Appendix

Acute Chest Pain

Adult presenting with chest pain < 24 h. Exclude the five killers first.

Stepwise approach

    Is the patient hemodynamically unstable (SBP < 90, altered mental status, shock)?

    HEART score

    0
    Low risk (1.7% MACE) — consider early discharge

    Bedside differential

    • Acute coronary syndrome
      Pressure, exertional, radiation to arm/jaw, diaphoresis
    • Pulmonary embolism
      Pleuritic, dyspnea, tachycardia, DVT signs
    • Aortic dissection
      Tearing pain to back, pulse/BP differential
    • Tension pneumothorax
      Unilateral absent breath sounds, hypotension
    • Pericarditis
      Positional, friction rub, diffuse ST elevation

    Confirmatory criteria

    • NSTEMI: hs-troponin rise/fall > 99th percentile + ischemic symptoms/ECG
    • PE: Filling defect on CTPA
    • Aortic dissection: Intimal flap on CT aortography or TEE