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Wednesday, October 26, 2022

Acute Chest pain (ACC 2022)

Fist10EM - By Justin Morgenstern - October 26, 2022
The paper: Writing Committee, Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI Jr, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Oct 6:S0735-1097(22)06618-9. doi: 10.1016/j.jacc.2022.08.750. Epub ahead of print. PMID: 36241466
Summary
  • Their assumptions about CCTA seem unfounded
  • I like their assumption about clinical judgment (but it might be equally unfounded
  • Low risk patients don’t need more testing
  • Phasing out “atypical”
  • Moving beyond “STEMI”
  • I think their comments about echocardiography, although probably true, are problematic for many emergency doctors
  • Detectable troponin is never normal, but it isn’t all ACS
  • We should be using age and sex adjusted troponin thresholds
  • MI can be ruled out with a single high sensitivity troponin at time zero in many patients
  • Clinical decision pathways using either 0 and 1 hour or 0 and 2 hour high sensitivity troponins are recommended
  • Risk scores don’t help
  • The treatment is different, but don’t downplay the importance of type 2 MI
  • Seriously, stop with the stress tests