Clinical decision aids for chest pain in the emergency department: identifying low-risk patients

Abstract

Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS). However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT); Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT); North American Chest Pain Rule (NACPR); and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting.

Keywords: acute coronary syndrome; chest pain; decision aid; risk score.

Figure 1

TIMI score and GRACE score. Abbreviations: ACS, acute coronary syndrome; Cr, creatinine; ECG, electrocardiogram; GRACE, Global Registry of Acute Coronary Events; HR, heart rate; SBP, systolic blood pressure; TIMI, thrombosis in myocardial infarction.

Figure 2

ADAPT, NACPR, and the HEART Score. Notes: ADAPT and NACPR, a patient is considered to be in low risk if they have none of the high-risk criteria. For ADAPT, risk factors include family history of coronary disease, hypertension, hypercholesterolemia, diabetes mellitus, and current smoker. The HEART Score; low risk =0–3, high risk =4 or greater. Risk factors include currently treated diabetes mellitus, current or recent (<90 days) smoker, diagnosed and/or treated hypertension, diagnosed hypercholesterolemia, family history of coronary artery disease, obesity (body mass index >30), or a history of significant atherosclerosis (coronary revascularization, myocardial infarction, stroke, or peripheral arterial disease). Abbreviations: ACS, acute coronary syndrome; ADAPT, Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins; ECG, electrocardiogram; HEART, history, ECG, age, risk factors, troponin; NACPR, North American Chest Pain Rule; TIMI, thrombolysis in myocardial infarction.