Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes (Executive Summary): Approved by the ACEP Board of Directors June 27, 2018 Endorsed by the Emergency Nurses Association July 26, 2018

Abstract

For the complete list of authors including the members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) and to read this ACEP clinical policy please go to: https://www.annemergmed.com/article/S0196-0644(18)30678-4/fulltext. For the complete list of authors including the members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) and to read this ACEP clinical policy please go to: https://www.annemergmed.com/article/S0196-0644(18)30678-4/fulltext. This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of adult emergency department patients with suspected non–ST-elevation acute coronary syndromes. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the below critical questions. For each question a systematic literature search was performed, evidence was graded and synthesized, and recommendations were made based on the strength of the available data. 1.In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events? None specified. In adult patients without evidence of ST-elevation acute coronary syndrome, the History, ECG, Age, Risk factors, Troponin (HEART) score can be used as a clinical prediction instrument for risk stratification. A low score (≤3) predicts a 30-day major adverse cardiac event miss rate within a range of 0% to 2%. In adult patients without evidence of ST-elevation acute coronary syndrome, other risk-stratification tools, such as Thrombolysis in Myocardial Infarction (TIMI), can be used to predict a rate of 30-day major adverse cardiac events.2.In adult patients with suspected acute non–ST-elevation acute coronary syndrome, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events? None specified. None specified. (1) In adult patients with suspected acute non–ST-elevation acute coronary syndrome, conventional troponin testing at 0 and 3 hours among low-risk acute coronary syndrome patients (defined by HEART score 0 to 3) can predict an acceptable low rate of 30-day major adverse cardiac events. (2) A single high-sensitivity troponin result below the level of detection on arrival to the emergency department, or negative serial high-sensitivity troponin result at 0 and 2 hours is predictive of a low rate of major adverse cardiac events. (3) In adult patients with suspected acute non–ST-elevation acute coronary syndrome who are determined to be low risk based on validated accelerated diagnostic pathways that include a nonischemic ECG result and negative serial high-sensitivity troponin testing results both at presentation and at 2 hours can predict a low rate of 30-day major adverse cardiac events allowing for an accelerated discharge pathway from the emergency department.3.In adult patients with suspected non–ST-elevation acute coronary syndrome in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography [CT] angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events? None specified. Do not routinely use further diagnostic testing (coronary CT angiography, stress testing, myocardial perfusion imaging) prior to discharge in low-risk patients in whom acute myocardial infarction has been ruled out to reduce 30-day major adverse cardiac events. Arrange follow-up in 1 to 2 weeks for low-risk patients in whom myocardial infarction has been ruled out. If no follow-up is available, consider further testing or observation prior to discharge (Consensus recommendation).4.Should adult patients with acute non–ST-elevation myocardial infarction receive immediate antiplatelet therapy in addition to aspirin to reduce 30-day major adverse cardiac events? None specified. None specified. P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors may be given in the emergency department or delayed until cardiac catheterization.