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Emergentology: Trust Your Gut When It Comes to Vague Chest Pain

Walker, Graham MD

doi: 10.1097/01.EEM.0000470671.32315.28
Emergentology

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him @grahamwalker, and read his past columns athttp://bit.ly/WalkerEmergentology.

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Attention: This article is meant only for people who evaluate patients with undifferentiated chest pain. Everyone else, please stop reading.

OK, 100 percent of you, listen up: Can we stop with the chest pain nonsense already? It's wasting our time, our patients' time and money, our nurses' time, our ED beds, our observation beds, our hospital admissions, our hospitalists' time, our cardiologists' time, and just about any other precious resource you can think of in health care. (I would also like to blame chest pain for worsening the California drought, just because.)

I'm going to walk the tightrope of boredom and brevity here today, and briefly run through some studies and risk scores, and issue a plea to our guideline developers to stop the madness.

But before data, let's just clarify what I'm talking about, and describe my experience as a physician. First, I'm talking about the vague, not-terribly-concerning chest pain that your gut tells you is nothing, but your experience tells you very rarely is actually something (like an NSTEMI). I'm not referring to chest pain that worries you for any of the reasons you worry as an experienced emergency physician. I'm not talking about chest pain that you're working up for PE, dissection, or tamponade. I'm talking about that not-very-impressive story without a lot of risk factors or a lot of years under his belt. In my experience, this is a large portion of chest pain that I see.

And in my experience, this chest pain is rarely anything life-threatening or given a clear diagnosis. Admission diagnosis? Chest pain. Discharge diagnosis? Chest pain. The test is rarely positive when these patients are evaluated with stress testing.

Also in my experience, cardiologists don't particularly want to be included in the evaluation of possible cardiac chest pain. Having an MI? Sure, call them up. But undifferentiated chest pain? They actually don't see a whole lot of undifferentiated chest pain. That's really our turf; they're only dragged in to break a tie or make a decision. They weigh in with their guidelines about chest pain because, well, they're heart doctors, and the heart is in the chest, and they see all of the patients who end up having heart attacks (but importantly, very few of the patients that don't.)

And yet, I feel like our hands are tied as emergency physicians. We have these guidelines from our specialty as well as others recommending the most conservative of conservative approaches (like stress testing within 72 hours, for example) with little to no data to support it (and even maybe some data against it; see below). Lest Amal Mattu strike me down: Yes, I get it; I get that chest pain is a serious, potentially life-threatening symptom. Remember, I'm talking about the chest pain patients who have nothing that really excites you about their story, past history, EKG, or troponin. (I also get that the unimpressive chest pain on rare occasion is life-threatening, and I am not proposing that it's blown off.)

So, what am I proposing? Simply this: A more evidence-based approach to these chest pain patients that is just as safe (maybe even safer) as our current approach, but saves everyone time and resources. May I present some evidence? Don't say no; I'm going to anyway.

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The Stress Test

If you really want to be floored, listen to David Newman and Ashley Shreves' podcast about stress testing. (http://bit.ly/1Gt9n1p.) You'll be flabbergasted when you realize how we got to this point, and why stress testing is such a miserable medical test. (I acknowledge that cath clearly has risks, and we're doing stress tests because we think we need our best to evaluate noninvasively via stress testing.)

Now that you're enraged about how terrible stress testing is, let's look at Judd Hollander's 2003 study of 962 hospital admissions for chest pain. He asked the question: Was the outcome different if patients received an inpatient, outpatient, or no stress test? (The admitting medicine teams decided who got what.) The conclusion: There was no statistical difference in 30-day cardiovascular outcomes among patients who received inpatient, outpatient, or no ETT within 30 days. This suggests that patients with chest pain who are admitted to non-intensive-care telemetry (or observation unit) beds might not need stress testing before hospital release. (Am J Emerg Med 2003;21[4]:2282.)

Stress testing — whether in-house, outpatient, or none at all — had no effect on mortality, rate of MI, or CABG. (One could argue that these patients hopefully got some medication optimization, education, and counseling while they were admitted that doesn't show up in these hard outcomes, but this also could arguably have been done with a close outpatient follow-up program.)

But maybe there's benefit to just keeping people in-house?

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The Chest Pain Observation Admission

A really fantastic study just came out in May by Weinstock et al. trying to answer this exact question: Who benefits from a chest pain admission with negative troponins? (JAMA Intern Med 2015 May 17; doi:10.1001/jamainternmed.2015.1674.)

The authors only looked at those with negative troponins x2 who were admitted, and then excluded patients that any of us would reasonably want to admit as well: The hypotensive or hypoxic, those with abnormal EKGs, etc. And then they said, “Over five years in three hospitals out of all 7,266 patients that were admitted or observed but have negative troponins, and by EKG, vitals, and labs we're not really worried about, how many people had a bad outcome?” (Bad outcome was life-threatening arrhythmia, STEMI, cardiac or respiratory arrest, or death.)

Four. There were four of these patients. (And one was a GI bleed and another had asystole after iatrogenic nitroglycerin was given.)

If you ever follow up on your patients, you intuitively always kind of suspected this. You know how rare it is that you find a patient who you weren't worried about that surprised your clinical acumen. This paper then goes on to think about the risk and harm to these 7,266 patients (when only one in 1,816 had a relevant bad outcome), given estimates of harm to hospitalizing patients around one in 160.

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I'll also point out the practitioner extrapolation: If you work 30 hours a week for 50 weeks a year and see 2.5 patients an hour, and five to 10 percent of patients come to the ED for chest pain, you'd have to admit all of these “I'm not too worried” chest pains for almost five years of your career to help one of them. Did I mention the complication rate of cath is at least one percent?

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The Low-Risk ED Rule-Out

Several other chest pain teams around the world have been asking whether all of those 7,266 patients really need two troponins six hours apart? Aren't some of them pretty low risk? Can't we figure out who those low-risk people are and expedite their workup and discharge?

Yes. Yes, we can.

Several scores have been developed to do just this: The HEART Score, the EDACS, and the Vancouver Chest Pain Rule. (They're available, of course, on http://www.mdcalc.com. Just type “ACS” in the search bar.) They all essentially do the same thing: Use EKG, troponin, history, and risk factors to identify which patients are at low risk of having a bad outcome (MI, death, etc.) and recommend “early” discharge in these patients (depending on the rule, one or two troponins a few hours apart, with or without stress testing afterwards). (A list of studies are available at the end of this article so you can make up your own mind.) These scores are often able to classify up to 40 to 50 percent of patients as low-risk, meaning their average length of stay is several hours as opposed to double digits. And if you're not low-risk? No big deal; just do what you do normally in terms of your chest pain, repeat-troponins evaluation. (I'd like big U.S.-based validations of these scores, but the data look quite convincing that they objectify risk of bad outcome very well.)

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What to Make of This

Lawyers and the medicolegal system: Relax. I am not advocating that all emergency physicians stop what we've been doing for decades now and admit no one, stress no one, and test no one. I'm also not saying that physician experience and expertise should be put out to pasture when it comes to chest pain.

What I am saying, however, is that it seems apparent that we've got at least a little wiggle room for improvement when it comes to our workups of possible cardiac chest pain, especially when it's low-risk, and we have the data to prove it. (There are many other studies besides these.)

It's time for the leaders of our specialty to look through these data, understand that we in emergency medicine own chest pain, and that we're hurting ourselves and our patients by aggressively working up anyone and everyone who says those almighty words in our presence. Guidelines need to be updated to reflect this, and if you've got an opportunity to publish data or run analyses similar to the ones I've presented, it will only strengthen our case further.

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Make Up Your Own Mind

These articles shed light on how to determine which chest pain patients are low risk of having a bad outcome. Find live links for each of them on our website or in our iPad app.

  • “Development and Validation of the Emergency Department Assessment of Chest Pain Score and 2 H Accelerated Diagnostic Protocol,” Emerg Med Australas 2014;26(1):34; http://1.usa.gov/1LgbNCt.
  • HeartScore, European Society of Cardiology; www.heartscore.org.
  • “Impact of Stress Testing on 30-Day Cardiovascular Outcomes for Low-Risk Patients with Chest Pain Admitted to Floor Telemetry Beds,” Am J Emerg Med 2003;21(4):282; http://1.usa.gov/1ftvxGA.
  • “Risk for Clinically Relevant Adverse Cardiac Events in Patients with Chest Pain at Hospital Admission,” JAMA Intern Med 2015 May 18; http://1.usa.gov/1SCU9Lh.
  • “Stress Testing: A Moment of Clarity,” SMART EM: http://bit.ly/1Gt9n1p.
  • “Validation of the Vancouver Chest Pain Rule: A Prospective Cohort Study,” Acad Emerg Med 2012;19(7):837; http://1.usa.gov/1QMcUyt.

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