rewFor a patient presented to emergency room due to non-traumatic chest pain

1 – viral sign should be taken immediately

a- If stable vitals go to 2
b- If unstable << resuscitation and cardiology consultation

2 – focused history and clinical examination and obtain 12 leads ECG within 10 minutes,, consider aortic
dissection if sharp severe pain radiate to back

a- If ecg shows stemi or stemi equivalent then treat according to hospital protocols
b- If no stemi or stemi equivalent go to 3

3- do a chest x ray for the patient

a- If chest x-ray diagnostic -pneumothorax – widened mediastinum- pneumonia – sign of

tamponade- treat according to cause
b- If chest x-ray not diagnostic go to 4

4- apply \heart score for the patient with serial ECG every 30 minutes

a- Is Troponin < lab cutoff or heart\ score < 3 points or st depression or dynamic ecg changes
b- if yes so consult cariologist
c- if no and troponin > lab cutoff more than 4 hours from onset of symptoms or 3 hours from ER
visit and two ecg are normal then go to 5

Risk Stratification
Low risk:
a- Very low Troponin level
b- Delta Troponin level > 5
c- HEART score > 3
**No ACS. Discharge to home.
Intermediate risk:
HEART score 4-6
**Admission
High risk:
HEART score 7-10
**Admission

5- scoring system for pe

a- YEAR criteria if zero then do PERC

b- If no YEAR and no PERC so PE is excluded
c- If 1-3 YEAR so obtain D-Dimer and if less than 500 so pe excluded if more than 500 so CTPA is
required
 d- If no year but any of PERC so obtain D-Dimer and if less than 1000 PE is excluded ,if more than
1000 so CTPA is required
e- If PE is excluded then go to 6

6 -consider another cause non-cardiac of chest pain

Appendix >> heart\heart score ,, year\perc criteria

Patient ID
□ Initial Assessment
History: □ Second Assessment

High-Risk Features: Low-Risk Features:

• Middle- or left-sided 2 points • Well localized
• Heavy chest pain 1 point • Sharp Pain
• Radiation 0 points • Non-exertional
• Diaphoresis • No diaphoresis
• N/V • No N/V
• Exertional Mostly high-risk features
• Relief of symptoms by sublingual nitrates Mixture of high-risk and low-risk features
Mostly low-risk features
□ Highly Suspicious
□ Moderately Suspicious
□ Slightly Suspicious

ECG:
□ New ischemic changes 2 points • Ischemic ST-segment depression
□ Non-specific changes 1 point • New ischemic T-wave inversions
• Repolarization abnormalities
□ Normal 0 points
• Non-specific T wave changes
• Non-specific ST-segment depression or
elevation
• Bundle branch blocks
• Pacemaker rhythms
• LVH
• Early repolarization
• Digoxin effect
• Completely normal

Age:
□ ≥ 65 2 points
□ 45-64 1 point
□ <45 0 points
Risk Factors:
□ Obesity (BMI >30)
□ Current or recent (<90 days) smoker
□ Currently treated diabetes mellitus
□ Family history of CAD (1st degree relative <55 y.o.)
□ Diagnosed and/or treated hypertension
□ Hypercholesterolemia

□ 3 or more risk factors listed above OR any of the following:

2 points
□ Known CAD=2 points
□ Prior stroke=2 points
□ Peripheral arterial disease =2 points

□ 1-2 risk factors 1 point

□ No risk factors 0 points
Ckmb(initial): Troponin (initial):
□ > 40 2 points □ > 3 normal
□ 0.25-40 1 point limit
□ 0-0.<25 0 points □ 1-3 normal
limit
□ less than
normal limit
HEARC Score (total points) Add points from each category above