Identifying Urgent Care Patients With Chest Pain Who Are at Low Risk for Acute Coronary Syndromes

Table of Contents

 

About This Course

Most patients who present to urgent care with chest pain are not experiencing acute coronary syndromes (ACS), but it is imperative that patients who are at high risk for ACS be identified as quickly as possible. For patients at low risk for ACS, the history, physical examination, ECG, and validated clinical risk scores can be used to help clinicians determine whether urgent care management is appropriate. In this issue, you will learn:

The elements of the history and physical examination that are most important in the initial evaluation of chest pain

The role of ECG in assessing a patient’s risk of ACS and major adverse cardiac events, and the risks associated with errors in ECG interpretation

How to utilize the Marburg Heart Score and the HEAR Score to risk stratify patients with chest pain when troponin testing is not available

The special considerations for evaluation of chest pain in women, younger adults, and older adults

CHARTING & CODING: How to appropriately document a patient encounter for the symptom of chest pain when the cause is not ACS

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Definitions
   1. Acute Coronary Syndromes
   2. Low-Risk Patient
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Urgent Care Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Electrocardiogram
   2. Biomarkers
   3. Risk Stratification and Clinical Risk Scores
      1. The TIMI Score
      2. The HEART Score
   4. Risk Stratification Scores Used in Settings Without Troponin Testing
      1. The Marburg Heart Score
      2. The HEAR Score
   5. Chest Radiography
   6. Confirmatory Testing
10. Treatment
11. Special Populations
    1. Chest Pain in Women
    2. Younger Patients
    3. Older Adult Patients
    4. Patients With Known Coronary Artery Disease or Previous Cardiac Testing
12. Controversies and Cutting Edge
    1. High-Sensitivity Troponin Testing
    2. Triple-Rule-Out Computed Tomography
13. Disposition
14. Summary
15. Critical Appraisal of the Literature
16. Risk Management Pitfalls for Urgent Care Evaluation of Patients With Chest Pain
17. 5 Things That Will Change Your Practice
18. Case Conclusions
19. Clinical Pathway for Urgent Care Evaluation of Patients With Chest Pain
20. Charting & Coding: What You Need To Know
21. References

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

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…

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…

A 20-year-old woman comes to urgent care complaining of chest pain that 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…

Clinical Pathway for Urgent Care Evaluation of Patients With Chest Pain

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Key References

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