These accelerated diagnostic protocols may involve one-hour or two-hour repeat testing, or, if the time of onset of the more recent symptoms is adequately remote, a single troponin on arrival may prove sufficient. Protocol sensitivity typically exceeds 95 percent, with negative predictive values in excess of 99 percent, even in patients with known coronary disease or coronary risk factors.5
Explore This IssueACEP Now: Vol 37 – No 04 – April 2018
Determining the best next step fundamentally asks the purpose of admission or observation. For an admission or observation to have value, whether on a health-system level or to a patient on a deductible health insurance plan, the intervention should offer a reasonable expectation of identifying a problem potentially amenable to treatment. Unfortunately, despite our reliance on various stress tests and the increasing prevalence of CT coronary angiography, population-based and claims-based data find no clear benefit signal.6,7 These data don’t rule out individual benefit to intelligently-selected downstream testing, but the premise that admission or observation will benefit patients with known cardiac disease remains unproven.
However, the risk score data does make clear non-low risk patients are precisely that. These patients do have elevated risk for serious outcomes, some preventable, some not. When assessing whether a non-low risk patient is safe for discharge after accelerated biomarker rule-out, the key element is follow-up. Many patients have well-established coronary anatomy and disease, and the benefit from subsequent invasive or non-invasive testing ranges may easily be zero for a patient who’s primarily medically-managed. This follow-up can occur via established primary care or a cardiologist, depending on the complexity of the subsequent decision-making process—or, better yet, prior to disposition, if a specialist familiar with the patient‘s management can be looped in contemporaneously.
The bottom line: A diagnosis of ACS can be rapidly excluded in the emergency department in most patients, and we can think of our various decision instruments for risk-stratification as tools not to determine which patients we should discharge, but tools to help us triage patients for varying follow-up intensity. Anecdotally, at my institution, with well-integrated follow-up, more than 85 percent of biomarker-negative chest-pain presentations are discharged directly from the emergency department without untoward patient safety. It might seem implausible, but it can be done!
- Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158.
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64(24):2713-2714.
- Than M, Flaws D, Sanders S, et al. Development and validation of the emergency department assessment of chest pain score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014;26(1):34-44.
- Hollander JE, Than M, Mueller C. State-of-the-art evaluation of emergency department patients presenting with potential acute coronary syndromes. Circulation. 2016;134(7):547-564.
- Zhelev Z, Hyde C, Youngman E, et al. Diagnostic accuracy of single baseline measurement of elecsys troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: Systematic review and meta-analysis. BMJ. 2015;350:h15.
- Sandhu AT, Heidenreich PA, Bhattacharya J, et al. Cardiovascular testing and clinical outcomes in emergency department patients with chest pain. JAMA Intern Med. 2017;177(8):1175-1182.
- Morris JR, Bellolio MF, Sangaralingham LR, et al. Comparative trends and downstream outcomes of coronary computed tomography angiography and cardiac stress testing in emergency department patients with chest pain: An administrative claims analysis. Acad Emerg Med. 2016;23(9):1022-1030.