Identifying Emergency Department Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes -
Publication Date: July 2017 (Volume 19, Number 7)
CME: This issue includes 4 AMA PRA Category 1 Credits™; 4 ACEP Category I credits; 4 AAFP Prescribed credits; and 4 AOA Category 2 A or 2B CME credits.
David Markel, MD
Attending Physician, Tacoma Emergency Care Physicians, Tacoma, WA
Keith A. Marill, MD, MS
Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
Andrew Schmidt, DO, MPH
Assistant Professor of Emergency Medicine; Deputy Medical Director, TraumaOne Flight Program, University of Florida College of Medicine - Jacksonville, Jacksonville, FL
Though a minority of patients presenting to the emergency department with chest pain have acute coronary syndromes, identifying the patients who may be safely discharged and determining whether further testing is needed remains challenging. From the prehospital care setting to disposition and follow-up, this systematic review addresses the fundamentals of the emergency department evaluation of patients determined to be at low risk for acute coronary syndromes or adverse outcomes. Clinical risk scores are discussed, as well as the evidence and indications for confirmatory testing. The emerging role of new technologies, such as high-sensitivity troponin assays and advanced imaging techniques, are also presented.
Excerpt From This Issue
A 65-year-old man with a history of hypertension, diabetes, and prior myocardial infarction presents to the ED after he experienced a 20-minute episode of dull, aching, left-sided chest discomfort while doing yard work an hour ago. His wife tells you that he’s been having similar episodes on and off for the past 2 weeks. He is pain-free on arrival, and his vital signs are unremarkable. His ECG, chest x-ray, and troponin are all normal. When you go back into the room to reassess him, he says he feels fine and asks if he can go home. You hesitate and wonder if it would be safe to send him home without further testing.
A 22-year-old college student presents with sharp, left-sided chest pain and shortness of breath. He recently returned from a spring break trip to Mexico and reports symptoms of an upper respiratory infection. He feels that his chest pain is worse when lying flat, and is concerned he’s having a heart attack. His vital signs and physical examination are normal. He has no past medical history, no cardiac risk factors, and no family history of heart disease. His triage ECG is normal. ACS seems unlikely, but as you’re thinking through your differential diagnosis, you wonder if you need to do any other tests to rule it out definitively.
N, T., MD - 09/04/2018 By incorporating scoring rules into my practice I will be able to better identify low-risk patients.
Sarah Yakubova - 04/20/2018 After reading this article, I will risk stratify each patient regardless of age.
Steven Fahlen - 04/20/2018 I will practice medicine as recommended in article
Fernando Gonzalez-Torres, MD - 04/18/2018 Will pay more attention to the signs of MI than tests.
Ahren Shubin, MD - 04/18/2018 I will add obesity as a risk factor when I calculate a HEART score. I will likely stop using CK-MB and use troponin only. Now I know a 20% troponin increase over baseline elevated troponins is the percentage which strongly suggests MI. Excellent review! Thank you
Walt Carroll, MD - 02/01/2018 Great product!
Harold K Moores, MD - 01/30/2018 excellent topic and very helpful
Ahren Shubin, MD - 11/11/2017 Excellent article. I will be telling my coworkers about this.
Harold K Moores, MD - 11/08/2017 I will now provide better care for elderly pts as well as those under 40!
David J Pillow Jr, MD - 11/07/2017 After reading this article, I will be more rigorous about using the HEART score for risk stratification. Also refreshed the criteria for STEMI for men and women in V2-V3.
Sarah Yakubova, PA-C - 11/06/2017 Amazing, organized, clear information. Love it
Matthew A Wakeley, DO - 09/07/2017 Nice presentation. I enjoyed reading this.
Laura Lee Helfman, MD - 09/05/2017 With this course, I will have better use of clinical tools.
Jennifer Boutwell, NP - 09/05/2017 Going forward, I will use TIMI score & chart this score on all CP patients.
Anne Messman, MD FACEP - 08/17/2017 Excellent article; very helpful. I will be more careful with utilizing single troponin to rule-out ACS.
Kerith Joseph, MD - 08/14/2017 After reading this article, I will approach young people with chest pain with greater caution.
Jose Cabanas, MD - 08/10/2017 Excellent article; a must read! I now have a better understanding of clinical decision rules.
Carmen Davis, NP - 07/06/2017 Excellent article! Loved the podcast. Now I will have early identification in atypical patients.
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