Testing of low-risk patients presenting to the emergency department with chest pain: A scientific statement from the American Heart Association

Ezra A. Amsterdam, J. Douglas Kirk, David A. Bluemke, Deborah Diercks, Michael E. Farkouh, J. Lee Garvey, Michael C. Kontos, James McCord, Todd D. Miller, Anthony Morise, L. Kristin Newby, Frederick L. Ruberg, Kristine Anne Scordo, Paul D. Thompson

Research output: Contribution to journalReview article

396 Scopus citations

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's 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.

Original languageEnglish (US)
Pages (from-to)1756-1776
Number of pages21
JournalCirculation
Volume122
Issue number17
DOIs
StatePublished - Oct 26 2010

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Keywords

  • AHA Scientific Statements
  • acute care
  • angina
  • chest pain unit
  • coronary disease
  • cost-effectiveness
  • diagnostic techniques and procedures
  • emergency department
  • prognosis
  • stress test

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Amsterdam, E. A., Kirk, J. D., Bluemke, D. A., Diercks, D., Farkouh, M. E., Garvey, J. L., Kontos, M. C., McCord, J., Miller, T. D., Morise, A., Newby, L. K., Ruberg, F. L., Scordo, K. A., & Thompson, P. D. (2010). Testing of low-risk patients presenting to the emergency department with chest pain: A scientific statement from the American Heart Association. Circulation, 122(17), 1756-1776. https://doi.org/10.1161/CIR.0b013e3181ec61df