Standardized emergency department protocol for non-traumatic chest pain: experience from the USL Umbria 1 Health Authority

This document describes the standardized corporate procedure developed by the USL Umbria 1 Health Authority to standardize the multidisciplinary approach to patients presenting with non-traumatic chest pain across its network of emergency departments, a common presentation requiring rapid differentiation between life-threatening conditions [e.g., acute coronary syndrome (ACS), aortic dissection, pulmonary embolism] and benign etiologies. The protocol mandates a structured pathway focusing on early risk stratification, including a 12-lead electrocardiogram (ECG) within 10 minutes of arrival and a comprehensive assessment to determine initial triage priority. For suspected ACS, the procedure involves serial cardiac biomarker (troponin) measurement (T0, T3h, and T6h) and HEART Score calculation to estimate the 30-day risk of major adverse cardiovascular events. High-risk patients (HEART Score 7 or clinically unstable) receive immediate cardiology consultation. Specifically for diagnosed ST-elevation myocardial infarction (STEMI) cases, the protocol integrates with the regional Umbria STEMI Network, ensuring immediate activation of the 118 emergency service for rapid secondary transport from spoke/antenna hospitals to a primary percutaneous coronary intervention (pPCI) hub center, with pPCI being the preferred reperfusion strategy and fibrinolysis reserved only if the time to pPCI exceeds 110-120 minutes from the first medical contact. Bedside echocardiography is an encouraged tool for rapid differential diagnosis and left ventricular function assessment. The implementation of this standardized, evidence-based protocol, integrated with the regional STEMI Network and leveraging rapid ECG teletransmission and risk scoring tools (Chest Pain Score, HEART), aims to ensure timely, guideline-driven, and appropriate care for all patients with non-traumatic chest pain across the USL Umbria 1 Emergency Departments.