Patients with recurrent low-risk chest pain cannot (and should not) all be admitted, but discharging these patients legally exposes the EP.
“It is interesting to me that the cardiologists themselves have a bit of variability in how they handle low-risk chest pain,” says David Ledrick, MD, associate residency director and clinical clerkship director in the department of emergency medicine at Mercy St. Vincent Medical Center in Toledo, OH.
Some cardiologists aggressively work up patients who others might discharge with only a serial cardiac troponin.
“I find it hard to say that there is an absolute standard that is in practice consistently,” Ledrick says. “It seems that there is a relatively wide range of what is acceptable.”
As for ED care, EPs tend to involve cardiologists for patients with recurrent chest pain, or those with higher HEART scores who might go straight to catheterization without stress testing. “We also tend to cancel the consults on patients needing a screening study as opposed to patients with an anticipated procedure,” Ledrick observes.
Ledrick says the most important thing an EP can do is obtain a good history and correctly interpret the ECG. “This is hardly surprising. It also seems this is easy to get wrong,” Ledrick notes. As any experienced EP knows, the history surrounding chest pain can be highly variable. It can even change from provider to provider in the same visit. “We tested this once in an unpublished study in which we provided patient vignettes to emergency medicine residents and attendings,” Ledrick recalls. There was little agreement over whether the HEART score history should be rated as 0, 1, or 2.
The presence of an observation unit makes things much easier on the EP. In the absence of an observation unit, Ledrick says “the institution would be well served to have a defined and easily accessed system for follow-up” on truly low-risk patients (defined as those with negative serial ECGs and cardiac troponins, both repeated after three hours, and a concomitant history/risk factor assessment with a HEART score of less than 4). Solid documentation on medical decision-making lets anyone know the EP considered cardiac disease, whether it is another healthcare provider or a plaintiff attorney’s expert reviewing the chart.
“It is impossible to get to a 0% miss rate,” Ledrick admits. “Good documentation will at least demonstrate that the evaluation was a deliberate and careful one.”