AC-YES


ACS Calculator: Your Evaluation Simplified

Beta Version - Under Construction - feedback welcomed

Instructions:


Best use case: Score after initial encounter (HPI, PE, ECG) prior to further results.


A score of 3+ is considered a rule in for ACS anything less necessitates modifiers, which add additional points, for rule in.


Note: A score of 2 places highest priority of rapidly evaluating for potential modifiers


This tool is dynamic and significant changes in ECG or Clinical Picture necessitate a fresh scoring from step one.

Step 1

Clinical Picture

(DO YOU BUY IT?)


Your pretest probability: Is it the top differential, on your working differential, or not?

Yes,

+2

Possible

+1

No

+0

Step 2

ECG Changes


The read raises YOUR pretest probability of ACS

Yes

+2

No

+0

YES

4 points

Rules in without further testing

Priority on time to treat treatment

YES

3 points

Rules in without further testing

Priority on treatment

Maybe

2 points

Rules in with modifier


POCUS very helpful for early rule-in prior to labs

Priority on modifier

Maybe

2 points

Rules in with modifier


POCUS very helpful for early rule-in prior to labs

Priority on modifier

NO

1 point

Rules in with 2 modifiers




NO

0 points

Requires 3 modifiers

+

Step 3

MODIFIERS

(+1 each*)

  1. Troponin

Not simply a positive result.


  • Must support ACS or raise the probability of it on your differential.


*Bonus point w/ repeat lab

(+1 each for +2 total)


Not simply a rise in value.


  • Result must meaningfully increase the probability on your differential including if repeated and second result.

  1. Bedside Echo

RWMA, HFrEF, etc.


  1. Values

Shared decision making.


  • Patient prefers aggressive treatment strategy prior to further testing


  • Risk/Benefit favors aggressive treatment (baseline poor EF, rural ED, low risk for bleeding, etc.)

  • 25 yo F w/ textbook vasovagal syncope at restaurant and reassuring ecg has unexpectedly positive hs troponin.



    Step 1: 0 Step 2: 0 Modifier: 1
    Total: 1



    Without change in clinical picture/ecg this scenario would require 2 or more modifiers to treat as ACS.

  • 65 yo F hx of COPD presents SOB. ECG unchanged from prior. Troponin elevated without alternative explanation.


    Step 1: 1 Step 2: 0 Modifier: 1
    Total: 2



    Without change in clinical picture/ecg this scenario would require a single modifier to treat as ACS.

  • 55 yo M hx of hypertrophic cardiomyopathy bibems c/o SOB.
    v/s: T: 103 HR: 140 SpO2: 78 BP: 220/120
    ECG reassuring. Echo reassuring. Troponin neg. Troponin #2: mild elevation.

    Step 1: 1 Step 2: 0 Modifier: 0
    Total: 1

    Explanation: Troponin in range expected given hx HCM and v/s.

    Without change in clinical picture/ecg this scenario would require 2 or more modifiers to treat as ACS.

Examples

See the calculator at work for various clinical scenarios.

Impetus

  • All too often an ACS workup seems to hinge on single lab result, the troponin. The improvements in the latest generation of cardiac enzymes has not changed the foundation of clinical diagnosis in conjunction ecg.

    While the term myocardial injury has been introduced in guidelines, the "NSTEMI" diagnosis is likely even more frequently misapplied—even in patients whose clinical presentation is incompatible. Conversely, the patient presenting with an occlusive myocardial infarction even with ecg changes (such as hyperacute t waves) alongside a concerning history all too often have care delayed or hindered if first lab result is deemed unimpressive.

    Curiously, this is often with the same physicians who voice subscription to the now ascending OMI paradigm (1) (2).

  • The origin of this calculator is a direct result of experiences training residents puzzled at aggressive treatment despite, or prior to, the all important troponin result. I felt like the way I approached chest pain was logical and challenged myself to see if could be made into a simple protocol.

    This calculator helps give the groundwork to consistently and logically diagnose and treat ACS while emphasizing the most important tests and interaction with patient. While the inspirational work of Dr. Smith and others has made it plain to see the merit of moving beyond NSTEMI / STEMI paradigm the path for HOW remains less clear.

  • In truth, by consistently assuming the responsibility for diagnosis and treatment of ACS via the calculator pathway I find I have very little trouble getting the catheterizations I need despite not being always a STEMI

    There is a real danger with so many pressures on the emergency physician to grind the specialty down to a "triage specialist" whose role is to brainlessly consult for the go ahead to treat the most obvious of cases or due to a spurious lab result.

    I firmly believe initial ACS management is best performed by the most experienced specialty who is bedside with the patient: the emergency physician. While our cardiology colleagues are are an invaluable asset and part of the team to be utilized when necessary. The aim of this tool is to foster similar ownership and confidence in others whom use it.

  • The ideal physician…

    is a thinking physician

  • The ideal physician

    Diagnoses and treats ACS proactively rather than reactively.

    Prioritizes real-time bedside evaluations and clinical picture.

    Confidently assumes ultimate responsibility for initial workup, management, and diagnosis with patient buy-in.

    Click on any heading to expand context

Values and Goals

References

Some excerpts from current guidelines relevant to understanding the calculator.