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Appendix E1: Part A.

Chest Pain Worksheet

This worksheet is based on national guidelines for evaluation and disposition of patients with CP and is intended to guide but not substitute for clinical judgment.
I.	HISTORY, PHYSICAL, EKG:
	Treat and admit acute MI.
	If unable to perform EST (disability, age, LBBB, marked chronic EKG changes etc), exit guideline.
	ANGINA:
	• Chest pain occurring with exertion or stress and relieved by rest or nitrates. • Possible anginal equivalent (jaw, neck, ear, arm pain, dyspnea) with exertion or stress and relieved by rest or nitrates.
ANGINA LIKELIHOOD:
□DEFINITE□PROBABLE□PROBABLY NOT
II.	LIKELIHOOD OF SIGNIFICANT CAD:
	Y	N	Hx of prior MI or invasive, corrective procedures (CABG, stent, etc.)
	Y	N	Chest or left arm pain or discomfort as chief sx reproducing prior angina. (if pt has no hx of CAD, answer NO)
	Y	N	New MR, hypotension, diaphoresis, or rales
	Y	N	Dynamic ST segment deviation (>0.5 mm) with sxs
	Y	N	T-wave inversion (≥2 mm) in 2 contiguous leads with sxs
	Y	N	ST segment elevation or depression >1 mm
Any yes to the above, HIGH likelihood of CAD. Otherwise, continue:
	Y	N	Chest or left arm pain or discomfort as chief sx (if clearly not cardiac-chest wall pain, GERD, or pleurisy, answer NO)
	Y	N	Chest pain probably not angina with 2-3 cardiac risk factors
	Y	N	Diabetes
	Y	N	Extracardiac vascular disease (CVA, PVD, bruits, etc.)
	Y	N	ST depression 0.5 to 1 mm
	Y	N	T wave inversion ≥1 mm in leads w/ dominant R waves
	Y	N	Pathological Q waves
Any yes to above, INTERMEDIATE likelihood of CAD.
Otherwise, LOW likelihood of CAD, consider outpatient evaluation for noncardiac CP.
CAD LIKELIHOOD:
□HIGH□INTERMEDIATE□LOW

Appendix E1: Part B.

Unstable Angina1:

	• Rest angina - occurring at rest > 20 minutes occurring within one week of presentation • New onset angina - angina of at least Canadian Cardiovascular Society Classification (CCSC) III severity (walking < 2 blocks or climbing 1 flight stairs) within two months of presentation • Increasing angina - previously diagnosed angina that is distinctly more frequent, longer in duration or lower in threshold (but should be increased by at least one CCSC class within 2 months of initial presentation to at least CCSC III)
III.	RISK OF SHORT-TERM DEATH OR MORBIDITY:
	Y	N	Accelerating tempo of anginal sxs in preceding 48 hrs
	Y	N	Ongoing chest pain > 20 minutes. (Exclude chest pain not relieved by nitrates or analgesics, “probably not angina”.)
	Y	N	Angina w/ physiologic abnormality (S3, new/worse rales, murmur, hypotension, new or worsening MR).
	Y	N	Angina at rest (with dynamic ST changes ≥ 1 mm, new TWI, new BBB, VT)
Any yes, HIGH Risk → admit. Otherwise, continue:
	Y	N	Prior MI, PVD, CVA, or CABG
	Y	N	Prolonged (>20 min) rest angina resolved (but not low likelihood CAD)
	Y	N	Rest angina (<20 min) relieved with rest or sl NTG
	Y	N	Age > 70
	Y	N	New onset CCSC III (walking > 2 blocks or climbing 1 flight stairs) or CCSC IV (minimal exertion or rest) but not low likelihood CAD
	Y	N	T-wave inversions > 2 mm or pathological Q waves
Any yes, INTERMEDIATE Risk → Med/Card consult, admit, or go to Page 3. If all no, pt is considered LOW risk, may have outpatient evaluation and/or 72 hour EST.
	Y	N	Increased chest pain frequency, severity, duration, lower threshold but not CCSC III or IV
	Y	N	New onset chest pain within 2 weeks to 2 months
	Y	N	Chest pain occurred > 24 hours ago?
Any yes, LOW Risk → 72 hr EST. Otherwise, follow-up with PMD or routine EST.
RISK OF SHORT-TERM MORBIDITY AND MORTALITY:
□HIGH□INTERMEDIATE□LOW
High risk → AdmitIntermediate risk → consider CPULow risk → home
(Consult HBS)(Consult HBS)

Definition of unstable angina obtained from the ACC/AHA 2002 Guideline Update for the Management of Unstable Angina and Non-ST-Segment Elevation Myocardial Infaction. J Am Coll Cardiol 2002; 40 (7): pp. 2073-8. Also available at www.acc.org/clinical/guidelines/unstable/unstable.pdf. For description of CCSC classification I-IV see Table 4.