title: Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association.
abstract: The management of low-risk patients presenting to emergency departments is a common and challenging clinical problem entailing 8 million emergency department visits annually. Although a majority of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent treatment of a serious problem and those with more benign entities who do not require admission. Inadvertent discharge of patients with acute coronary syndrome from the emergency department is associated with increased mortality and liability, whereas inappropriate admission of patients without serious disease is neither indicated nor cost-effective. Clinical judgment and basic clinical tools (history, physical examination, and electrocardiogram) remain primary in meeting this challenge and affording early identification of low-risk patients with chest pain. Additionally, established and newer diagnostic methods have extended clinicians' diagnostic capacity in this setting. Low-risk patients presenting with chest pain are increasingly managed in chest pain units in which accelerated diagnostic protocols are performed, comprising serial electrocardiograms and cardiac injury markers to exclude acute coronary syndrome. Patients with negative findings usually complete the accelerated diagnostic protocol with a confirmatory test to exclude ischemia. This is typically an exercise treadmill test or a cardiac imaging study if the exercise treadmill test is not applicable. Rest myocardial perfusion imaging has assumed an important role in this setting. Computed tomography coronary angiography has also shown promise in this setting. A negative accelerated diagnostic protocol evaluation allows discharge, whereas patients with positive findings are admitted. This approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain.
authors.forename: Ezra A
authors.initials: EA
authors.lastname: Amsterdam
authors.forename: J Douglas
authors.initials: JD
authors.lastname: Kirk
authors.forename: David A
authors.initials: DA
authors.lastname: Bluemke
authors.forename: Deborah
authors.initials: D
authors.lastname: Diercks
authors.forename: Michael E
authors.initials: ME
authors.lastname: Farkouh
authors.forename: J Lee
authors.initials: JL
authors.lastname: Garvey
authors.forename: Michael C
authors.initials: MC
authors.lastname: Kontos
authors.forename: James
authors.initials: J
authors.lastname: McCord
authors.forename: Todd D
authors.initials: TD
authors.lastname: Miller
authors.forename: Anthony
authors.initials: A
authors.lastname: Morise
authors.forename: L Kristin
authors.initials: LK
authors.lastname: Newby
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Ruberg
authors.forename: Kristine Anne
authors.initials: KA
authors.lastname: Scordo
authors.forename: Paul D
authors.initials: PD
authors.lastname: Thompson
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications* / Q000175:diagnosis* / Q000453:epidemiology; D000572:American Heart Association; D002637:Chest Pain / Q000209:etiology*; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics; D004636:Emergency Service, Hospital / Q000191:economics / Q000639:trends*; D006801:Humans; D012307:Risk Factors; D014481:United States