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.
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Following are the most informative references cited in this paper, as determined by the authors.
2. * Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-1776. (Consensus statement) DOI: 10.1161/CIR.0b013e3181ec61df
5. Urgent Care Association. The urgent care industry trends looking to fulfill the demand of a growing segment in the healthcare market. 2019. (Press release)
6. * Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;144(22):e368-e454. (Consensus guidelines) DOI: 10.1161/CIR.0000000000001030
8. * O'Connor RE, Al Ali AS, Brady WJ, et al. Part 9: acute coronary syndromes: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S483-S500. (Consensus guideline) DOI: 10.1161/CIR.0000000000000263
18. * Moumneh T, Penaloza A, Cismas A, et al. Evaluation of HEAR score to rule-out major adverse cardiac events without troponin test in patients presenting to the emergency department with chest pain. Eur J Emerg Med. 2021;28(4):292-298. (Prospective observational study; 1452 patients) DOI: 10.1097/MEJ.0000000000000791
22. * Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020-2035. (Consensus statement) DOI: 10.1161/CIR.0b013e31826e1058
26. * Fanaroff AC, Rymer JA, Goldstein SA, et al. Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review. JAMA. 2015;314(18):1955-1965. (Systematic review) DOI: 10.1001/jama.2015.12735
44. * Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196. (Prospective; 120 patients) DOI: 10.1007/BF03086144
53. * National Association of Community Health Centers. Population health management risk stratification. 2019. Accessed October 10, 2022. (Guideline)
63. * Than MP, Flaws DF, Cullen L, et al. Cardiac risk stratification scoring systems for suspected acute coronary syndromes in the emergency department. Curr Emerg Hosp Med Rep. 2013;1(1):53-63. (Review) DOI: 10.1007/s40138-012-0004-0
65. * Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ. 2010;182(12):1295-1300. (Cross-sectional diagnostic study; 1249 patients) DOI: 10.1503/cmaj.100212
66. * Russell J, Weinstock MB. No troponin, no problem: reimagining chest pain assessment in urgent care. Journal of Urgent Care Medicine. 2022;16(8):1-3. (Review)
67. Haasenritter J, Bösner S, Vaucher P, et al. Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule. Br J Gen Pract. 2012;62(599):e415-e421. (Cross-sectional diagnostic study; 844 patients) DOI: 10.3399/bjgp12X649106
68. * Harskamp RE, Laeven SC, Himmelreich JC, et al. Chest pain in general practice: a systematic review of prediction rules. BMJ Open. 2019;9(2):e027081. (Systematic review; 8 studies) DOI: 10.1136/bmjopen-2018-027081
71. * Todd F, Duff J, Carlton E. Identifying low-risk chest pain in the emergency department without troponin testing: a validation study of the HE-MACS and HEAR risk scores. Emerg Med J. 2022;39(7):515-518. (Randomized-controlled trial; 629 patients) DOI: 10.1136/emermed-2021-211669
76. U.S. Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. 2022. Updated April 26, 2022. Accessed October 10, 2022. (Consensus guideline)
96. Vysma C, Roche. Breakthrough development for Americans with suspected heart attack - Next generation Troponin T test from Roche cleared by FDA. Updated January 19, 2017. Accessed October 10, 2022. (Press release)
107. Vibhakar N, Mattu A. Beyond HEART: building a better chest pain protocol. Emergency Physicians Monthly. Updated October 1, 2015. Accessed October 10, 2022. (Review)
108. Centers for Medicare & Medicaid Services. ICD-10-CM Official Guidelines for Coding and Reporting FY 2022 -- UPDATED April 1, 2022 (October 1, 2021 - September 30, 2022). Accessed October 10, 2022. (Coding guideline updates)
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Keywords: chest pain, angina, coronary artery disease, CAD, acute coronary syndromes, ACS, myocardial infarction, myocardial ischemia, MACE, major adverse cardiac event, ECG, EKG, electrocardiogram, risk stratification, clinical risk score, low risk, HEAR, Marburg, triple rule out, biomarker, troponin
Keith Pochick, MD, FACEP
Editor-in-Chief; Attending Physician, Urgent Care
Lorilea Johnson, FNP-BC, DNP
Update Author; Veterans Affairs Clinics of Cape Girardeau
Huai Lee Phen, MD
Diane Sixsmith, MD, MPH
James B. Haering, DO, SFHM, CHCQM
November 1, 2022
November 1, 2025
4 AMA PRA Category 1 Credits™.