clinical scores, identify problems, and provide directions for future research. Medical interviews should focus on the character and location of chest pain (is it accompanied by radiating pain?) and the duration, induction, and ameliorating factors. An ECG should be recorded within 10 minutes of the presentation. The serial performance of an ECG is recommended for emergency department (ED) evaluation of suspected ACS. Characteristic ECG traces, such as Wellens syndrome and De Winter T-waves, should be understood. Therefore, troponin levels in all patients with suspected ischemic heart disease should be examined using a highly sensitive assay system. Depending on the ED facility, the patient should be risk stratified by serial measurements of cardiac troponin levels (re-testing at one hour would be preferred) to determine the appropriate time to perform an invasive strategy for a definitive diagnosis. The diagnostics should be based on Bayes' theorem; however, care should be taken to avoid the influence of heuristic bias.

Keywords: 0-hour/1-hour algorithm; chest pain; emergency department; high sensitive cardiac troponin.

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Conflict of interest statement

Dr. Inoue received a research grant from Grant-in-Aid for Scientific Research C (No. 18K09954), Roche Diagnostics, SB Bioscience Co., Ltd., Fujirebio Inc., Bayel Sysmex, and Kanto Chemical Co. Inc. Dr. Minamino received a research grant from Roche Diagnostics. Kenji Inoue is serving as Guest Editor of this journal. We declare that Kenji Inoue had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Stefano De Servi. Otherwise, there are no conflicts of interest to declare.

Figures

Fig. 1.
Fig. 1.
The typical electrocardiogram (ECG) that should be considers for urgent coronary angiography. (A) Wellens syndrome. (B) De Winter T waves.
Fig. 2.
Fig. 2.
The 0-hour/1-hour algorithm with high sensitivity cardiac troponin T. The assay system to measure troponin must meet the conditions the International Federation of Clinical Chemistry recommends. NSTEMI, non-ST-elevation myocardial infarction.
See this image and copyright information in PMC

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