13 However, only 5.1% of patients presenting to the ED with chest pain are ultimately diagnosed with ACS, whereas more than half of these visits for chest pain are attributable to non-cardiac causes. Indeed, chest pain is the second-most common presenting concern of patients in emergency departments (EDs) in the US, representing approximately 6.5 million ED visits annually. The most common clinical presentation of ACS is acute chest pain however, triaging and identifying the underlying cause of chest pain can be a diagnostically challenging feat because most individuals with acute chest pain do not have an ACS. 8,9 Studies have shown greater angina severity at the time of diagnosis to be associated with higher mortality rates, cardiovascular hospitalizations, coronary revascularization, and overall healthcare costs. The Canadian Cardiovascular Society angina classification is a symptom severity scale used to assess and grade physical limitation due to symptoms. 4–7 Angina pectoris is defined as chest discomfort attributed to myocardial ischemia. Plaque rupture can subsequently lead to coronary artery occlusion, often without warning or with angina. 4 The pathophysiology of ACS involves disruption of coronary atherosclerotic plaque, leading to activation of platelets and the coagulation cascade. Early intervention for those with ACS can be life-saving thus, appropriate risk stratification is crucial.Ītherosclerotic lesions develop over many years, with one of the longest incubation periods known for human diseases. 2,3 The diagnosis of ACS is made based on clinical presentation, physical examination, ECG findings, and cardiac biomarker elevation. 1 Acute coronary syndrome (ACS) encompasses unstable angina, ST-elevation MI (STEMI), and non-ST elevation ACS (NSTE ACS). In this review, we describe contemporary risk stratification methods for acute coronary syndrome and summarize the recommendations put forth by the guidelines.Ĭoronary artery disease (CAD) affects more than 20.1 million adults in the US and remains the leading cause of mortality and morbidity. The contemporary risk stratification methods described in these guidelines allow for the identification of patient subgroups: patients who do not require further testing, patients who should proceed directly to the cath lab, and patients who will benefit from further anatomic or functional testing. The 2021 American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain represent the first ever guidelines for the evaluation of patients with acute chest pain. Initial evaluation should focus on characterizing symptoms and identifying risk factors, but further risk stratification using clinical decision pathways and biomarkers (cardiac troponin) is essential. Chest pain is one of the most common presenting concerns of patients seeking care in the emergency department, and the underlying etiology can range from acute coronary syndrome to various other non-cardiac causes.
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