Perhaps no medical mythologies are as ingrained as the work-up of chest pain in the emergency department, and this article aims to be the Top 10 list of chest pain myth-busters.
1. Women do not present differently from men with ACS. Contrary to pop culture medical shows, we do know a lot about women and heart disease; and they present similarly to men. (JAMA Intern Med 2014:174:241.)
2. Cardiac risk factors do not help in the ED. The AHA/ACC 2010 guidelines on acute coronary syndrome state, “Cardiac risk factors are usually not helpful in the identification of acute coronary syndromes in patients presenting with acute chest pain.” (Circulation 2010;122:1756.)
3. Family history is rarely meaningful. Most relatives interpret “cardiac arrest” on family members' death certificate as “heart attack.” The agreement between patients' histories and their children's knowledge of their histories is poor. (J Epidemiol Community Health 2000;54:859.)
4. Grading “pain” may miss ACS. A substantial portion of patients don't experience pain. We should use the word “discomfort,” which is more likely to include “pressure” and “tightness.” We should stop asking patients to grade their pain on a scale of 1 to 10, and start asking them to grade their discomfort.
5. “RUBS” may prevent any workup. Reproducible (pleuritic, upon movement), Under a thumb (localized), Brief (seconds to few minutes), and Sharp (or stabbing) each have likelihood ratios of 0.2-0.3. In combination in the otherwise typical patient, one may not need any testing, including an EKG. Using this simple tool (RUBS) can save the patient up to $5,000 of routine protocol charges. (J Clin Epidemiol 1992;46:621.)
6. “Response to nitro” is not therapeutic or diagnostic. Why are we routinely using nitrates? And why are we reporting clinical responses to nitroglycerin? It has no diagnostic capability, and it can be harmful in the inferior MI or the LV infarct. (Ann Emerg Med 2005;45:581.)
7. Troponin is the only biomarker needed, and “negative” is not enough. Only very rarely should one consider a CK-MB (e.g., re-infarction) or a BNP. A troponin reported only as “negative” is meaningless. The amount of time of “continuous discomfort” will help determine the negative predictive value of the troponin. A “negative” troponin of only four hours has extremely poor negative predictive value. Even an eight-hour “negative” troponin may be helpful only for the low-risk individual.
8. Routine chest x-rays are unnecessary and unhelpful. Portable chest x-rays in overweight and obese individuals provide false-positive results by showing larger than normal heart size and a wide mediastinum. A routine chest x-ray is unhelpful in other typical individuals without dyspnea or hypoxia.
9. We are not saving lives; we are just documenting for dollars. (New Engl J Med 2013;369:901; N>95,000.) Getting an EKG in less than 10 minutes to pick up a STEMI to make your door-to-balloon time in less than 90 minutes has done nothing to improve mortality. We do all of this for the hospital to get CMS dollars or to acquire a stamp of approval called “chest pain center” from an outside source for the purpose of marketing. One can even argue that this approach results in more unnecessary cardiac stenting, which increases mortality in individuals going for other noncardiac operative procedures (JAMA 2013;310:1462), and certainly dramatically increases medical costs to the patient.
10. Chest pain protocols have promoted malpractice. Protocols were historically a preapproved physician order by the medical staff that could be initiated by nurses in the absence of a bedside physician (like in the CCU). The current market-driven emphasis on speed has led many EDs to start chest pain protocols before any physician is even aware the patient is in a room, though the physician may be less than 20 feet away! Often chest pain protocols are initiated before anyone has done anything resembling an adequate history or physical exam. Once the “chest pain protocol” has been started, many physicians acquiesce to completing it. Many physicians believe it may protect them legally. Ironically, all of the unnecessary testing, added expense of running patients routinely through the whole protocol, false-positives, and unnecessary caths and stents is truly promoting malpractice.
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