{"text_format":"1","workbook":"xlsx","n_sheets":10,"sheets":["The heart Score","hs-cTn ","OMC-Lab","questions","Algorithm-Stress test","Observation-C.Pain-MCMC","Isch.Cascade","When S.T with Imaging first ","Typical-CP","ER-2-Hour-Prot."],"not_rendered":{"charts":0,"images":18,"macros":1,"external_links":0,"defined_names":13,"comments":2,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"The heart Score","index":0,"n_rows":51,"n_cols":11,"rows_kept":51,"cut":false,"hidden":false,"merged":[[50,2,51,12],[3,7,3,8],[0,1,0,9],[31,6,31,8],[32,6,32,8],[18,7,18,8],[10,7,10,8],[10,3,12,3],[26,0,26,1],[3,9,3,11],[4,9,4,11],[5,9,5,11],[7,9,7,11],[20,10,20,12],[6,6,6,7],[6,9,6,11],[40,6,40,9],[33,6,33,8],[37,6,37,9],[21,10,21,12],[22,10,22,12],[23,10,23,12],[24,10,26,12],[39,6,39,10]]}
[null,"Scoring system for patients presenting with chest pain at the emergency room of MCMC"]
[]
[null,"History ",null,{"$f":"IF(C3=\"Highly Suspicious \",2,IF(C3=\"Moderately Suspicious \",1,IF(C3=\"Slightly or Non-Suspicious \",0,IF(C3=\"\",\"\"))))","v":""}]
[null,null," ",null,null,null,"Score","Risk of MACE , next 6 wks ",null,"Action "]
[null,null,null,null,null,null,"0-3","Low ","<2%","Discharge Home "]
[null,null,null,null,null,null,"4 to 6","Medium ","10-30%","Admit for Clinical Observation & Consult cardiology "]
[null,"ECG ",null,{"$f":"IF(C7=\"Significant ST-Depression \",2,IF(C7=\"Non-specific Repolarization \",1,IF(C7=\"Normal \",0,IF(C7=\"\",\"\"))))","v":""},null,null,"4 to  6 with + troponin",null,null,"Consult cardiology "]
[null,null,null,null,null,null,"7 to 10","High ","50-70%","Consider early Invasive Strategy/transfer to OMC"]
[null,null,null,null,null,null,null," "]
[]
[null,"Age groub","65 years or older"]
[null,null,"Age 46 to 64 years ",null,null,"No","\u0080","Hx. of CAD ",null,{"$f":"IF(F12=\"Yes\",3,0)","v":0}]
[null,null,"45 years or younger ",null,null,"No","\u0080","Hypercholesterolemia ",null,{"$f":"IF(F13=\"Yes\",1,0)","v":0}]
[null,null,null,null,null,"No","\u0080","Hypertension ",null,0]
[null,"Risk Factors  ","Select Yes or No in the list to the right  ð",{"$f":"IF(J19=0,\"\",IF(J19=1,1,IF(J19=2,1,IF(J19>2,2,IF(J19=\"\",\"\")))))","v":""},null,"No","\u0080","Diabetes Mellitus ",null,0]
[null,null,null,null,null,"No","\u0080","Cigarette Smoking ",null,0]
[null,null,null,null,null,"No","\u0080","Positive Family History ",null,0]
[null,null,null,null,null,"No","\u0080","Obesity ",null,0]
[null,null,null,{"$f":"IF(C19=\"3 x upper Limit or more\",2,IF(C19=\"1-3x Normal Limit\",1,IF(C19=\"Within Normal Limit\",0,IF(C19=\"\",\"\"))))","v":""},null,null,null,"Total Risk Factors",null,{"$f":"SUM(J12:J18)","v":0}]
[null,"hs-Troponin ",null,{"$f":"IF(C20=\"> 51 ng/L (F), >76 ng/L (M) OR Delta 0/2h ≥ 20 ng/L\",2,IF(C20=\"Critical > 120 ng/L\",3,IF(C20=\"0h & 2h ≤ 51 ng/L (F), ≤76 ng/L (M) & Delta 0/2h  < 20ng/L\",1,IF(C20=\"0h < 8ng/L AND Delta 0/2h < 7ng/L\",0,\"\"))))","v":""},null,null,"Sex  ð",null,"Hs-Troponin"]
[null,null,null,null,null,null,"Time-0(00:00)"]
[null,null,null,null,null,null,"2-Hours"]
[null,"Total Score",null,{"$f":"SUM(D3:D22)","v":0},null,null,"Delta Time/HsTrop",{"$f":"H22-H21","v":"00:00:00"},{"$f":"I22-I21","v":0}]
[null,null,null,null,null,null,null,{"$f":"HOUR(H23)","v":0}]
[null,null,null,null,null,null,null,null,null,null,"hs-cTnT >50 ng/L or HEART score ≥7 appear effective strategies to identify high-risk NSTEMI at presentation to emergency room with chest pain."]
[]
["References"]
[null,null,null,null,"65 years or older",null,null,"3 or more Risk Factors or Hx. of CAD "]
["Highly Suspicious ",null,"Significant ST-Depression ",null,"Age 46 to 64 years ",null,null,"1 or 2 Risk Factors "]
["Moderately Suspicious ",null,"Non-specific Repolarization ",null,"45 years or younger ",null,null,"No Known Risk Factors"]
["Slightly or Non-Suspicious ",null,"Normal "]
[null,"   hs-Troponin-Olathe M.Center Lab -Different Analyzer",null,null,null,null,"3 x upper Limit or more"]
[null,"Early Rule out criteria",null,null,null,null,"1-3x Normal Limit"]
[null,"·        0h < 8ng/L AND Delta 0/2h < 7ng/L",null,null,null,null,"Within Normal Limit",null,null,null,"Age 65 years or older"]
[null,"Early Rule in criteria",null,null,null,null,null,null,null,null,"Age 46 to 64 years"]
[null,"·        Troponin > 51 ng/L (F), > 76 ng/L (M) OR Delta 0/2h  ≥ 20 ng/L ",null,null,null,null,null,null,null,null,"Age 45 years or younger"]
[null,"·        Critical > 120 ng/L",null,null,null,null,"MCMC"]
[null,"Continued observation – needs 4 hr troponin",null,null,null,null,"Critical > 120 ng/L"]
[null,"·        Chest pain onset < 2 hrs",null,null,null,null,"> 51 ng/L (F), >76 ng/L (M) OR Delta 0/2h ≥ 20 ng/L"]
[null,"·        0h and 2h ≤ 51 ng/L (F), ≤ 76 ng/L (M) AND Delta 0/2h  < 20ng/L",null,null,null,null,"0h & 2h ≤ 51 ng/L (F), ≤76 ng/L (M) & Delta 0/2h  < 20ng/L"]
[null,"Late Rule in ",null,null,null,null,"0h < 8ng/L AND Delta 0/2h < 7ng/L"]
[null,"·        Troponin > 51 ng/L (F), > 76 ng/L (M) OR Delta 0/4h ≥ 20 ng/L"]
[null,"Late Rule out"]
[null,"All Troponins ≤ 51 ng/L (F) ≤ 76 ng/L (M) AND Delta 0/4h  < 20 ng/L"]
[]
[null,null,"If high senetivity troponin level is ctritical, more than 120 nanogram per liter, or  more than 34 in females or more than 53 in males and the difference in two hours is more than 19, then MI is ruled in. "]
[null,null,"If Chest pain onset  was less than  2 hours,  or If high senetivity troponin level is less than 34 nanogram per liter in females or less than 53 in males, in 2 hours and difference is less than 20 then you need 4 hour troponin"]
[null,null,"Late Rule out All Troponins ≤ 34 ng/L (F) ≤ 53 ng/L (M) AND Delta 0/4h  < 20 ng/L"]
[null,"Male"]
[null,"Female"]
[null,"MACE: ","Major adverse cardiac events (MACE); a composite end point of all-cause mortality, myocardial infarction, or coronary revascularization during the index visit or within 30 days. "]

{"sheet":"hs-cTn ","index":1,"n_rows":70,"n_cols":20,"rows_kept":70,"cut":false,"hidden":false,"merged":[[0,19,0,20],[1,19,1,20],[2,19,2,20],[3,19,3,20],[4,19,4,20],[0,2,0,5],[2,10,2,11],[8,7,8,8],[8,10,8,11],[23,11,23,12],[2,0,2,5],[14,7,14,11]]}
[null,null,"High Sensetivity Troponin    hs-cTn ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Diagnosis","Peak hs TnI (ng/L)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Chronic Injury","55 (34-145)"]
["OMC - Lab",null,null,null,null,null,null,"0 h","∆ 0/2-3",null,"Results",null,null,null,null,null,null,null,"Acute Injury","74 (37 - 307)"]
["Early Rule out criteria",null,null,null,null,null,null,"< 3 ng/L",null,"ð","Rule-Out @ 0 h","NPV: 99.8%",null,null,null,null,null,null,"Type 2 MI","125 (48 - 604)"]
["·        0h < 8ng/L AND Delta 0/2h < 7ng/L",null,null,null,null,null,null,null,null,null,null,"Sens: 99.5%",null,null,null,null,null,null,"Type 1 MI","855 (104 - 6755)"]
["Early Rule in criteria",null,null,null,null,null,null,"< 6 ng/L","< 7 ng/L","ð","Rule-Out @ 2-3 h","NPV: 99.8%"]
["·        Troponin > 34 ng/L (F), > 53 ng/L (M) OR Delta 0/2h  ≥ 20 ng/L ",null,null,null,null,null,null,null,null,null,null,"Sens: 99.5%"]
["·        Critical > 120 ng/L"]
["Continued observation – needs 4 hr troponin",null,null,null,null,null,null,"Other",null,null,"Continue Evaluation"]
["·        Chest pain onset < 2 hrs"]
["·        0h and 2h ≤ 34 ng/L (F), ≤ 53 ng/L (M) AND Delta 0/2h  < 20ng/L",null,null,null,null,null,null,"≥ 120 ng/L","ð","Yes","Rule-In @ 0 h","PPV: 70%"]
["Late Rule in ",null,null,null,null,null,null,"ò",null,null,null,"Spec: 96.5%"]
["·        Troponin > 34 ng/L (F), > 53 ng/L (M) OR Delta 0/4h ≥ 20 ng/L",null,null,null,null,null,null,"No","≥ 20 ng/L","ð","Rule-In @ 2 -3 h","PPV:69 %"]
["Late Rule out",null,null,null,null,null,null,null,null,null,null,"Spec: 99 %"]
["All Troponins ≤ 34 ng/L (F) ≤ 53 ng/L (M) AND Delta 0/4h  < 20 ng/L",null,null,null,null,null,null,"Ann Emerg Med. 2019; 76: 1-13 "]
["Comments: "]
["©    Strategies employing either very low levels of hs-cTn on presentation or the lack of any change over a 1 or 2 h period after presentation have been advocated to exclude myocardial injury and MI (the NPVis better than the PPV)."]
["©     Troponin is a better rule-out test than a rule-in test. "]
["©     The negative predictive value is better than the positive predictive value. "]
["ü If the patient’s result is < 99th percentile: at least a 50-60% change"]
["ü If the patient’s result is  > 99th percentile: at least a 20% change"]
["ü Absolute changes are assay dependent but appear superior to relative percent changes"]
[]
["Journal of the American College of Cardiology August 2018"]
[]
[]
[]
[]
[]
[]
[]
[null,null,"Reasons for the Elevation of Cardiac Troponin"]
[null,null,"Values Because of Myocardial Injury"]
[null,null,"1.     Myocardial Injury Related to Acute Myocardial Ischemia"]
[null,null," ",null,"Atherosclerotic plaque disruption with thrombosis"]
[null,null,"2.     Myocardial Injury Related to Acute Myocardial Ischemia because of oxygen supply/Demand Imbalance"]
[null,null,"A ) Reduced myocardial perfusion"]
[null,null,"P Coronary artery spasm"]
[null,null,"P Microvascular dysfunction"]
[null,null,"P Coronary embolism"]
[null,null,"P Coronary artery dissection"]
[null,null,"P Sustained bradyarrhythmia"]
[null,null,"P Hypotension or shock"]
[null,null,"P Respiratory failure"]
[null,null,"P Severe anemia"]
[null,null,"B ) Increased myocardial oxygen demand"]
[null,null,"P Sustained tachyarrhythmia"]
[null,null,"P Severe hypertension with or w/o ventricular hypertrophy"]
[null,null,"3.     Other Causes of Myocardial Injury"]
[null,null,"Cardiac conditions"]
[null,null,"©     Heart failure"]
[null,null,"©     Myocarditis"]
[null,null,"©     Cardiomyopathy (any type)"]
[null,null,"©     Takotsubo cardiomyopathy"]
[null,null,"©     Coronary revascularization procedure"]
[null,null,"©     Cardiac procedures other than revascularization"]
[null,null,"©     Catheter ablation"]
[null,null,"©     Defibrillator shocks"]
[null,null,"©     Cardiac contusion"]
[null,null,"Systemic conditions"]
[null,null,"֎  Sepsis, infectious disease"]
[null,null,"֎  Chronic kidney disease"]
[null,null,"֎  Stroke, Subarachnoid hemorrhage"]
[null,null,"֎  Pulmonary embolism"]
[null,null,"֎  Pulmonary hypertension"]
[null,null,"֎  Infiltrative diseases, e.g. amyloidosis, sarcoidosis"]
[null,null,"֎  Chemotherapeutic agents"]
[null,null,"֎  Critically ill patients"]
[null,null,"֎  Strenuous exercise"]
[null,null,"4 th UDMI Am Coll Card Aug 7, 2018"]

{"sheet":"OMC-Lab","index":2,"n_rows":15,"n_cols":4,"rows_kept":15,"cut":false,"hidden":false,"merged":[[2,3,2,8]]}
[]
[]
[null,null,null,"OMC - Lab"]
[null,null,null,"Early Rule out criteria"]
[null,null,null,"·        0h < 8ng/L AND Delta 0/2h < 7ng/L"]
[null,null,null,"Early Rule in criteria"]
[null,null,null,"·        Troponin > 34 ng/L (F), > 53 ng/L (M) OR Delta 0/2h  ≥ 20 ng/L "]
[null,null,null,"·        Critical > 120 ng/L"]
[null,null,null,"Continued observation – needs 4 hr troponin"]
[null,null,null,"·        Chest pain onset < 2 hrs"]
[null,null,null,"·        0h and 2h ≤ 34 ng/L (F), ≤ 53 ng/L (M) AND Delta 0/2h  < 20ng/L"]
[null,null,null,"Late Rule in "]
[null,null,null,"·        Troponin > 34 ng/L (F), > 53 ng/L (M) OR Delta 0/4h ≥ 20 ng/L"]
[null,null,null,"Late Rule out"]
[null,null,null,"All Troponins ≤ 34 ng/L (F) ≤ 53 ng/L (M) AND Delta 0/4h  < 20 ng/L"]

{"sheet":"questions","index":3,"n_rows":9,"n_cols":12,"rows_kept":9,"cut":false,"hidden":false,"merged":[[0,2,0,8],[1,2,1,8],[3,1,3,9],[5,1,5,9],[8,1,8,9],[6,1,6,9],[7,1,7,9]]}
[null,null,"Chest pain with negative Cardiac Enzymes"]
[null,null,"Determining the appropriate Stress Test"]
[]
[1,"Is the patient with an intermediate or high probability of CAD ? Age, risk factors, typical chest pain, etc.",null,null,null,null,null,null,null,null,"Yes","No"]
[2,"Contraindccations to stress testing (e.g., CHF, acute MI or unstable angina, serious arrhythmias, endocarditis, acute pericarditis, P. embolus or infarction)? ",null,null,null,null,null,null,null,null,"Yes","No"]
[3,"Symptoms or clinical findings warranting angiography? ",null,null,null,null,null,null,null,null,"Yes","No"]
[4,"Can the patient exercise and walk without assistance at a normal pace?",null,null,null,null,null,null,null,null,"Yes","No"]
[5,"Known coronary artery disease by history or angiography? ",null,null,null,null,null,null,null,null,"Yes","No"]
[6,"Resting ECG abnormalities? Like LBBB",null,null,null,null,null,null,null,null,"Yes","No"]

{"sheet":"Algorithm-Stress test","index":4,"n_rows":27,"n_cols":20,"rows_kept":27,"cut":false,"hidden":false,"merged":[[2,14,2,20],[24,0,24,1],[18,4,18,15],[22,4,22,6],[22,8,22,12],[0,4,0,5],[20,8,20,9],[2,2,2,10],[7,1,7,5],[10,0,10,3],[14,1,14,3],[17,0,17,2],[9,9,9,19],[7,9,7,11],[13,5,13,20],[20,0,20,3],[4,1,4,15]]}
[null,null,null,null,"Chest pain ",null,"Determining the appropriate Stress Test"]
[]
[null,"\n","Patient  with an intermediate (10 to 20 percent) to high  probability of CAD / Framingham risk estimate ",null,null,null,null,null,null,null,null,null,"No ",null,"Atypical C/P & low CV risk Treat the cause : Musculoskeletal, etc."]
[null,null,null,"Yes"]
[null,"Contraindications to stress testing (e.g., CHF, acute MI or unstable angina. serious arrhythmias, endocarditis or acute pericarditis, P. embolus or infarction)? "]
[null,null,null,"No",null,null,null,null,null,"Yes"]
[]
[null,"Symptoms or dinical findings warranting angiography? ",null,null,null,null,null,null,null,"Cardiology consultation"]
[null,null,"No",null,"Yes"]
[null,null,null,null,null,null,null,null,null,"Discuss with cardiologist the need to transfer to OMC for coronary angiography and higher level of care "]
["Patient able to achieve 5  METS of exercise? ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "," "]
[null,"Yes",null,"No",null,null,null,null,null,"Yes"]
[]
[null,null,null,null,null,"Pharmacologic stress imaging: Regadenoson Stress test  (or Dobutamine       stress test  if no LBBB, Ventricular Pacing or wall motion abnormalities on most recent echo)"]
[null,"Known CAD by Hx or angiography? "]
[null,"No",null,"Yes"]
[]
["Resting ECG abnormalities? "]
["No",null,"Yes",null,"Exercise imaging study (stress MiBi)                (or     treadmill  stress Echo-    cardiography  test  if  no LBBB, or Ventricular Pacing)"]
[null,null,null,null,null,null,null,null,null,null,null,null," "]
["Standard nonimaging treadmill exercise test ",null,null,null,null,null,null,null,"High-risk test? ",null,null,null," "]
[]
[null,"High-risk test? ",null,null,"Adequate information available? ",null,null,null,"Consider imaging study or  coronary angiography "]
[]
["** Contraindications:"]
[null,"Vasodilators(Regadenoson): 2nd or 3rd degree block or SSS without a pacemaker,  Hypotension (<90), Caffeine intake within 24 h., use of theophylline/aminophylline / OK with B-Blockers"]
[null,"Dobutamine T.: V. arrhythmias, recent AMI (1‐3 days), unstable angina, hemodynamically significant LV outflow tract obstruction, aortic dissection, severe HTN."]

{"sheet":"Observation-C.Pain-MCMC","index":5,"n_rows":21,"n_cols":18,"rows_kept":21,"cut":false,"hidden":false,"merged":[[1,1,1,15],[3,1,3,15],[2,1,2,15],[18,1,18,2],[0,1,0,14],[6,1,6,6],[7,1,9,1],[7,4,9,6],[11,12,12,15],[6,8,7,14],[13,5,17,5],[11,8,13,8],[16,7,17,11],[13,1,15,1],[13,3,15,3],[16,13,18,15]]}
[null,"Chest Pain / Observation Unit: Optimal Cardiac Stress Testing Selection Algorithm"]
[null," No: Unstable angina / Serious arrhythmias / CHF / Acute pericarditis / Endocarditis / Pul. embolism or infarct/ Uncontrolled HTN"]
[null,"If cardiac enzymes are normal"]
[null,"Can the patient exercise and walk without assistance at a normal pace?"]
[]
[null,null,null,"Yes",null,null,null,null,null,null,null,null,"No",null,null,null,null," "]
[null,"Does the patient have any of the following?  ",null,null,null,null,null,null,"Does the patient have any of the following?  \n LBBB /  Ventricular Pacing "]
[null," LBBB   /  Ventricular Pacing ",null,null,"LVH /  On Digoxin / Pre‐excitation / Hx. Of CABG/PCI or ECG abnormalities"]
[]
[null,null,null,null,null,null,null,null,"Yes",null,null,null,null,null,"No"]
[]
[null,"Yes",null,"No",null,"Yes",null,null,"Myocardial Perfusion Rest Stress Test MCMC with Regadenoson (select from dropdown)**",null,null,null,"Does the patient have resting wall motion abnormalities on most recent echocardiogram?"]
[null,null,null,null,null,null,null," "]
[null,"Myocardial Perfusion Rest Stress Test MCMC with Regadenoson (select from dropdown)**",null,"CV Stress Test/Treadmill Only — Standard Prep (unless otherwise specified) ",null,"Myocardial Perfusion Rest Stress Test MCMC— Treadmill (select from dropdown) or Stress Echocardiography With Contrast (if indicated)/ Treadmill (select from dropdown)"]
[null,null,null,null,null,null,null,null,null,null,"Yes",null,null,null,"No"]
[]
[null,null,null,null,null,null,null,"Myocardial Perfusion Rest Stress Test MCMC with Regadenoson (select from dropdown)**",null,null,null,null,null,"Myocardial Perfusion Rest Stress Test MCMC with Regadenoson (select from dropdown)** or Stress Echocardiography With Contrast (if indicated)/ Dobutamine (select from dropdown) **"]
[]
[null,"** Contraindications:"]
[null,"Vasodilators(Regadenoson): 2nd or 3rd degree block or SSS without a pacemaker,  Hypotension (<90), Caffeine intake within 24 h., use of theophylline/aminophylline / OK with B-Blockers"]
[null,"Dobutamine T.: V. arrhythmias, recent AMI (1‐3 days), unstable angina, hemodynamically significant LV outflow tract obstruction, aortic dissection, severe HTN."]

{"sheet":"Isch.Cascade","index":6,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"When S.T with Imaging first ","index":7,"n_rows":8,"n_cols":5,"rows_kept":8,"cut":false,"hidden":false,"merged":[[4,2,4,11],[5,2,5,11],[6,2,6,11],[7,2,7,11]]}
[]
[]
[]
[null,"Stress test with Imaging first",null,null," (as opposed to a standard exercise stress test)"]
[null,1,"If the patient can not exercise for enough time to get heart working at its hardest. (such as arthritis, etc.)"]
[null,2,"Have abnormal rhythm. Like atrial fibrillation."]
[null,3,"LVH, LBBB or abnormal baseline ECG, that prevent a standard exercise stress test from giving correct results."]
[null,4,"Had a heart procedure in the past, such as CABG or PTCA."]

{"sheet":"Typical-CP","index":8,"n_rows":12,"n_cols":11,"rows_kept":12,"cut":false,"hidden":false,"merged":[[1,6,1,7],[7,5,7,6]]}
["Criteria to Classify Chest Discomfort "]
[null,1,"Precipitated by exercise. ","No",{"$f":"IF(D2=\"yes\",1,0)","v":0}]
[null,2,"Brief duration (2 to 15 min). ","No",0]
[null,3,"Relieved promptly by rest or nitroglycerin. ","No",0]
[null,4,"Substernal location. ","No",0]
[null,5,"Radiation from chest to jaw, left arm or neck. ","No",0]
[null,6,"Absence of other causes for pain. ","No",0]
[null," ",null,null,{"$f":"E2+E3+E4+E5+E6+E7","v":0},"(Total Risk)"]
[]
["Classification: ","I."," Typical angina pectoris ",null,"II.","Atypical chest pain ",null,null,null,"III.","Nonanginal chest pain "]
[null,null,"         Criteria I to 3 all positive. ",null,null,"         Any two criteria positive. ",null,null,null,null,"         Only one criterion positive. "]
[null," ","         Any four criteria positive. ",null,null,"         Only criteria 4 to 6 positive. "]

{"sheet":"ER-2-Hour-Prot.","index":9,"n_rows":34,"n_cols":13,"rows_kept":34,"cut":false,"hidden":false,"merged":[[20,8,20,9],[20,12,20,13],[12,2,12,3],[17,2,17,3],[17,6,17,7],[14,4,14,5],[6,2,6,4],[6,9,6,10],[2,5,2,7],[8,9,8,11],[8,2,8,5]]}
[null,null,null,"Proposed Algorithm to Rule-in and Rule-out Acute Coronary Syndrome in ER using hs-Troponins"]
[]
[null,null,null,null,null,"Patient presenting to the ED with chest paln "]
[null,null,null,null,null,null,"ECG"]
[null,null,null,null,null,null,"Suspected ACS• "]
[]
[null,null,"Time of onset < 2 hours or uncertaln ",null,null,null,null,null,null,"Time of onset ³ 2 hours "]
[]
[null,null,"hs-cTn test at baseline (0 hour) # ",null,null,null,null,null,null,"hs-cTn test at baseline (0 hour) # "]
[]
[null,null,"Negatve test result** ",null,null,null,"Positive test result**",null,null,"Negatve test result** ",null,null,"Positive test result**"]
[]
[null,null,"Repeat hs-cTn test' + ECG ",null,null,null,null,null,null,"Rlsk scores $"]
[]
[null,null,"Negative test result ## ",null,"Positive test result ## ",null,null,null,"Low risk",null,"High risk "]
[]
[null,null,null,null,null,null,null,null,null,null,"Repeat hs-cTn + ECG"]
[null,null,"DISCHARGE^ ",null,null,null,"ADMIT to hospital with CCU"]
[null,null,null,null,null,null,null,null,null,"Negaüve test result ",null,"Posltlve test result: "]
[]
[null,null,null,null,null,null,null,null,"DISCHARGE^^ ",null,null,null,"ADMIT to hospital with CCU"]
[null,null,"*Suspicion of ocute myocardial ischemia or infarction (NSTEM/. unstable angina or STEMI. "]
[null,null,"# Serial hs-cTn measurements at 0 and 2 hours are recommended if the centre has the capacity to produce results within a good turnaround time."]
[null,null,"The 0/2 hour algorithm is preferable because of shorter length of stay would prevent overcrowding in the ED, thus being ideal for resource-imited centres. "]
[null,null,"If retesting wittin 2 hours is chalanging, the 3 hour algorithm is recommended. "]
[null,null,"**Baseline result of >99th percentile of the URL can assist in the decision for admission. whereas a result of £99%th percentile of the URL may benefit from further risk strastification and/or serial hs-cTn measurements."]
[null,null," $ The Heart score is recommended because it is better at distinguishing patients at low risk for MACE and risk stratification than the GRACE and TIMI scoring systems; it also has lower rate of missed MACE. "]
[null,null,"      Low risk indicates a HEART score of 0-3; intermediate to high risk indicotes a HEART score >3. "]
[null,null,"## Decision thresholds include a RCV of >20% from a baseline volue of >99th percentile URL; and an RCV>50% from a baseline value of £ 99th percentile URL. "]
[null,null,"^ Risk scores are not needed for patients who present with chest pain onset <2 hours. "]
[null,null,"^^ Patients with negative troponin results and a low HEART risk score have 6-18% risk of MACE. Patients with chest pain onset ³2 hours and hs-cTn result with undetectable or very low levels of cardiac troponin (,40%) at the time of arrival, con be discharged without depending on the risk score "]
[null,null,"ED = emergency department; GRACE = Global Registry of Acute Coronary Events; HEART score = history, ECG, age, risk factors, troponin; hs-cTn = high-sensetivity cardiac troponin; MACE = major adverse cardiac events;"]
[null,null,"NSTEMI = non-ST-elevation MI: RCV = reference change value: STEMI = ST-elevation MI: TIMI = Thrombolsis in MI; URL = upper reference limit. "]
[null,null,"https://www.radcliffecardiology.com/image-gallery/30963/18530/proposed-algorithm-to-rule-in-and-rule-out-acute-coronary-syndrome-in-the-emergency-department-using-high-sensitivity-cardiac-troponin"]