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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Friday, August 5, 2016

Risk Scores for Chest Pain in the ED

EM Ottawa - August 4, 2016 - By Calder-Sprackman S
Emergency Department (ED) physicians must assess and risk stratify patients presenting with chest pain nearly every shift. As we all know, acute ischemic coronary syndrome (ACS) is defined as the manifestation of coronary artery disease which is seen as a spectrum from stable angina to STEMI. In certain cases, a diagnosis can be made quickly and easily, particularly in the case of where there are biomarker and ECG changes such as in the case of a STEMI. However, in the absence of these abnormalities, it can be harder to risk stratify patients for both the inexperienced and experienced physician alike.
In order to help evaluate patients who present with chest pain many clinical chest pain scores have been developed. The aim of this blog post is to: 
  1. Provide an overview and assessment of the most popular chest pain risk scores in the ED 
  2. Evaluate the effectiveness of clinical gestalt for the assessment of chest pain ED
  3. Discuss the medical legal implications surround the utilization and documentation of chest pain scores.
Before diving into discussing chest pain scores, we must first understand that even though ED physicians are careful and well trained, the literature quotes that ED physicians have a natural miss rate of 2% for the diagnosis of ACS in the ED.
However, when ED physicians are asked what they feel an acceptable miss rate is, it appears that is it less than our natural miss rate! Than et al. (2013) conducted a survey of ED physicians, of which 17% were Canadian respondents, and found that the overall consensus of acceptable miss rate for ACS would be approximately 1%...

  • There are many chest pain scores with varying degrees of evidence.
  • HEART Pathway is the only score with approximately a 1% MACE at 30 days.
  • Clinical Gestalt performs well for patients we feel ‘definitely don’t have ACS’ and have negative TnI and ECG.
  • Chest pain scores are not the standard of care but at the moment, but are an AHA/ACC class IIa recommendation.