Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

Publication Date: November 1, 2018
Last Updated: March 14, 2022


In adult patients without evidence of ST-elevation ACS, other risk-stratification tools, such as Thrombolysis in Myocardial Infarction (TIMI), can be used to predict rate of 30-day MACE. (C)

(1) In adult patients with suspected acute NSTE ACS, conventional troponin testing at 0 and 3 hours among low-risk ACS patients (defined by HEART score 0 to 3) can predict an acceptable low rate of 30-day MACE.
(2) A single high-sensitivity troponin result below the level of detection on arrival to the ED, or negative serial high-sensitivity troponin result at 0 and 2 hours is predictive of a low rate of MACE.
(3) In adult patients with suspected acute NSTE ACS who are determined to be low risk based on validated ADPs that include a nonischemic ECG result and negative serial high-sensitivity troponin testing results both at presentation and at 2 hours can predict a low rate of 30-day MACE allowing for an accelerated discharge pathway from the ED. (C)

Do not routinely use further diagnostic testing (coronary CT angiography, stress testing, myocardial perfusion imaging) prior to discharge in lowrisk patients in whom acute MI has been ruled out to reduce 30-day MACE. (B)

Arrange follow-up in 1 to 2 weeks for low-risk patients in whom MI has been ruled out. If no follow-up is available, consider further testing or observation prior to discharge. (C)
(Consensus recommendation)

P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors may be given in the ED or delayed until cardiac catheterization. (C)

Recommendation Grading




Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

Authoring Organization

Publication Month/Year

November 1, 2018

Last Updated Month/Year

June 9, 2022

Document Type


External Publication Status


Country of Publication


Document Objectives

This clinical policy from the American College of Emergency Physicians addresses key issues in the evaluation and management of patients with suspected non–STelevation acute coronary syndromes.

Target Patient Population

Patients with NSTEMI

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Emergency care

Intended Users

Paramedic emt, nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Management, Treatment

Diseases/Conditions (MeSH)

D009203 - Myocardial Infarction, D004635 - Emergency Medicine, D000072658 - Non-ST Elevated Myocardial Infarction


myocardial infarction (MI), emergency medicine, nstemi

Source Citation

Ann Emerg Med. 2018;72:e65-e106.


Number of Source Documents
Literature Search Start Date
January 1, 2005
Literature Search End Date
December 8, 2017