Best Clinical Practice: Current Controversies in the Evaluation of Low-Risk Chest Pain with Risk Stratification Aids. Part 2

Brit Long, Alex Koyfman
Journal of Emergency Medicine 2017, 52 (1): 43-51

BACKGROUND: Chest pain accounts for 10% of emergency department (ED) visits annually, and many of these patients are admitted because of potentially life-threatening conditions. A substantial percentage of patients with chest pain are at low risk for a major cardiac adverse event (MACE).

OBJECTIVE: We investigated controversies in the evaluation of patients with low-risk chest pain, including clinical scores, decision pathways, and shared decision-making.

DISCUSSION: ED patients with chest pain who have negative biomarker results and nonischemic electrocardiograms are at low risk for MACE. With the large number of chest pain patients evaluated in the ED, several risk scores and pathways are in use based on history, electrocardiographic results, and biomarker results. The Thrombolysis in Myocardial Infarction and Global Registry of Acute Coronary Events scores are older rules with validation; however, they do not have adequate sensitivity or are not easy to use in the ED. The Vancouver chest pain and North American chest pain rules may be used for patients with undifferentiated chest pain in the ED. The Manchester Acute Coronary Syndromes rule uses eight factors, several of which are not available in the United States. The history, electrocardiography, age, risk factors, and troponin (HEART) score and pathway are easy to use, have high sensitivity and negative predictive values, and have better discriminatory capability for categorization. The use of pathways with shared decision-making involves the patient in management, shortens the duration of stay, and decreases risk to both the patient and the provider.

CONCLUSIONS: Risk stratification of ED patients with chest pain has evolved, and there are many tools available. The HEART pathway, designed for ED use, has several attributes that provide safe and efficient care for patients with chest pain.


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