Managing Low-Risk Recurrent Chest Pain in the Emergency Department: Guide to Reasonable and Appropriate Care

This first Guide to Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society of Academic Emergency Medicine addresses the topic: Low-risk, recurrent chest pain in the emergency department.

The multidisciplinary guideline panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with low-risk recurrent chest pain.

Chest pain is the second most common chief complaint in the emergency department (ED), accounting for 5% of visits with an estimated cost of up to $10 billion annually.

The differential diagnosis of chest pain is broad. While providers often prioritize exclusion of cardiac causes of chest pain, such as acute coronary syndromes (ACS), other causes such as acute aortic syndromes, pericarditis, myocarditis, pulmonary embolism, pneumothorax, pneumonia, and perforated peptic ulcer also cause chest pain.

However, only 5% of chest pain visits are diagnosed with one of these life-threatening acute conditions, most commonly ACS.

Despite this low prevalence , undetected acute myocardial infarction (AMI) and associated adverse events rank as common causes of malpractice claims and, consequently, emergency physicians are reluctant to overlook these conditions. There is a variation in the evaluation (diagnostic tests and admission) of these patients.

Clinical practice guidelines can assist clinicians in the assessment of low-risk chest pain but significant variation in practice remains and is often subject to available local resources or lack thereof.

For example, a recent study found that physician-level admission rates ranged from 54% to 96% for patients with chest pain at a single center. Recurrent visits for chest pain are common, and up to 40% of patients return to the emergency department (ED) for chest pain within 1 year.

Evaluation of patients in the ED with chest pain is further complicated by varying degrees of patients’ prior diagnostic evaluations. Patients may also develop new or multiple etiologies that contribute to recurrent or evolving symptoms, or the quality and character of symptoms may fluctuate under the influence of psychosocial factors, without any progression of the underlying physical illness. These factors create a diagnostic dilemma of particular importance for the emergency physician.

There are clinical practice guidelines for the diagnosis and management of ACS, but they neglect the preponderance of patients with chest pain in the emergency room who are low risk , as well as the subset of those who present with recurrent chest pain.

The ED population with recurrent chest pain reflects the diagnostic uncertainty associated with this condition and raises several critical questions including, but not limited to, (1) whether a repeat visit represents a previously missed diagnosis; (2) Does the review justify an escalation in diagnostic approach? (3) What if the patient has already had what can be considered a recent, reasonable, and complete diagnostic evaluation? (4) And for how long is this prior evaluation valid?

The goal of these guidelines is to provide an evidence-based framework intended to assist patients, physicians, and other health care professionals in their decisions regarding the evaluation and treatment of patients with low-risk, recurrent chest pain in the emergency service.

The GRACE-1 writing committee used the following definitions:

Recurrent chest pain

It was defined as patients who had a previous visit to an emergency department (ED) with chest pain that resulted in a diagnostic protocol for evaluation that did not demonstrate evidence of ACS or flow-limiting coronary stenosis. This included two or more emergency department visits for chest pain in a 12-month period.

Low risk

Low risk was defined by a HEART score <4 points (and other ED-validated scores, such as the HEART2 pathway or TIMI27 score) for poor disease-related outcomes within 30 days, all of which require an electrocardiogram (ECG) for risk. stratification.

Accelerated

This time period was defined as 3-5 days.

These represent reasonable and appropriate care with the understanding that individual physicians should always use their judgment in applying these recommendations.

recommendations

Recommendation 1: In adult patients with low-risk recurrent chest pain, lasting more than 3 h, we suggest a single high-sensitivity troponin below a validated threshold to reasonably exclude ACS within 30 days. (Conditional, in favor) [Low level of evidence].
Recommendation 2: In adult patients with low-risk recurrent chest pain and a normal stress test in the previous 12 months, we do not recommend repeating routine stress testing as a means of decreasing 30-day MACE rates. (Conditional, Against) [Low level of evidence].
Recommendation 3 : In adult patients with low-risk, recurrent chest pain, there is insufficient evidence to recommend hospitalization (either standard hospitalization or observation stay) over discharge as a strategy to mitigate major adverse cardiac events over time. of 30 days. (No evidence, either.)
Recommendation 4: In adult patients with low-risk recurrent chest pain and nonobstructive CAD (<50% stenosis) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for hospital evaluation. (Conditional, in favor) [Low level of evidence].
Recommendation 5: In adult patients with low-risk recurrent chest pain and no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing, as warranted, rather than admission for hospital evaluation. (Conditional, in favor) [Low level of evidence].
Recommendation 6: In adult patients with low-risk recurrent chest pain and prior CCTA within the past 2 years without coronary stenosis, we suggest that no further diagnostic testing other than a single high-sensitivity troponin be performed below a validated threshold to exclude SCA within that 2 year time frame. (Conditional, Para) [Moderate level of evidence].
Recommendation 7: In adult patients with low-risk, recurrent chest pain, we suggest the use of depression and anxiety screening tools as they may have an effect on healthcare utilization and subsequent ED visits. (Conditional, Any) [Very low level of evidence].
Recommendation 8: In adult patients with low-risk, recurrent chest pain, we suggest referral for management of anxiety or depression, as this could have an impact on health care use and subsequent health care visits. emergencies. (Conditional / Any) [Low level of evidence].

Conclusions

These guidelines describe and summarize the evidence and strength of GRACE recommendations regarding eight priority questions of interest to emergency physicians, other health care professionals, patients, and policymakers regarding the evaluation and treatment of patients. with low-risk recurrent chest pain seen in the ED.

Direct evidence is lacking for selected priority questions in this population, highlighting areas that will benefit from more robust prospective research in this specific population.

Managing Low-Risk Recurrent Chest Pain in the Emergency Department: Guide to Reasonable and Appropriate Care

Guide offers recommendations for reasonable and appropriate care of patients presenting with low-risk recurrent chest pain in the emergency department, emphasizing evidence-based approaches to diagnostic evaluation and management to optimize patient outcomes and resource utilization.