There are some fresh recommendations for EDs treating patients with suspected non-ST-elevation acute coronary syndromes (ACS).1 A new clinical policy from the American College of Emergency Physicians (ACEP) addresses the evaluation and management of these patients.

The policy was needed because of the large numbers of chest pain patients presenting to EDs every day, according to the study’s lead author Christian Tomaszewski, MD, MS, MBA, FACEP. “Lots of resources are being used unnecessarily on these patients,” says Tomaszewski, a professor of clinical emergency medicine and chief medical officer at El Centro Regional Medical Center in San Diego and an attending EP at UC San Diego Health.

Patients stay in the ED for four to six hours undergoing serial testing of cardiac troponins, wreaking havoc with patient flow. “We still miss up to 1-2% of myocardial infarctions in spite of excessive testing and workups of low-risk cases,” Tomaszewski reports.

The ACEP committee saw the need for a more accurate, expedited workup for these patients, given the availability of newer troponins. “It will allow quicker turnover of these low-risk patients, with no increase in risk of missed MI,” Tomaszewski explains. Evidence-based protocols offer some degree of legal protection for the EP in the rare event a patient is sent home and experiences an MI. “Standardized care will help protect physicians and, in turn, patients when they follow societal agreed-upon practices,” Tomaszewski says.

Solveig Dittmann, RN, BA, BSN, CPHRM, senior risk specialist at Coverys, offers some reasons for why EPs fail to diagnose STEMI:

  • Some patients do not have chest pain but rather “atypical” symptoms like back pain, vertigo, or weakness;
  • Some patients do not present with typical risk factors for MI (hypertension, hyperlipidemia);
  • Some younger patients are high risk due to medication therapy (this includes HIV patients and those on steroids);
  • Some MI patients’ symptoms improve with antacids;
  • Sometimes, the first ECG can look normal.

Tomaszewski predicts adherence to the recommendations in the ACEP clinical policy is not expected to change the current miss rates. Between 1% and 2% of discharged chest pain patients will experience an MI or die within 30 days. “We cannot pick up every single case because then costs and incidental findings and harm will increase above an acceptable threshold,” Tomaszewski notes.

Even “low-risk” chest pain patients can become plaintiffs in malpractice litigation if unexpected outcomes occur. “EDs can mitigate some of this risk by practicing evidence-based medicine and discharging home patients who are truly low risk,” says Adnan Sabic, MD, an emergency medicine attending at Ascension St. John Hospital and Medical Center in Detroit. St. John’s ED providers use the HEART score (History, ECG, Age, Initial Troponin) to risk-stratify patients. Based on the score, low-risk patients are discharged home after two negative troponins in the ED. Medium-to-high scoring patients stay for further workup and management. “Most of us will not miss slam-dunk chest pain cases,” Sabic says. “It is those in the middle who can trip us up and cause a major headache.” In a review of low-risk chest pain cases, Sabic found these frequent allegations:

  • The patient’s complaint was not taken seriously; as a result, the appropriate workup was not initiated;
  • The patient was not involved in the decision-making process;
  • The differential diagnosis was not expanded, resulting in delayed care.

For EPs to refute such allegations, “it is imperative to document all conversations with the patient,” Sabic stresses. This should reflect that risks and benefits were discussed and that the patient agreed with the plan of care.

“This can make a difference in mounting a successful defense,” Sabic adds.


  1. Tomaszewski CA, Nestler D, Shah KH, et al. Clinical policy: Critical issues in the evaluation and management of emergency department patients with suspected non-ST-elevation acute coronary syndromes. Ann Emerg Med 2018;72:e65-e106.