The next step in ED-centric decision-instrument development may come from New Zealand and Australia, with the Emergency Department Assessment of Chest Pain Score (EDACS).⁶ This score incorporates many of the same elements seen in the HEART Score but at a more detailed and granular level. Rather than each of the five elements being awarded up to two points, the EDACS breaks age, coronary disease, and signs and symptoms into myriad additive and subtractive elements. The advantage of this is greater specificity. In the original derivation and validation cohort, it was used in conjunction with zero-hour and two-hour troponin measurements to classify nearly 50 percent of the cohort as low risk, with a sensitivity greater than 99 percent. The downside: get out your calculator. While not nearly as bad as the GRACE (Global Registry of Acute Coronary Events) Score, this decision instrument approaches the complexity limit for clinical acceptability. Increasing availability of computerized decision support potentially decreases the resultant cognitive strain, but this remains a limitation. Prospective validation of the EDACS-Accelerated Diagnostic Protocol is under way in Europe and North America.

Most important, however, the development of these ED-centric decision instruments and disposition pathways, along with the North American Chest Pain Rule, indicate emergency medicine has moved beyond the hand-me-downs from our cardiology brethren. Not only is it time for TIMI to be retired, it’s likely time to reconsider the relevance of the other American Heart Association recommendations for the evaluation of acute nonspecific chest pain in the emergency department. Universal recommendations for early provocative or anatomic testing are discordant with the reality of our resource-limited settings, and a recognition of the harms of false positives further informs the need for practice evolution. ACEP should support emergency physicians utilizing these prospectively derived risk-stratification tools for early disposition of patients from the emergency department, specifically to address the medical legal fallout from moving to a rational, but not “zero miss,” strategy. We’ve gone too far down the rabbit hole, but there may yet be light at the end of the tunnel.

Dr. Radecki is assistant professor of emergency medicine at The University of Texas Medical School at Houston. He blogs at Emergency Medicine Literature of Note (emlitofnote.com) and can be found on Twitter @emlitofnote.

References

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