This month JC is going to be looking at the management of the low risk ED chest pain patient. Despite advances in the development and broad implementation of decision rules such as PECARN and Wells for pediatric head trauma and PE respectively, we do not have a widely validated decision rule for management of the NSTEMI ED CP patient. Current level (A/B) recommendations from the 2014 AHA/ACC guidelines include serial cardiac enzymes, risk stratification, and treadmill exercise testing ‘within 72 hours of the ED visit’. For risk stratification, these guidelines reference TIMI or GRACE scores both of which have been derived primarily from non-ED patient populations with known cardiac disease. In the past few years, there have been a host of risk stratification tools that have been derived. Examples include: The North American Chest Pain Rule the ASPECT Study the ADAPT Trial and the HEART score. We will be reviewing the HEART score including its derivation, retrospective and prospective validation studies and most recently, an RCT comparing it to ‘usual ED care strategies’
This is surely a hot topic in EM and covered widely on podcasts such as EM Rap and by opinion leaders such as Amal Mattu. Should be lots to discuss in our attempt to find the ‘holy grail’ for ED CP patients that meets our risk tolerance, decreases patients harms from false positive stress testing, saves money and informs your shared decision making discussions.
Backus BE et al. Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol. 2010 Sep;9(3):164-9. Appraisal
Backus BE et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. Appraisal
Mahler SA, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015 Appraisal