Updated October 2025

ED Chest Pain Playbook

Evaluation and Management of Chest Pain in the Emergency Department

A concise, evidence-based framework for rapid assessment, risk stratification, diagnostic pathways, and initial management of chest pain in the ED with emphasis on acute coronary syndrome, high-sensitivity troponin algorithms, and safe disposition.

Clinical question

How should clinicians in the ED evaluate, risk stratify, and manage adults presenting with nontraumatic chest pain, with specific emphasis on suspected acute coronary syndrome?

Emergency MedicineCardiologyACSTroponinRisk StratificationDisposition

Key points

Immediate Triage and ECG

Obtain ECG within 10 minutes; treat life threats. STEMI triggers emergent reperfusion.

High-Sensitivity Troponin Strategy

Use validated 0/1-h or 0/2-h algorithms; integrate absolute delta changes with clinical risk.

Structured Risk Assessment

Use HEART or EDACS with hs-cTn to guide disposition; aim for <1% 30-day MACE in discharge cohort.

Safe Disposition

Discharge low-risk with rapid follow-up; admit or observe intermediate-risk; activate cath for STEMI/high-risk NSTEMI.

Pathways and Chest Pain Centers

Standardized ED pathways and dedicated chest pain centers improve accuracy, speed, and resource use.

Evidence highlights

<10 minutes

Goal door-to-ECG

0/1-h or 0/2-h preferred

hs-cTn rule-out pathways

<1%

30-day MACE after low-risk rule-out

Rapid Care Pathway

Stepwise ED Approach to Chest Pain

A prioritized sequence from triage to disposition built on contemporary guidelines and consensus.

Primary Survey and Immediate Actions

Assess airway, breathing, circulation; place on monitor, obtain IV access, pulse oximetry. Obtain 12‑lead ECG within 10 minutes. Treat hypoxemia, severe hypertension, and arrhythmias. If STEMI is present, activate reperfusion pathway immediately ^[1].

Focused History and Risk Flags

Characterize pain (onset, exertional, pressure-like), associated symptoms (dyspnea, diaphoresis, syncope), risk factors (CAD, diabetes, CKD), and red flags (hemodynamic instability, new HF, ongoing ischemia). Consider important differentials: PE, aortic syndromes, pericarditis, pneumothorax, esophageal rupture ^[6].

Initial Diagnostics

Obtain hs-cTn at presentation with repeat per validated algorithm (0/1‑h or 0/2‑h), BMP, CBC if indicated. Chest radiograph for alternative diagnoses. Serial ECGs if ongoing pain or dynamic symptoms. Use hs‑cTn thresholds and absolute deltas to adjudicate MI per guideline-aligned pathways ^[6], ^[8].

Risk Stratification and Pathway Selection

Combine clinical impression with a structured score (e.g., HEART or EDACS) plus hs‑cTn trajectory to classify as low, intermediate, or high risk for 30‑day MACE. Low-risk patients with negative hs‑cTn and nonischemic ECG are candidates for ED discharge with expedited follow-up ^[3], ^[6], ^[8].

Treatment Aligned to Risk/Diagnosis

Provide analgesia, nitrates if ischemic pain and not hypotensive, and antiplatelet therapy when ACS is likely. STEMI: immediate reperfusion. NSTEMI/Unstable angina: antithrombotics and early cardiology evaluation; consider invasive strategy by risk profile ^[1], ^[6].

Disposition and Follow-up

Low risk: discharge with clear return precautions and rapid outpatient testing if indicated. Intermediate risk: ED observation with repeat hs‑cTn, ECGs, and possible noninvasive testing. High risk or diagnostic uncertainty: admit. Use chest pain center protocols to optimize throughput and outcomes ^[2], ^[7].

ED Tools

Key Checklists and Algorithms

Operational elements that standardize care and reduce missed ACS.

Time Targets

ECG completed and interpreted: ≤10 minutes

Repeat ECG: for persistent/recurring pain or dynamic changes

hs‑cTn repeat draw: 1 hour (preferred) or 2 hours per assay validation

hs‑cTn Algorithms

0/1‑h: baseline and 1‑h hs‑cTn; use assay‑specific rule‑out/rule‑in cutoffs and absolute delta

0/2‑h: alternative when 1‑h logistics limited

Single‑sample rule‑out possible if symptom onset >3 h and very low hs‑cTn, nonischemic ECG, low clinical risk ^[6], ^[8]

Risk Scores (with hs‑cTn)

HEART score: history, ECG, age, risk factors, troponin

EDACS: symptom characteristics + risk factors + age

Use scores to guide disposition; target <1% 30‑day MACE for discharge cohorts ^[3], ^[6]

Red Flags for Immediate Action

ST‑elevation or new LBBB with ischemic symptoms

Hypotension, shock, new/worsening heart failure

Refractory chest pain or dynamic ST‑T changes

Concern for aortic dissection, PE, tamponade, tension pneumothorax

ACS Initial Therapies

Aspirin loading if no contraindication

Nitrates for pain/ischemia; avoid if hypotension, RV infarct, or PDE‑5 inhibitors

Anticoagulation for NSTEMI/UA when diagnosis likely

High‑intensity statin initiation for confirmed ACS

Beta‑blocker if no contraindications; defer in shock/acute HF

Disposition Guide

Low risk + negative hs‑cTn algorithm + nonischemic ECG: discharge with expedited follow‑up

Intermediate risk: observation, serial hs‑cTn/ECG ± functional or anatomic testing

High risk or positive algorithm: admit; STEMI/NSTEMI pathways

Evidence Highlights

What the Evidence Supports

Synthesis of high‑impact findings informing ED chest pain care.

Guideline Consensus

Recent multisociety guidance endorses hs‑cTn‑based accelerated diagnostic pathways with early ECG and structured risk assessment to safely increase ED discharges while maintaining low 30‑day MACE rates ^[6].

High‑STEACS and Rapid Rule‑Out

Implementation of hs‑cTnI with low thresholds enables rapid rule‑out within 1 hour for many patients, reducing admissions without increasing adverse events; these strategies underpin modern ED pathways ^[8].

Chest Pain Centers and Pathways

Dedicated chest pain centers and standardized protocols improve diagnostic speed, accuracy, and cost‑effectiveness compared with ad hoc care, supporting system‑level adoption ^[2], ^[7].

Focused ACS Risk Stratification

Combining clinical scores (e.g., HEART/EDACS) with hs‑cTn trajectories improves identification of low‑risk cohorts suitable for discharge, aiming for <1% short‑term MACE, aligning with guideline thresholds ^[3], ^[6].

References

Source material

Primary literature that informs this article.