Chest Pain Observation Unit

Aka: Chest Pain Observation Unit, Chest Pain Emergency Department Observation Unit, Chest Pain EDOU

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II. Indications: Observation Unit Admission

  1. Low Risk Chest Pain in an intermediate to high risk patient
    1. Barriers to outpatient Chest Pain follow-up (e.g. lack of primary care, transportation, cognitive capacity)
    2. HEART Score 4 to 6 (thirty day major cardiac event risk of 12 to 17%)
  2. Initial emergency department thorough evaluation for Chest Pain presentations
    1. Electrocardiogram (single or serial)
    2. Serum Troponin (single or serial)
    3. Chemistry panel (consider hepatic panel and Lipase)
    4. Complete Blood Count
    5. Chest imaging
    6. Additional testing if indicated (e.g. D-Dimer, CTA Chest, Aortic Survey)
  3. Initial evaluation in Emergency department excluded conditions requiring inpatient care or intervention
    1. Excluded ST Elevation Myocardial Infarction (STEMI)
    2. Excluded Non-ST elevation Myocardial Infarction (NSTEMI)
    3. Excluded critical Chest Pain Causes (e.g. Pulmonary Embolism, Aortic Dissection, Pneumothorax, severe Pneumonia)

III. Contraindications

  1. Higher risk presentations (inpatient hospital admission is recommended or intervention is required)
    1. Ischemic EKG changes
    2. Hypotension
    3. Serum Troponin elevated above intermediate range
    4. Active, acute medical comorbidities requiring inpatient care
  2. Low risk presentations for which outpatient management is recommended
    1. Low Risk Chest Pain in a low risk patient (HEART Score 0-3, TIMI 0, T-Macs <1%)
    2. Recent negative cardiac workup
      1. Normal stress test in last 12 months
      2. No coronary stenosis on Coronary CT Angiogram (CCTA) in last 2 years
      3. Angiography with <50% coronary stenosis in last 5 years

IV. Evaluation

  1. Exercise Stress Testing modalities
    1. Exercise Stress Test
    2. Stress Echocardiogram
    3. Stress Myocardial Perfusion Imaging
  2. Cardiac Imaging with Pharmacologic Provocation
    1. Dobutamine Echocardiogram
    2. Myocardial Perfusion Imaging with Adenosine
    3. Myocardial Perfusion Imaging with Dipyridamole
  3. Alternatives and Adjuncts to Exercise Stress Testing
    1. CT Coronary Angiography
    2. MR Coronary Angiography
    3. Coronary Angiography
    4. CT Coronary Calcium

V. Management

  1. Consult cardiology as needed regarding cardiac evaluation and interpretation
    1. Ischemic EKG changes
    2. Serum Troponin elevation
    3. Abnormal cardiac stress testing or imaging (and consideration for Coronary Angiography, PTCA)
  2. Education
    1. Tobacco Cessation
    2. Hypertension Management
    3. Hyperlipidemia Management
    4. Diabetes Mellitus Management
  3. Disposition: Discharge indications
    1. Diagnostic studies reassuring without acute coronary ischemia or infarction
    2. Alternative Chest Pain Causes are sufficiently excluded
    3. Primary care follow-up

VI. References

  1. Busman and Pasternak (2025) Crit Dec Emerg Med 39(7): 4-13
  2. Berwanger (2017) Cochrane Database Syst Rev 2017(11):CD004820 [PubMed]
  3. Gulati (2021) Circulation 144(22):e368-e454 +PMID: 34709879 [PubMed]

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