Chest pain is one of the most common complaints seen in the ED. Guidelines abound on how to evaluate and manage such patients. However, missing from most of this guidance are evidence-driven recommendations regarding patients with recurrent chest pain, a huge group. Data suggest 40% of patients who present to the ED with chest pain return with a similar complaint within one year.1,2

In such cases, should practitioners repeat the tests that were performed during the initial visit? Should patients be discharged, sent to observation, or admitted? When it comes to patients presenting with recurrent, low-risk chest pain, as determined by a validated scoring system such as the HEART score, the answers to these and other important questions are not entirely clear. This leads to significant practice variability, excess testing, and higher costs.

Considering patients with recurrent, low-risk chest pain are so common in the ED, the Society for Academic Emergency Medicine addressed this guidance gap with the first in a series of practice Guidelines for Reasonable and Appropriate Care in the ED (GRACE), an effort aimed at identifying and rooting out low-value practices in emergency medicine.3

Like most practice guidelines, the authors behind GRACE go into some depth regarding the reasoning behind their guidance. They offer eight specific recommendations designed to help emergency providers make good decisions for patients who have visited the ED and undergone a diagnostic workup that showed no evidence of coronary stenosis, only to return with similar complaints within 12 months.

For instance, in recommendation 1, the authors suggested that for patients with recurrent, low-risk pain that lasts for more than three hours, a single, high-sensitivity troponin result below a validated threshold can reasonably rule out acute coronary syndrome within 30 days. However, considering many U.S. medical centers have not adopted high-sensitivity troponin tests, practitioners at these sites will be unable to apply this recommendation, at least for now.

Christopher Carpenter, MD, MSC, FACEP, FAAEM, AGSF, a professor of emergency medicine at Washington University School of Medicine in St. Louis and one of the authors of the GRACE guideline, says the panel could not identify direct evidence for conventional troponin assays. He notes investigators from the University of Texas Southwestern expect to shed more detail on this issue soon.

“Ultimately, we believe that for better or for worse, hospitals in the United States will adopt high-sensitivity troponin [assays] and discard conventional troponin [assays]. Extrapolating these results to conventional troponin assays will become a non-issue,” Carpenter predicts. “Whether that uptake of high-sensitivity troponin occurs in five years or 20 years is another issue.”

In recommendation 2, Carpenter and colleagues advised against repeat stress testing to reduce major adverse cardiac events (MACE) in patients with low-risk, recurrent chest pain who produced normal results on a stress test that was conducted within the previous 12 months.

Similarly, in recommendation 3, the authors noted there is not enough evidence to advise hospitalization as opposed to discharge in these patients for the purposes of mitigating the potential for a MACE within 30 days. The authors said this recommendation applies to both inpatient hospitalizations and observation stays.

Recommendation 4 refers to patients with non-obstructive (i.e., less than 50% stenosis) coronary artery disease on angiography that has been performed within five years. The authors recommended such patients be referred for expedited outpatient testing as needed rather than inpatient evaluation. In recommendation 5, the GRACE panel similarly advised a referral for expedited outpatient testing as needed rather than hospitalization for patients with no occlusive coronary artery disease on prior angiography within five years.

“We believe significant practice variability exists in this population based upon existing descriptive research and much older research,” Carpenter says.4-6 “Practice variability probably also fuels health disparities, but we lacked direct or indirect evidence to provide recommendations.”

It is important for clinicians to avoid anchoring bias or relying too heavily on the first bit of information they receive with each new evaluation they do not miss alternative diagnoses that may be life-threatening or disabling. For example, Carpenter notes that soon after these guidelines were released, the parent of a recurrent chest pain patient reported her son had a pulmonary artery malformation that created recurrent chest pain, which could have been life-threatening if not accurately diagnosed.

“Emergency medicine does encounter zebras, and [practitioners] are master diagnosticians when provided adequate time and resources,” Carpenter observes. “Identifying clinical pathways to safely reduce medical waste and the problem of overtesting, overdiagnosis, and overtreatment should also be valued by emergency medicine and society.”

Recommendation 6 applies to patients with recurrent, low-risk chest pain and a prior coronary CT angiography (CCTA) evaluation that revealed no coronary stenosis within the previous two years. In this group, the authors suggested no further testing beyond a high-sensitivity troponin below a validated threshold to rule out acute coronary syndrome within the two-year window. Inherent in this recommendation is a message regarding the potential value of CCTA. Carpenter believes this message may produce the most profound, long-term effect.

“The majority of emergency departments do not have access to CCTA currently, but our writing panel felt that the quality and volume of research supported a moderate level of evidence and a conditional recommendation in favor of CCTA,” he says. “I worry about overtesting with CCTA, but the recommendation also provides a two-year shelf life for CCTA. The test would not need to be repeated each visit.”

In recommendation 7, the GRACE panel suggested practitioners use depression and anxiety screening tools for patients presenting with recurrent chest pain. These could affect the use of healthcare going forward as well as return ED visits. Further, in recommendation 8, the authors advised referring appropriate patients for anxiety or depression management.

Carpenter believes these recommendations are practice-changing because it adds the concept of anxiety and depression to his differential diagnosis of recurrent chest pain patients. Nonetheless, he carries some reservations practitioners should consider.

“One concern is to avoid premature closure by misattributing symptoms to a psychiatric diagnosis. The other concern is the unintended consequences on the overall ED operational mission if we are now expected to screen patients for depression/anxiety without resources for appropriate inpatient or outpatient care,” he cautions. “Will emergency medicine be left [with any resulting] liability and patient dissatisfaction?”

Carpenter acknowledges most of the GRACE recommendations are based on a low level of evidence. The guidance regarding CCTA is based on a moderate level of evidence, and the depression/anxiety recommendations are based on a very low level of evidence. He says each covered area requires more ED-based research, but pushes back against any suggestion the guideline is premature.

“Recurrent, low-risk chest pain patients are presenting today and every day. Physicians require CPGs [clinical practice guidelines] to support decision-making and shared decision-making,” Carpenter stresses. “We do not know when or if future research will arrive. GRACE provides a foundational first step forward.”

To pave the way for additional guidance for emergency providers, Carpenter wants to see federal support for a national entity that will tackle the questions that are most germane to emergency clinicians. “The world leaned heavily on emergency medicine during the COVID-19 pandemic and our specialty stood tall,” he says. “Rather than simply concluding that more research is required, my vision is that the time is ripe for the NIH to create a ‘National Institute of Emergency Care’ with sufficient funding to realistically begin generating high-quality evidence for emergency medicine’s most challenging situations. GRACE guidelines can serve as one compass for those research priorities.”

REFERENCES

  1. Fleet RP, Lavoie KL, Martel JP, et al. Two-year follow-up status of emergency department patients with chest pain: Was it panic disorder? CJEM 2003;5:247-254.
  2. Leise MD, Locke GR 3rd, Dierkhising RA, et al. Patients dismissed from the hospital with a diagnosis of noncardiac chest pain: Cardiac outcomes and health care utilization. Mayo Clin Proc 2010;85:323-330.
  3. Musey PI Jr, Bellolio F, Upadhye S, et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021;28:718-744.
  4. Diercks DB, Panacek EA. Evaluation of the chest pain patient: Survey of current practice patterns 2010. J Emerg Med 2010;39:282-290.
  5. Prasad V, Cheung M, Cifu A. Chest pain in the emergency department: The case against our current practice of routine noninvasive testing. Arch Intern Med 2012;172:1506-1509.
  6. Shesser R, Smith M. The chest pain emergency department and the outpatient chest pain evaluation center: Revolution or evolution? Ann Emerg Med 1994;23:334-341.