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2.3. Diagnostic Testing
2.3.1. Setting Considerations
COR LOE
Recommendations
1 B-NR 1. Unless a noncardiac cause is evident, an ECG should be
performed for patients seen in the office setting with stable
chest pain; if an ECG is unavailable the patient should be
referred to the ED so one can be obtained.
1 C-LD 2. Patients with clinical evidence of ACS or other life-
threatening causes of acute chest pain seen in the office setting
should be transported urgently to the ED, ideally by EMS.
1 C-LD 3. In all patients who present with acute chest pain regardless
of the setting, an ECG should be acquired and reviewed for
STEMI within 10 minutes of arrival.
1 C-LD 4. In all patients presenting to the ED with acute chest pain and
suspected ACS, cTn should be measured as soon as possible
after presentation.
3: Harm C-LD 5. For patients with acute chest pain and suspected ACS initially
evaluated in the office setting, delayed transfer to the ED for
cTn or other diagnostic testing should be avoided.
2.3.2. Electrocardiogram (ECG)
COR LOE
Recommendations
1 C-EO 1. In patients with chest pain in which an initial ECG is
nondiagnostic, serial ECGs to detect potential ischemic
changes should be performed, especially when clinical
suspicion of ACS is high, symptoms are persistent, or the
clinical condition deteriorates.
1 C-EO 2. Patients with chest pain in whom the initial ECG is consistent
with an ACS should be treated according to STEMI and
NSTE-ACS guidelines.
2a B-NR 3. In patients with chest pain and intermediate-to-high clinical
suspicion for ACS in whom the initial ECG is nondiagnostic,
supplemental electrocardiographic leads V7 to V9 are
reasonable to rule out posterior MI.
