In June 2018, the ACEP Board of Directors approved a clinical policy on the evaluation and management of adult patients presenting with suspected non–ST-elevation acute coronary syndrome (NSTE ACS).1 In its complete form, this policy can be found on the ACEP website .
Emergency physicians routinely rule out ACS in patients presenting with chest pain and have become very good at targeting timely interventions in the obvious cases of ST-elevation myocardial infarction but still miss up to 2 percent of acute myocardial infarctions, particularly those with non–ST-elevation myocardial infarction (NSTEMI). The purpose of this policy was to focus on the initial diagnosis and treatment of patients who present with potential NSTE ACS.
In developing the policy, the ultimate outcome measure was the 30-day incidence of major adverse cardiovascular event (MACE). This includes cardiovascular death and myocardial infarction, as well as what some argue is more subjective in terms of actual need, coronary revascularization. Most emergency physicians strive to attain a miss rate of less than 1 percent. However, it is questionable if the benefits of further testing outweigh the risks of harm of untreated disease once that threshold reaches 2 percent, which the committee felt was a more realistic expectation. With shared decision making, patients may be willing to accept rates higher than those to which physicians hold themselves accountable.
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One Response to “How to Manage Suspected Non–ST-Elevation Acute Coronary Syndrome”
December 2, 2018
Jerry W. Jones, MD FACEP FAAEMOverall, a good presentation and I do agree with many of your views though there are a few statements that give me pause.
“Most emergency physicians strive to attain a miss rate of less than 1 percent. However, it is questionable if the benefits of further testing outweigh the risks of harm of untreated disease once that threshold reaches 2 percent, which the committee felt was a more realistic expectation. With shared decision making, patients may be willing to accept rates higher than those to which physicians hold themselves accountable.”
0% rate of MACE remains the holy grail of all physicians treating patients with chest pain and especially emergency physicians. I think every ER physician should strive for 0% MACE, no matter HOW unattainable that figure may realistically be. Aiming for 2% will only result in figures higher than 2%. And I can’t imagine trying to talk a patient into leaving the ER with a potential for MACE greater than that with which I myself would feel comfortable. That just seems hypocritical and unethical to me. At some point we must ask ourselves, “Are we working for the patient or for an insurance company?” In the quote above, you essentially ask if it is worth trying to reduce incidents of MACE from 2% to less than 1%. Worth to whom – the patient or the insurance companies? These percentages are not spanning a career in EM – many of us will reach those percentages every few months.