New Technologies for the Evaluation of Acute Coronary Syndromes: The Next Generation of Super Electrocardiogram?

As well outlined in previous chapters, chest pain remains one of the most common and complex chief complaints presenting to emergency departments (EDs) in the USA today. Ischemic heart disease (IHD) is a major cause of death (almost nine million people globally in 2017) (Roth et al., Lancet. 392(10159), 1736–88, 2018), its noninvasive early detection remains a clinical challenge (Montalescot et al., Eur Heart J, 34(38), 2949–3003, 2013), especially in patients presenting with acute chest pain in the ED, where the electrocardiogram (ECG) is commonly nondiagnostic at first presentation. It is well known that in more than one-third of patients with acute coronary syndrome (ACS), biomarker concentrations can also be within normal limits even using high-sensitivity (hs) cardiac troponin assays (Roffi et al., Eur Heart J, 37(3), 267–315, 2016). Although the time needed to arrive at a safe ED disposition has been shortened significantly by the introduction of risk algorithms incorporating hs cardiac troponin assays (Greenslade et al., Ann Emerg Med, 71(4), 439–451.e3, 2018), it may still require on average 3–6 h or more to make a differential diagnosis between cardiac and noncardiac chest pain allowing for a safe disposition. Despite significant efforts and guidelines that are being followed, the missed ACS rate remains at approximately 2% or more, as atypical presentations are very common (11–14%). Unrecognized ACS significantly increases morbidity and mortality, and in addition, can lead to a high medicolegal risk (Vukmir, Med Law, 23(3), 495–513, 2004). This has not appreciably changed over recent decades (Roth et al., Lancet. 392(10159), 1736–88, 2018; Montalescot et al., Eur Heart J, 34(38), 2949–3003, 2013; Roffi et al., Eur Heart J, 37(3), 267–315, 2016; Greenslade et al., Ann Emerg Med, 71(4), 439–451.e3, 2018).