Institutions are increasingly adopting HEART score-based algorithms for early discharge. Recent publications call widespread provocative testing into question.⁶

However, the proponents of CT coronary angiograms (CTCA) for patients with low-risk chest pain refuse to fold. Despite the failure of major trials to demonstrate an advantage of CTCA over standard care and impassioned editorials questioning the fundamental insanity of their use, the American Heart Association (AHA) has issued new guidelines for appropriate cardiac imaging.^7,8 Oddly, according to these guidelines, nearly every possible permutation of potential cardiac chest pain is deemed appropriate for CTCA, explicitly including even low-risk, troponin-negative patients with Thrombolysis in Myocardial Infarction (TIMI) scores of zero.

Even more damning, the authors of the AHA guidelines also endorse the so-called “triple rule-out” scan for cases in which a “leading diagnosis is problematic or not possible.” Considering the various conflicts of interest relating to imaging technology on the writing and rating panels, it’s not surprising the default recommendation is “don’t think, just scan.”

The right thing to do in medicine is rarely the easiest. Avoiding unnecessary admissions and CT scans requires communication and sharing uncertainty with patients, and such efforts require time we rarely have. Incentives—financial, medical-legal, and professional—only rarely align to support the highest-value practice of medicine. Nonetheless, we should continue striving to such ideals.

References

1. Benayoun MD, Allen JW, Lovasik BP, et al. Utility of computed tomography imaging of the cervical spine in trauma evaluation of ground level fall. J Trauma Acute Care Surg. 2016 Mar 30. [Epub ahead of print]
2. Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med. 2011;57(6):628-652.e75.
3. Stojanovska J, Carlos RC, Kocher KE, et al. CT pulmonary angiography: using decision rules in the emergency department. J Am Coll Radiol. 2015;12(10):1023-1029.
4. Menoch M, Simon HK, Hirsh D, et al. Imaging for suspected appendicitis: variation between academic and private practice models. Pediatr Emerg Care. 2016 Apr 5. [Epub ahead of print]
5. Drescher FS, Sirovich BE. Use of computed tomography in emergency departments in the United States: a decade of coughs and colds. JAMA Intern Med. 2016;176(2):273-275.
6. Greenslade JH, Parsonage W, Than M, et al. A clinical decision rule to identify emergency department patients at low risk for acute coronary syndrome who do not need objective coronary artery disease testing: the no objective testing rule. Ann Emerg Med. 2016;67(4):478-489.e2.
7. Redberg RF. Coronary CT angiography for acute chest pain. N Engl J Med. 2012;367(4):375-376.
8. Rybicki FJ, Udelson JE, Peacock WF, et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate utilization of cardiovascular imaging in emergency department patients with chest pain: a joint document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol. 2016;67(7):853-879.