Advanced Practice: ACEP Guidelines Advocate for Discharge of Low Risk Chest Pain Patients!
Here are the most interesting new guidelines with a "bottom line" analysis of each:
1. In adult patients without evidence of ST-elevation acute coronary syndrome, can initial risk stratification be used to predict a low rate of 30-day major adverse cardiac events?
Level B Recommendations In adult patients without evidence of ST-elevation acute coronary syndrome, the History, ECG, Age, Risk factors, Troponin (HEART) score can be used as a clinical prediction instrument for risk stratification. A low score (≤3) predicts a 30-day major adverse cardiac event miss rate within a range of 0% to 2%.
Level C Recommendations In adult patients without evidence of ST-elevation acute coronary syndrome, other risk-stratification tools, such as Thrombolysis in Myocardial Infarction (TIMI), can be used to predict a rate of 30-day major adverse cardiac event.
Bottom Line: ACEP specifically endorses the usage of the HEART score, which is an easy to use tool that accurately identifies patients at very low risk of short term Major Adverse Cardiac Events (MACE). This is very good news.
2. In adult patients with suspected acute non–ST-elevation acute coronary syndromes, can troponin testing within 3 hours of emergency department presentation be used to predict a low rate of 30-day major adverse cardiac events?
Level C Recommendations
1. In adult patients with suspected acute non–ST-elevation acute coronary syndrome, conventional troponin testing at 0 and 3 hours among low-risk acute coronary syndrome patients (defined by HEART score 0 to 3) can predict an acceptable low rate of 30-day major adverse cardiac events.
2. A single high-sensitivity troponin result below the level of detection on arrival to the emergency department, or negative serial high-sensitivity troponin result at 0 and 2 hours is predictive of a low rate of major adverse cardiac events.
3. In adult patients with suspected acute non–ST-elevation acute coronary syndrome who are determined to be low risk based on validated accelerated diagnostic pathways that include a nonischemic ECG result and negative serial high-sensitivity troponin testing results both at presentation and at 2 hours can predict a low rate of 30-day major adverse cardiac events allowing for an accelerated discharge pathway from the emergency department.
Bottom Line: Although only a Level C recommendation (expert consensus), the common practice of measuring serial conventional troponins (or a single high sensitivity troponin) in a low risk patient is validated.
3. In adult patients with suspected acute non–ST-elevation acute coronary syndromes in whom acute myocardial infarction has been excluded, does further diagnostic testing (eg, provocative, stress test, computed tomography [CT] angiography) for acute coronary syndrome prior to discharge reduce 30-day major adverse cardiac events?
Level B Recommendations Do not routinely use further diagnostic testing (coronary CT angiography, stress testing, myocardial perfusion imaging) prior to discharge in low-risk patients in whom acute myocardial infarction has been ruled out to reduce 30-day major adverse cardiac events.
Level C Recommendations Arrange follow-up in 1 to 2 weeks for low-risk patients in whom myocardial infarction has been ruled out. If no follow-up is available, consider further testing or observation prior to discharge (Consensus recommendation)
Bottom line: Did you get that last one? This is the big one. ACEP specifically recommends against the common practice of admitting patients for further provocative testing once they are identified as low risk and have been ruled out for acute myocardial infarction. The previous American College of Cardiology guidelines advocating for obtaining provocative testing within 72 hours in essentially every patient without another clear cause of chest pain had hamstrung efforts to discharge low risk patients largely because of the concern for lack of timely access to followup. This Level C recommendation means it is ok if your patient can't see their doctor within a few days, with the caveat that patients with poor or no access to care should be considered for further testing before discharge.
Conclusions: Bravo to ACEP for finally publishing common sense guidlines to support emergency medicine physicians. For too long the onus of a "missed MI" or sudden unexpected cardiac death in low risk ACS patients was unfairly placed squarely on individual physicians, resulting in decades of over-admission and over-testing, with little benefit to patients. With the advent of high-sensitivity troponin, we will likely be able to push the definition of low-risk ACS patient even further and hopefully prevent even more unnecessary admissions and testing.