July 19, 2021

In the United States, a patient with chest pain presents to the emergency department (ED) every 5 seconds. By the time you finish reading this post, 60 patients will have sought treatment for chest pain. In 2017, chest pain was the second most common chief complaint in US EDs totaling more than 6.5 million visits,[1] or approximately 2.5x the population of Chicago. There have been dramatic advances in the management of ACS and low-risk chest pain. Prior to the days of observation units, I recall admitting high-risk patients with chest pain to a telemetry floor. However, admissions have changed to observation stays, 6-hour 𝚫 troponins changed to 2-hour 𝚫 troponins, conventional troponins changed to high sensitivity troponins, and much more. Remarkably, up to 40% of patients with chest pain will return to the ED with similar concerns within one year.[2] Yet, there is sparse evidence to address the subset of low-risk patients with recurrent chest pain.

February 18, 2016

Chest Pain (CP) is a very common complaint seen in emergency departments around the world.  In the US specifically  anywhere from 8 - 10 million patients present to the ED complaining of CP.  Many use liberal testing strategies to prevent missing acute coronary syndrome (ACS) or other major adverse cardiac events (MACE), but this is not without increase in healthcare cost and false positive testing leading to more downstream testing.  In recent years there have been several diagnostic protocols developed to help determine a portion of these patients as low risk to facilitate early discharge, prevent this over testing, while still having a >99% NPV for MACE at 30 days. Disclaimer: To be clear, this is the way I manage low risk chest pain and certainly there is more than one way, but I think at the current time in the US, this is the best we have.  Also, at the time of this post being written, we DO NOT have high sensitivity troponins in the US.

June 4, 2015

Background: In 2010, 5.4% of all emergency department (ED) visits in the United States were for chest pain. Admission or observation of such patients cost about $11 billion dollars in the United States in 2006. The majority of these admissions are commonly determined to be non-cardiac in etiology. Many physicians and patients believe that a hospital admission or extended observation after a “negative” ED workup has a safety benefit for patients. Previous studies have looked at 30-day mortality, but no current large trials have looked the short-term risk for clinically relevant adverse cardiac events, including inpatient STEMI, life-threatening arrhythmias, cardiac or respiratory arrest, or death. Other things to keep in mind is that one of the pitfalls of hospitalization of chest pain patients can lead to false-positive testing, hospital-acquired infections, venous thromboembolism, and other iatrogenic events, and can have greater than a 2% rate of adverse events at 30 days often cited as the upper boundary estimate for low-risk chest pain patients. The purpose of the current study was to quantify the incidence of short-term clinically relevant adverse cardiac events (CRACE), or more simply put, life-threatening events  in patients admitted to the hospital after a “negative” ED evaluation of ischemia. The definition of “negative” was negative serial cardiac biomarkers, normal vital signs, and non-ischemic electrocardiograms (ECGs). And by the way, checkout the authors: Scott Weingart and David Neman….
0