Littleton Regional Healthcare — ED accelerated diagnostic pathway for suspected ACS
Not a substitute for clinical judgment.
This algorithm is not applicable to patients with ESRD.
Personal decision-support aid — not part of any hospital IT system / EHR. Verify all values independently.
⚠ ESRD selected — this algorithm is not applicable to ESRD patients. Use clinical judgment.
1 Presentation
Patient presenting to the ED with symptoms suggestive of acute coronary syndrome, STEMI already excluded on EKG. If STEMI is present, use the STEMI cognitive aid on the Codes card instead — this pathway does not apply.
Sex assigned at birth — sets HEART troponin normal limit
Chest pain duration > 3 hours?
2 hs-Troponin — 0 / 1-hour (± 3-hr reflex)
Enter the 0-hr and 1-hr values. A 0-hr alone can complete the pathway (≥ 50 rules in; ≤ 3, or < 4 with pain > 3 h, rules out). A 3-hr value is only needed if the pathway reflexes.
–
1-hr Δ
Enter the 0-hr and 1-hr troponin to classify.
Troponin pathway logic (per posted protocol)
Condition
Result
Any hs-troponin ≥ 50 ng/L, or Δ ≥ 15 ng/L
Rule-in zone → consider cardiology consult
< 4 ng/L & chest pain > 3 h, or < 5 ng/L & Δ < 4
D/C home, outpatient follow-up as needed
Single 0-hr troponin: ≥ 50 (rules in) · ≤ 3 (below detection) · < 4 with pain > 3 h
Pathway completes without the 1-hr draw
5–49 ng/L & 0/1-hr Δ < 4
AMI ruled out → HEART score vs discharge w/ PCP
< 50 ng/L & 0/1-hr Δ ≥ 4 but < 15
Reflex to 3 h; then Δ < 15 → HEART score, Δ ≥ 15 → rules in
Δ is the absolute change between serial values. Not applicable to ESRD.
3 HEART Score
Used once AMI is ruled out to guide stress-testing vs discharge. Troponin points auto-fill from the 0-hr value and sex.
Consider a HEART score for discharge planning - always use your clinical accumen and patient preferences in association with any score
History
ECG
Age
Risk factors
— HTN, hyperlipidemia, diabetes, obesity (BMI>30), smoking (current/quit ≤3 mo), family history of CAD
Troponin — auto-fills from 0-hr value & sex; you can also tap it
–/ 10 points
Incomplete
4 Disposition
Recommendation
Complete the sections above
Enter the troponins, and (if AMI is ruled out) complete the HEART score.
Transfer center — DHMC Transfer Center: (877) 999-9870 — for cardiology consultation or transfer.
Disposition logic (per posted protocol)
Rule-in zone (any hs-Trop ≥50 or Δ≥15) → consider cardiology consult if clinically appropriate.
D/C home (<5 & Δ<4 on the 0/1-hr pair; or, on a single 0-hr, ≤3, or <4 with pain>3h) → discharge, outpatient follow-up as needed. Once a 1-hr value exists, the 0/1-hr Δ governs — a low 0-hr with a rising 1-hr reflexes to 3 h rather than discharging.
Reflex to 3 h (< 50 & Δ ≥ 4 but < 15) → repeat troponin; Δ≥15 rules in, else AMI ruled out.
AMI ruled out → apply HEART score:
0–3 (low) → D/C, no stress test, F/U PCP
4–6 (medium) → consider outpatient stress testing within 72 hours–1 week, using clinical acumen in conjunction with patient preference — emphasis on rapid follow-up with cardiology or PCP rather than a fixed hour count; document that follow-up is arranged, along with clear return precautions.
7–10 (high) → consider stress testing prior to d/c, using clinical acumen in conjunction with patient preference → D/C w/ PCP F/U or cardiology consult