Chest pain pathway: from ER, ECG and troponin to the next test
Works through suspected ACS step by step: STEMI or STEMI equivalents, very high-risk features, the ESC 0h/1h hs-troponin algorithm with assay-specific cut-offs (hs-cTnT Elecsys, hs-cTnI Architect, or another assay) and NSTE-ACS invasive timing. Once ACS is ruled out, it uses the ESC 2024 clinical likelihood of obstructive CAD and the 2021 AHA/ACC chest pain categories to choose between deferring tests, CCTA, exercise ECG, stress echo (exercise or dobutamine), SPECT/PET, stress CMR and invasive angiography. It checks each test against the patient's contraindications, replaces CCTA with functional imaging when CCTA is unsuitable, and lists when angiography is indicated despite a normal troponin.
STEMI equivalents: posterior MI, De Winter T waves, and LBBB or paced rhythm meeting Sgarbossa criteria. See the STEMI equivalents tool.
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- Winther S, et al. Incorporating coronary calcification into pre-test assessment of the likelihood of coronary artery disease. J Am Coll Cardiol 2020;76:2421-2432.
- Mark DB, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:849-853.