Not everyone with low-risk chest pain needs to be admitted to the hospital. Yet no EP wants to find out one of his or her patients suffered a heart attack shortly after leaving the ED.
“We still are overadmitting patients for chest pain. But this is better than underadmitting,” says Stephen Colucciello, MD, FACEP, a professor of emergency medicine at Charlotte, NC-based Atrium Health. Colucciello says EPs can reduce risks by following two practices:
• Ensure the patient really is low-risk by documenting an assessment with a validated scoring system. “There are many good scoring systems,” Colucciello says.
These include the history, electrocardiogram, age, and risk factors (HEAR) score; the history, electrocardiogram, age, risk factors, and initial troponin (HEART) score; the Emergency Department Assessment of Chest Pain Score (EDACS); Troponin-only Manchester Acute Coronary Syndromes (T-MACS); and more.1-4
• Ensure the timing of troponins is appropriate. If pain started more than six hours before a blood draw for fourth-generation troponins, or more than three hours for high-sensitivity troponins, only then is a single troponin level reliable.
That is not the case if symptoms started more recently, are worsening, or are waxing and waning. For those cases, says Colucciello, “you must draw a second [delta] troponin. An increase of 20% over the first level likely indicates acute coronary syndrome.”
EPs should draw at least a two-hour delta for fourth-generation troponins and a one-hour delta for high-sensitivity troponins, according to Colucciello. Ordering a repeat ECG can clarify where things stand. If the ECG looks worse, the patient is exhibiting dynamic changes that could be ischemia. “If the repeat ECG looks better, that, too, is worrisome — meaning the patient was having ischemia when the first ECG was taken,” Colucciello says.
The plaintiff’s expert will look for two specific actions, says Colucciello: That a scoring system showed the patient was low-risk, and that a delta troponin was obtained appropriately. “Also, discuss why you do not believe the patient has another cause of potentially lethal chest pain, especially pulmonary embolism or aortic dissection,” Colucciello adds.
EPs can use the Pulmonary Embolism Rule-out Criteria (PERC) score to eliminate PE or the Aortic Dissection Detection Risk Score (ADD-RS) to rule out aortic dissection. “The Aortic Dissection Detection Risk Score is very nonspecific,” Colucciello notes.
The vast majority of patients with severe pain do not experience aortic dissection. “However, sudden severe pain, especially migrating to the back, is worrisome, as is an abnormal chest X-ray that suggests a mediastinal abnormality,” Colucciello cautions.
Many ED charts do not include any information on scoring methods that were used, says David Sumner, JD, a Tucson, AZ, medical negligence specialist with a multistate trial practice.
Plaintiff attorneys will make an issue of any cardiac risk factors that were not specifically documented. That includes current smoking or vaping, smoking history, hypertension, high cholesterol, low HDL, diabetes, obesity, COPD, COVID-19 exposure, peripheral vascular disease, heart valvular irregularities such as aortic stenosis, history of prior myocardial infarction or angina, family history of early onset coronary artery disease, or history of past percutaneous interventions or bypass.
“Plaintiffs’ attorneys highlight key omissions or errors in the ER record to challenge the overall veracity of the record,” Sumner explains.
EP defendants will not recall the history they obtained by the time a deposition happens months or years later. Instead, EPs will be relying on the record to defend the workup and management. “Sloppy, incomplete, or inaccurate records connote a lack of attention to detail and mistake-prone care and treatment — a damaging circumstance when you are relying entirely upon the chart for your defense of the ER management,” Sumner warns.
Even if the patient is low-risk, with no prior cardiac history, “you still need pulse oximetry, ECG, and troponins,” Sumner says.
If there is no evidence on ECG of STEMI, NSTEMI, suspicious T wave changes, or emerging Q waves; if the troponin shows no suggestion of ongoing ischemia or recent injury; if the patient has no risk factors — and all this is well-documented, the EP “should be OK, even if the patient is discharged from ER and later has a cardiac event,” Sumner says.
The defense could argue convincingly that everything possible occurred to detect the condition at the time of the ED visit. Sumner says that in low-risk chest pain cases, these practices are especially helpful to the ED defense:
- Repeat the ECG after a period of observation if the test reveals ambiguous, unusual, or equivocal findings.
- Request cardiology confirmatory interpretation of any uncertain ECG findings.
- Do not discharge the patient if the vital signs show blood pressure derangement or unresolved tachycardia or bradycardia.
- Try to obtain prior ECGs for comparison.
Plaintiff attorneys will argue the chest pain patient was discharged prematurely if there are any unresolved or uncertain issues as to vital signs, labs, or ECGs. That includes the patient’s COVID-19 status. “COVID-19 has placed patients at risk for cardiovascular inflammatory syndromes,” Sumner observes.
This means ED charts should include inquiries on whether the patient has ever tested positive for COVID-19 or was recently exposed to COVID-19, even if the patient’s current COVID-19 status is unknown. “Given the reality that cardiac symptoms could be the first expression of symptomatic COVID, I would recommend COVID testing if [that] is feasible, especially rapid testing,” Sumner offers.
The arteritis and prothrombotic states that sometimes accompany COVID-19, even in ostensibly mild cases, put patients at substantial risk for adverse coronary events. The cardiac manifestations of COVID-19 can occur even in younger patients with few or no comorbidities.5
EPs are going to need to document this risk factor also was considered. “What is important is to document that COVID was in the differential, and that a reasonable, focused history on COVID issues was obtained,” Sumner says.
- Otsuka Y, Takeda S. Validation study of the modified HEART and HEAR scores in patients with chest pain who visit the emergency department. Acute Med Surg 2020;7:e591.
- Moumneh T, Sun BC, Baecker A, et al. Identifying patients with low-risk of acute coronary syndrome without troponin testing: Validation of the HEAR score. Am J Med 2020 Oct 27;S0002-9343(20)30906-2. doi: 10.1016/j.amjmed.2020.09.021. [Online ahead of print].
- Mark DG, Huang J, Kene MV, et al. Automated retrospective calculation of the EDACS and HEART scores in a multicenter prospective cohort of emergency department chest pain patients. Acad Emerg Med 2020;27:1028-1038.
- Body R, Almashali M, Morris N, et al. Diagnostic accuracy of the T-MACS decision aid with a contemporary point-of-care troponin assay. Heart 2019;105:768-774.
- Spencer R, Choi NH, Potter K, et al. COVID-19 and the young heart: What are we missing? World J Pediatr 2020;16:553-555.