Identifying Emergency Department July 2017 Volume 19, Number 7 Patients With Chest Pain who are Author David Markel, MD at Low Risk for Acute Coronary Attending Physician, Tacoma Emergency Care Physicians, Tacoma, WA Peer Reviewers Syndromes Keith A. Marill, MD, MS Assistant Professor, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA Abstract Andrew Schmidt, DO, MPH Assistant Professor of Emergency Medicine; Deputy Medical Director, TraumaOne Flight Program, University of Florida College of Medicine – Though a minority of patients presenting to the emergency Jacksonville, Jacksonville, FL department with chest pain have acute coronary syndromes, identifying the patients who may be safely discharged and CME Objectives determining whether further testing is needed remains chal- Upon completion of this article, you should be able to: 1. Identify major pitfalls that can lead to a missed diagnosis of acute lenging. From the prehospital care setting to disposition and coronary syndromes. follow-up, this systematic review addresses the fundamentals of 2. Effectively apply clinical risk scores for better risk stratification. the emergency department evaluation of patients determined to 3. Identify patients who are at low risk of acute coronary syndromes and be at low risk for acute coronary syndromes or adverse out- short-term major adverse cardiac outcome. 4. Apply a current, evidence-based strategy on the use of confirmatory comes. Clinical risk scores are discussed, as well as the evidence testing following ED evaluation. and indications for confirmatory testing. The emerging role of Prior to beginning this activity, see “Physician CME Information” new technologies, such as high-sensitivity troponin assays and on the back page. advanced imaging techniques, are also presented. Editor-In-Chief Daniel J. Egan, MD Shkelzen Hoxhaj, MD, MPH, MBA Alfred Sacchetti, MD, FACEP Joseph D. Toscano, MD Andy Jagoda, MD, FACEP Associate Professor, Department Chief Medical Officer, Jackson Assistant Clinical Professor, Chairman, Department of Emergency Professor and Chair, Department of of Emergency Medicine, Program Memorial Hospital, Miami, FL Department of Emergency Medicine, Medicine, San Ramon Regional Director, Emergency Medicine Thomas Jefferson University, Medical Center, San Ramon, CA Emergency Medicine, Icahn School Eric Legome, MD Residency, Mount Sinai St. Luke's Philadelphia, PA of Medicine at Mount Sinai, Medical Chair, Emergency Medicine, Mount Director, Mount Sinai Hospital, New Roosevelt, New York, NY Sinai West & Mount Sinai St. Luke's; Robert Schiller, MD International Editors York, NY Nicholas Genes, MD, PhD Vice Chair, Academic Affairs for Chair, Department of Family Medicine, Peter Cameron, MD Associate Professor, Department of Emergency Medicine, Mount Sinai Beth Israel Medical Center; Senior Academic Director, The Alfred Emergency and Trauma Centre, Associate Editor-In-Chief Emergency Medicine, Icahn School Health System, Icahn School of Faculty, Family Medicine and Monash University, Melbourne, Kaushal Shah, MD, FACEP of Medicine at Mount Sinai, New Medicine at Mount Sinai, New York, NY Community Health, Icahn School of Medicine at Mount Sinai, New York, NY Australia Associate Professor, Department of York, NY Keith A. Marill, MD Emergency Medicine, Icahn School Scott Silvers, MD, FACEP Michael A. Gibbs, MD, FACEP Assistant Professor, Department Giorgio Carbone, MD of Medicine at Mount Sinai, New Associate Professor and Chair, Professor and Chair, Department of Emergency Medicine, Harvard Chief, Department of Emergency York, NY Department of Emergency Medicine, of Emergency Medicine, Carolinas Medical School, Massachusetts Medicine Ospedale Gradenigo, Editorial Board Medical Center, University of North General Hospital, Boston, MA Mayo Clinic, Jacksonville, FL Torino, Italy Saadia Akhtar, MD Carolina School of Medicine, Chapel Charles V. Pollack Jr., MA, MD, Corey M. Slovis, MD, FACP, FACEP Suzanne Y.G. Peeters, MD Associate Professor, Department of Hill, NC FACEP Professor and Chair, Department Attending Emergency Physician, Emergency Medicine, Associate Dean Steven A. Godwin, MD, FACEP Professor and Senior Advisor for of Emergency Medicine, Vanderbilt Flevo Teaching Hospital, Almere, for Graduate Medical Education, Professor and Chair, Department Interdisciplinary Research and University Medical Center, Nashville, TN The Netherlands Clinical Trials, Department of Program Director, Emergency of Emergency Medicine, Assistant Hugo Peralta, MD Emergency Medicine, Sidney Kimmel Ron M. Walls, MD Medicine Residency, Mount Sinai Dean, Simulation Education, Chair of Emergency Services, Medical College of Thomas Jefferson Professor and Chair, Department of Beth Israel, New York, NY University of Florida COM- Hospital Italiano, Buenos Aires, University, Philadelphia, PA Emergency Medicine, Brigham and Jacksonville, Jacksonville, FL Argentina William J. Brady, MD Women's Hospital, Harvard Medical Michael S. Radeos, MD, MPH Professor of Emergency Medicine Joseph Habboushe, MD MBA School, Boston, MA Dhanadol Rojanasarntikul, MD Associate Professor of Emergency and Medicine; Chair, Medical Assistant Professor of Emergency Attending Physician, Emergency Medicine, Weill Medical College Emergency Response Committee; Medicine, NYU/Langone and Critical Care Editors Medicine, King Chulalongkorn of Cornell University, New York; Medical Director, Emergency Bellevue Medical Centers, New York, Memorial Hospital, Thai Red Cross, Research Director, Department of William A. Knight IV, MD, FACEP Management, University of Virginia NY; CEO, MD Aware LLC Thailand; Faculty of Medicine, Emergency Medicine, New York Associate Professor of Emergency Medical Center, Charlottesville, VA Chulalongkorn University, Thailand Gregory L. Henry, MD, FACEP Hospital Queens, Flushing, NY Medicine and Neurosurgery, Medical Calvin A. Brown III, MD Clinical Professor, Department of Director, EM Advanced Practice Stephen H. Thomas, MD, MPH Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Provider Program; Associate Medical Director of Physician Compliance, Vice-Chair, Emergency Medicine, Professor & Chair, Emergency Credentialing and Urgent Care of Michigan Medical School; CEO, Director, Neuroscience ICU, University Medicine, Hamad Medical Corp., Medical Practice Risk Assessment, Massachusetts General Hospital, of Cincinnati, Cincinnati, OH Services, Department of Emergency Boston, MA Weill Cornell Medical College, Qatar; Medicine, Brigham and Women's Inc., Ann Arbor, MI Scott D. Weingart, MD, FCCM Emergency Physician-in-Chief, Hospital, Boston, MA John M. Howell, MD, FACEP Robert L. Rogers, MD, FACEP, Associate Professor of Emergency Hamad General Hospital, Clinical Professor of Emergency FAAEM, FACP Medicine; Director, Division of ED Doha, Qatar Peter DeBlieux, MD Medicine, George Washington Assistant Professor of Emergency Critical Care, Icahn School of Medicine Professor of Clinical Medicine, Edin Zelihic, MD University, Washington, DC; Director Medicine, The University of at Mount Sinai, New York, NY Interim Public Hospital Director Head, Department of Emergency of Academic Affairs, Best Practices, Maryland School of Medicine, of Emergency Medicine Services, Medicine, Leopoldina Hospital, Inc, Inova Fairfax Hospital, Falls Baltimore, MD Senior Research Editors Louisiana State University Health Schweinfurt, Germany Church, VA Science Center, New Orleans, LA Aimee Mishler, PharmD, BCPS Emergency Medicine Pharmacist, Maricopa Medical Center, Phoenix, AZ Click on the icon for a closer look at tables and figures. Case Presentations (ECG) and cardiac biomarker testing in addition to the basic history, physical examination, and chest ra- 2-8 A 65-year-old man with a history of hypertension, diabetes, diography. If these tests are unremarkable, guide- and prior myocardial infarction presents to the ED after he lines then recommend further confirmatory testing. experienced a 20-minute episode of dull, aching, left-sided Despite the extensive testing typically performed for chest discomfort while doing yard work an hour ago. His patients with chest pain from suspected ACS, a land- wife tells you that he’s been having similar episodes on and mark study by Pope et al estimated that more than off for the past 2 weeks. He is pain-free on arrival, and his 2% of patients with ACS are mistakenly discharged vital signs are unremarkable. His ECG, chest x-ray, and from the ED, potentially leading to increased risk of 9 troponin are all normal. When you go back into the room harm. Although this study is nearly 20 years old, to reassess him, he says he feels fine and asks if he can go more-recent research has shown similar miss rates, home. You hesitate and wonder if it would be safe to send suggesting that the ED evaluation of chest pain for him home without further testing. suspected ACS remains challenging despite advanc- 10-12 A 22-year-old college student presents with sharp, es in knowledge and technology. left-sided chest pain and shortness of breath. He recently The term low-risk patient is inherently unclear and returned from a spring break trip to Mexico and reports can mean different things among providers. In most symptoms of an upper respiratory infection. He feels that literature, patients with chest pain who are described his chest pain is worse when lying flat, and is concerned as being at low risk for ACS are those who: (1) are he’s having a heart attack. His vital signs and physical hemodynamically stable,