Evaluation in the Emergency Department and Cardiac Biomarkers

Coronary artery disease is the leading cause of death in the United States. Approximately 5 million patients present to the emergency department (ED) for chest pain-related complaints every year [1]. In addition, a signifi cant number of patients may present to the ED with atypical symptoms. Early diagnosis and management of acute coronary syndrome (ACS) may lead to a sig-nifi cant reduction in associated morbidity and mortality. ED physicians play an important role in the rapid diagnosis and management of patients with suspected ACS. This provides a diagnostic challenge to the emergency physician. In this chapter, we discuss various presentations of ACS and tools available for rapid diagnosis and immediate management of patients in the ED. In addition, we propose the development of algorithms for the appropriate triage of patients based on severity and diagnosis. We also discuss testing in the ED and prognostic information provided by it and its signifi cance in the subsequent management of the patient.

Chest pain represents one of three most common presenting symptoms by patients in the ED (along with abdominal complaints and fever). Approximately 1.4 million of these patients are admitted for management of unstable angina/ non—ST-elevation myocardial infarction (UA/NSTEMI) [1, 2]. The remainder of the patients may still have serious and life-threatening conditions, such as aortic dissection and pulmonary embolism (Table 5.1). It is therefore necessary that a prompt diagnosis be made and that early recognition and treatment be instituted. It has been increasingly recognized that management of conditions constituting ACS has been inconsistent and not concurrent with guidelines. With frequent and important changes occurring in the field based on results of recent clinical trials, it is most appropriate to develop an algorithm-based management strategy that reduces the variability in the management of these patients.