Diagnostic strategies for the evaluation of the patient presenting with chest pain

The approach to the patient with chest pain should be a risk-based, goal-driven, and time-dependent process. The entire protocol must be structured around the needs of the highest-risk patients, which places strict time constraints on the primary risk stratification process. Many highest-risk patients can be identified by clear ECG criteria that are the sole indication for specific treatments. However, most chest pain patients do not demonstrate obvious diagnostic criteria and thus must be allocated into secondary risk stratification pathways aimed at determining the likelihood of ACS.The ECG is the simplest, most inexpensive, and most rapid means for primary risk stratification of chest pain patients. It is limited by its relatively low sensitivity, and thus further testing is necessary when it is nondiagnostic. In other cases, the history and physical examination suggest a high-risk presentation. In many of these patients, further secondary risk stratification is necessary. It can be achieved via detection of myocardial necrosis using biochemical markers and detection of ischemia using MPI (and soon by biochemical markers for ischemia). The goals and strategies for using these modalities differ based on the primary risk assignment. Use of structured risk-based protocols ensures that the evaluation is appropriate for the given level of risk. This also allows for the insertion of new risk evaluation technologies as they become available in a manner that optimizes appropriate use and cost effectiveness.When the approach to the evaluation of patients presenting with chest pain proceeds in a systematic fashion, it is possible to evaluate large numbers of patients safely and cost-effectively, even when employing advanced technology. Although the fundamental goal remains the reduction of cardiovascular mortality through the rapid identification and treatment of high-risk patients, the ability to eliminate the inadvertent discharge of patients having an ACS is equally important. Such programs should be inclusive of all patients presenting with potential ACS, should proceed systematically, should consider both diagnostic and prognostic data for risk stratification, and should manage risk through goal and time strategies appropriate to the level of risk. 83