An estimated 8 million people present to EDs in the United States with chest pain each year, 15% to 25% of whom receive a diagnosis of acute coronary syndrome (ACS). Of this group, between 2% and 5% are discharged home without an ACS diagnosis but receive one within 30 days. Due to a fear of missing this subset of patients, many people presenting to the ED with chest pain are unnecessarily admitted to the hospital for observation and further investigation. These cases can clog EDs, increase the likelihood of unneeded testing, and increase healthcare costs (see also, A New Look at Leaving Without Being Seen in EDs).
Algorithm to Manage Chest Pain Put to the Test
My colleagues and I in the department of emergency medicine collaborated with the cardiology and nuclear medicine departments at our hospital. We developed an algorithm designed to streamline approaches for managing patients with potential cardiac chest pain. Our algorithm was evaluated in a study published in the April 2012 Annals of Emergency Medicine.
With the algorithm, patients who presented to the ED with chest pain underwent a full history and physical examination, along with EKG and biomarker testing. Patients with high-risk clinical features (eg, worsening angina or an EKG suspicious for ischemia or positive troponins) were referred to the cardiology department immediately. The remainder of patients had tests repeated at both 2 and 6 hours. Those who developed new pain, had ongoing pain, had changes on EKG, or had subsequent positive troponin levels were referred to the cardiology department as well. If patients did not have high-risk clinical features, had a normal EKG, and displayed normal cardiac biomarkers at the end of 6 hours, they were discharged and scheduled for a stress test within 48 hours. This testing took place at the hospital, and a cardiologist immediately interpreted and commented on each test, thus taking responsibility for ED-arranged testing. Patients who were deemed to be at high cardiac risk by the cardiologist were referred immediately back to the ED for a formal cardiology assessment (see also, Addressing ED Crowding With Patient Flow Strategies).
Many people presenting to the ED with chest pain are unnecessarily admitted to the hospital for observation and further investigation.
According to study findings, our algorithm substantially cut down the number of cardiology consults in the ED for stress testing. More than one-quarter (25.6%) of patients presenting to the ED with chest pain did not warrant a cardiology consult and were discharged. A similar proportion (26.2%) was discharged within 6 hours with no further follow-up. About one-quarter (24.3%) of patients were referred for cardiology consult while in the ED. Outpatient provocative testing within 48 hours was recommended for 22.8% of patients, 17.0% of whom were found to have unstable angina. Although these patients were discharged from the ED, they were diagnosed within 48 hours and treated successfully.
What’s Next? Buy-In for Chest Pain Strategy
In order to apply our algorithm universally at EDs across North America, buy-in from emergency, cardiology, and nuclear medicine departments within the hospital is needed. Cardiologists must be also willing to take responsibility for tests they don’t order. More research is necessary to confirm our findings in larger, multicenter investigations. In the meantime, it’s hoped that the successes we observed with our algorithm will encourage emergency physicians to collaborate with hospitals to create and use innovative pathways to maximize the potential benefits for both patients and clinicians.
Readings & Resources (click to view)
Scheuermeyer F, Innes G, Grafstein E, et al. Safety and efficiency of a chest pain diagnostic algorithm with selective outpatient stress testing for emergency department patients with potential ischemic chest pain. Ann Emerg Med. 2012;59:256-264.
Greene J. The perils of low-risk chest pain: emergency physicians struggle to balance risk with overtesting. Ann Emerg Med. 2010;56:25A-28A.
Pines J, Pollack C, Diercks D, et al. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009;16:617-625.
Hess E, Perry J, Calder L, et al. Prospective validation of a modified thrombolysis in myocardial infarction risk score in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med. 2010;4:368-375.
Yeh R, Sidney S, Chandra M, et al. Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010;362:2155-2165.
Lee C, Van Gelder C, Cone D. Early cardiac catheterization laboratory activation by paramedics for patients with ST-segment elevation myocardial infarction on prehospital 12-lead electrocardiograms. Prehosp Emerg Care. 2010;14:153-158.
Diercks D, Roe M, Chen A, et al. Prolonged emergency department stays of non–ST-segment elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007;50:489-496.