Low-risk chest pain – if your ED doesn’t already have a chest pain unit set up for you to painlessly move patients through their enzymatic and non-invasive testing, you’re probably trying to find safe ways to discharge your chest pain patients home to avoid the repetitive calls to an unsympathetic hospitalist. Problem is, without some kind of imaging or functional study, you’re going to invariably get burned. This is another one of the TIMI-score-plus-X attempts at risk-stratifying patients in a prospectively applied dry run of their protocol. It’s TIMI 0 patients plus normal EKG plus negative zero and two-hour CKMB/troponin/myoglobin. Basically, 10% of their chest pain cohort fit this essentially zero-risk profile and were enzymatically ruled out. And 0.9% (0.02 to 2.1%) of this slam-dunk non-cardiac group came back with an MI within 30 days.
Now, for a rational person who thinks that we’re spending altogether too much money and resources to capture every last potential cardiac event – that sounds pretty reasonable. Home with follow-up. The problem is, the non-invasive testing in basically the same sort of low-risk cohort, whether stress or CTA, the negative tests have 6+ month event-free periods. So, the standard of care is unfortunately moving away from “no heart attack today!” to prognosticating distant events.
The other great thing about this article was their mini systematic review where they say there’s 115 of these prediction rules in the literature in the last fifteen years. Clearly someone everyone wants, but also something we can’t get right….