Best Clinical Practice: Current Controversies in Evaluation of Low-Risk Chest Pain-Part 1.
BACKGROUND
Chest pain is a common presentation to the emergency department (ED), though the majority of patients are not diagnosed with acute coronary syndrome (ACS). Many patients are admitted to the hospital due to fear of ACS.


OBJECTIVE
Our aim was to investigate controversies in low-risk chest pain evaluation, including risk of missed ACS, stress test, and coronary computed tomography angiography (CCTA).


CONCLUSIONS
Chest pain accounts for 10 million ED visits in the United States annually. Many patients are at low risk for a major cardiac adverse event (MACE). With negative troponin and nonischemic electrocardiogram (ECG), the risk of MACE and myocardial infarction (MI) is < 1%. The American Heart Association recommends further evaluation in low- to intermediate-risk patients within 72 h. These modalities add little to further risk stratification. These evaluations do not appropriately risk stratify patients who are already at low risk, nor do they diagnose acute MI. CCTA is an anatomic evaluation of the coronary vasculature with literature support to decrease ED length of stay, though it is associated with downstream testing. Literature is controversial concerning further risk stratification in already low-risk patients.


CONCLUSIONS
With nonischemic ECG and negative cardiac biomarker, the risk of ACS approaches < 1%. Use of stress test and CCTA for risk stratification of low-risk chest pain patients is controversial. These tests may allow prognostication but do not predict ACS risk beyond ECG and troponin. CCTA may be useful for intermediate-risk patients, though further studies are required.
Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas.
Brit
B
Long
The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas.
Alex
A
Koyfman
D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis*; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000209:etiology*; D000072226:Computed Tomography Angiography; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005080:Exercise Test; D006801:Humans; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012307:Risk Factors; D014336:Troponin / Q000097:blood
D015415:Biomarkers; D014336:Troponin
chest pain; coronary computed tomography angiography; low risk; stress test