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Identifying Urgent Care Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes
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Publication Date: November 2022 (Volume 1, Number 8)

CME Credits: 4 AMA PRA Category 1 Credits™. CME expires 11/01/2025

Editor-in-Chief

Keith A. Pochick, MD, FACEP
Attending Physician, Urgent Care, Charlotte, NC

Update Author

Lorilea Johnson, FNP-BC, DNP
Veterans Affairs Clinics of Cape Girardeau, Cape Girardeau, MO

Urgent Care Peer Reviewer

Keith A. Pochick, MD, FACEP
Attending Physician, Urgent Care, Charlotte, NC
Huai Lee Phen, MD
Assistant Professor of Family Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
Diane Sixsmith, MD, MPH
Attending Physician, Optum/ProHealth Urgent Care, New York, NY

Charting & Coding Author

James B. Haering, DO, SFHM, CHCQM
Associate Professor, Internal Medicine, Michigan State University College of Human Medicine, East Lansing, MI

Abstract

As the popularity and accessibility of urgent care centers have expanded, patients frequently present to urgent care without a working knowledge of the center’s clinical capabilities. Between 75% and 90% of patients seeking medical care for chest pain are not experiencing acute coronary syndromes, but it is imperative to quickly identify patients with true acute coronary syndromes and immediately disposition them to a higher level of care. Clinicians can avoid overtriage by using clinical findings and decision-making tools to identify patients with low-risk chest pain who can be safely evaluated in urgent care. This article reviews recommendations for evidence-based risk stratification of chest pain using decision-making tools that are appropriate for outpatient settings.

Case Presentations

CASE 1
A 65-year-old man presents to urgent care after he experienced a 20-minute episode of dull, aching, left-sided chest discomfort...
  • The pain began while he was doing yard work an hour ago. His wife reports that he has been having similar episodes on and off for the past 2 weeks.
  • He is pain free on arrival, and his vital signs are unremarkable. He has a history of hypertension, diabetes, and prior myocardial infarction.
  • His ECG and chest x-ray are normal.
  • When you go back into the room to reassess him, he says he feels fine and asks if he can leave. You hesitate, considering whether it is safe to send him home…
CASE 2
A 22-year-old man arrives at your urgent care with sharp, left-sided chest pain and shortness of breath…
  • He states that he is concerned that he’s having a heart attack.
  • He recently returned from a spring break trip to Mexico. He reports that he had symptoms of an upper respiratory infection shortly after the trip.
  • He says that he feels that his chest pain is worse when he is lying flat.
  • His temperature is 37°C, blood pressure is 124/80 mm Hg, pulse is 115 beats/min, respiratory rate is 18 breaths/min, and pulse oximetry is 98% on room air.
  • The physical examination is unremarkable, with no reproducible chest wall tenderness. He has no past medical history, no cardiac risk factors, and no family history of heart disease. His triage ECG and a chest x-ray are normal.
  • ACS seems unlikely, but as you think through your differential diagnosis, you wonder if any other tests are needed to rule it out definitively…
CASE 3
A 20-year-old woman comes to urgent care complaining of chest pain to occurs with certain movements and when she takes a deep breath...
  • She is a college student and has been preparing for final exams. She says she has been consuming energy drinks so she can stay up late to study.
  • She denies injury but recalls that she first noticed the pain when she awoke after falling asleep in an awkward position in a chair in the student lounge. Her pain is reproducible with palpation.
  • Her vital signs, ECG, and assessment are normal. She denies palpitations.
  • She has no past medical history, no cardiac risk factors, and no family history of heart disease. She is not taking any exogenous estrogens.
  • You wonder if any additional testing is needed to assess this young woman’s chest pain…

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