Chest Pain - Urgent Care

Action

1. Patient presents to urgent care with complaint of chest pain
2. Registration/check-in staff notifies nursing staff and patient is brought to exam room for immediate evaluation
3. Assess vitals, perform ECG, obtain history, perform physical examination
4. Utilize decision-making tool (Marburg Heart Score, HEAR Score)

Decision

ECG normal and low risk on Marburg Heart Score and HEAR Score?

Yes - Low Risk

No- Not Low Risk

Background

Differential Diagnosis of Chest Pain

ECG Changes and MACE

Scoring Systems

• HEAR (HEART) Score (MDCalc)
• “The HEAR score is a modification of the HEART Score that omits the troponin level. This makes it an ideal tool for UC clinics that do not have troponin testing capabilities, and the College of Urgent Care Medicine has embraced the use of the HEAR Score in UC settings.66 Initial research on the validity and specificity of the score for identifying low-risk cardiac pain has been supportive. A study of 1150 chest pain patients concluded that a HEAR Score ≤1 can identify the estimated 17% of all patients who are at very low risk for acute myocardial infarction and would be unlikely to benefit from troponin testing. As with any clinical prediction tool, the HEAR Score does not completely rule out ACS and should be used as a tool in a decision-making pathway and in conjunction with clinical gestalt.”
• Marburg Heart Score (MDCalc)
• “The Marburg Heart Score awards 1 point for each determinant found. Scores of 3 to 5 points were treated as positive predictors for CAD, while scores of ≤2 points were treated as negative. The score had a sensitivity of 86.4%, with a NPV of 97.3% and a false negative rate of 2.7%. The original study included a validation cohort in Switzerland that had an NPV of 97% (95% CI, 96.4%-99.1%), and other external validation studies have been done.”
• “The Marburg Heart Score does not include ECG, which is an essential tool for assessing patients with chest pain. Clinicians must utilize the tool in conjunction with patient assessment and history as well as clinical gestalt.”

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Identifying Urgent Care Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes | EB Medicine

About This Course Case Presentations Introduction Definitions Acute Coronary Syndromes Low-Risk Patient Etiology and Pathophysiology Differential Diagnosis Urgent Care Evaluation History Physical Examination Diagnostic Studies Electrocardiogram Biomarkers Risk Stratification and Clinical Risk Scores The TIMI Score The HEART Score Risk Stratification Scores Used in Settings Without Troponin Testing The Marburg

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Full Urgent Care Chest Pain Pathway

No, Not Low Risk

Yes, Low Risk