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Chest Pain

Cameron Berg, MD, Matthieu DeClerck, MD, and Mike Weinstock, MD
00:00
27:04

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Patients who present to the urgent care with chest pain can have their initial evaluation performed with an ECG, CXR and troponin testing then be risk stratified to go to the ER or be sent home for expedited outpatient evaluation

Pearls:

  • We should align our care with evidence when we're seeking to find a condition that is unlikely to be present.

  • An EKG, a diligent history/physical exam and troponin is all that is necessary to rule out acute coronary syndrome.

  • Excessive testing in patients with low risk chest pain is likely to result in more invasive downstream testing that is just as likely to result in harm as it is to prevent major adverse cardiac events.

 

  • There is a 20 fold variation in people's comfort with an acceptable miss-rate for ACS. Ranging from missing one or two in 100, to people who were only comfortable missing one in 10,000! (Than M et al, 2013)

  • Hospitalization for further testing in and of itself is not a benign act. 1 in 160 patients end up having a life ending event because of the act of hospitalization.

  • Even patients who do have an NSTEMI only have a 0.008% risk of death in the following 2 days.

  • Having an evidenced based Accelerated Diagnostic Pathway that has buy-in  from all players involved (eg. cardiology, emergency medicine, family medicine etc) is actually protective against lawsuits when a patient has a bad outcome.

  • When it is properly explained to patients that their risk of dying from their chest pain after a negative work up is low they are actually LESS likely to return to the ER with similar complaints in the future.

 

References:

  1. Faranoff AC, et al. Does This Patient With Chest Pain Have Acute Coronary Syndrome? The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955-1965. doi:10.1001/jama.2015.12735

  2. Hess EP, Hollander JE, Schaffer JT, et al. Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial. BMJ (Clinical research ed) 2016;355:i6165

  3. Than M, Herbert M, Flaws D, et al. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the emergency department?: a clinical survey. Int J Cardiol. 2013;166(3):752-754

Mike W., MD -

From Dr. Brown:
But the authors of this discussion failed to address the fact that most urgent care centers will not have the option of getting an immediate troponin level back before the patient is discharge? So now we are right back to where we have always been - to send of the ER for a troponin or not…
Sincerely,
Dr Jeff Brown

Response:
You are exactly right, this can only be done if there is an ability to do a troponin!
M

Jeffrey B., MD -

Thanks Mike for the response! So what would you guys suggest in the patient that you described in the case with normal ECG but with a few risk factors for ACS and the urgent care does not have ability to get trops? Are you suggesting that the majority of these patients should go to ER for a single trop to rule out ACS?

Thanks for furthering this conversation!

Mike W., MD -

Thx for the question Jeff, and the answer is yes, if there is a concern for ACS, a troponin should be done and if can't be done in the UC, should be sent to the ED.
M

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Bun (Not) In The Oven Full episode audio for MD edition 185:18 min - 87 MB - M4AUrgent Care RAP March 2019 Written Summary 360 KB - PDF

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