![Safe Discharge in Non-Low Risk Chest Pain Patients](https://www.acepnow.com/wp-content/uploads/2018/04/ACEP_0418_pg22a.png)
There’s been a clear shift in the emergency medicine mindset toward chest pain over the past few years, including an explosion of literature and professional guidance in support of the history, electrocardiogram, age, risk factors, and troponin (HEART) score.1 The primary application of this and other similar rules is to support risk-stratification and the early discharge of patients with chest pain at low risk for acute coronary syndrome (ACS).
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ACEP Now: Vol 37 – No 04 – April 2018In fact, various strategies for early discharge have been enshrined in the guidelines from the American College of Cardiology since 2014.2 These guidelines support the use of not only such stalwarts as the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores, but HEART, a modification of HEART called HEARTS3, and the Vancouver Rule. Suffice it to say, if you’re not at least risk-stratifying patients for early discharge using clinical judgement or an objective tool, you’re lagging.
However, this article isn’t about discharging patients with low-risk chest pain. This article discusses discharging the other 40–50 percent of emergency department patients with chest pain who don’t fall into such an optimal classification. For instance, a septuagenarian with non-obstructive coronary artery disease on a previous cardiac catheterization, a couple seconds of atypical chest pain, and an undetectable troponin I counts as a “moderate” risk by HEART. Or a 65-year-old male without any known risk factors and non-specific pain who falls into the “not low risk” classification of the Emergency Department Assessment of Chest Pain Score (EDACS).3 How should we manage the vast heterogeneous cohort of patients like these who aren’t in the low-risk strata?
It’s Two Questions
This question basically breaks down into two components, which people frequently stick together and address singly when evaluating the performance of these algorithmic approaches. These approaches try to pare down the cohort by defining certain discharge criteria in the emergency department, and they measure success by remaining free of major adverse cardiac events (MACE) for a certain period of time.
This approach seeks to prevent the dreaded, “Hey, remember that guy with chest pain you sent home last week?” follow-up conversation on a future shift. However, assessing safety for discharge truly breaks down into these two questions: 1) “Have I adequately ruled-out an acute coronary syndrome on today‘s visit,” and 2) “What follow-up or additional testing will prevent a future MACE?”
To answer question one, we rely upon the relevant presenting features of the chest pain, the electrocardiogram, and biomarker testing. In the vast majority of cases in which acute ischemia is not apparent or highly suspected, the limiting factor becomes biomarkers. In the past, concern over the relative lack of early sensitivity to cardiac ischemia led clinicians to routinely refer patients for admission or observation for repeat biomarker testing. However, in recent years, an explosion of new literature describes the early test characteristics of both conventional and highly-sensitive troponins, and it‘s clear the biomarker rule-out can be performed entirely within the emergency department.4
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4 Responses to “Safe Discharge in Non-Low Risk Chest Pain Patients”
June 18, 2018
John CharbonnetWhat does this mean, “more than 85 percent of biomarker-negative chest-pain presentations are discharged directly from the emergency department without untoward patient safety”? Are you saying that nearly 15 percent of biomarker negative chest-pain presentations are discharged directly from the emergency department WITH untoward patient outcomes? You are proud of that???
August 6, 2018
Ryan RadeckiHi John –
Good pick-up on ambiguously phrased wording allowing for the interpretation of rampant poor outcomes in our chest pain cohort.
Rather, 85% of our chest pain patients are managed as outpatient versus 15% who are managed as inpatient. We have not been able to detect, through QA review, any particular spike in mortality or morbidity associated with increasing the proportion of those managed as outpatient rather than inpatient.
– Ryan
August 14, 2018
Scott Knepper MDHi Ryan,
Love EMLitofNote btw, but essentially what I’m reading is, “We could safely discharge the majority of patients that we admit to the hospital for chest pain,” which is what all EM providers already know. What I still don’t see is the reliable way to discriminate who can safely go home in the non-low risk population, especially when we are still missing 2% of ACS in the ED.
August 16, 2018
Ryan RadeckiHi Scott –
I agree and disagree – we can send most home, even in a non-low-risk population. The trick is there’s so much heterogeneity within the non-low-risk population there’s no way to create a generalizable decision instrument to assist with disposition. It comes down an individual estimate of the pretest likelihood of ACS given the current presentation as to whether the initial biomarker rule-out in the ED is reliable, and then the specific context of the symptoms, known anatomy, and prospective follow-up when making a plan.
– Ryan