Perpetuating the Flawed Approach to Chest Pain

Everyone has their favored chest pain accelerated diagnostic risk-stratification algorithm or pathway these days.  TIMI, HEART, ADAPT, MACS, Vancouver, EDACS – the list goes on and on.  What has become painfully clear from this latest article, however, is this approach is fundamentally flawed.

This is a prospective effectiveness trial comparing ADAPT to EDACS in the New Zealand population.  Each “chest pain rule-out” was randomized to either the ADAPT pathway – using modified TIMI, ECG, and 0- and 2-hour troponins – or the EDACS pathway – which is its own unique scoring system, ECG, and 0- and 2-hour troponins.  The ADAPT pathway classified 30.8% of these patients as “low risk”, while the EDACS classified 41.6% as such.  Despite this, their primary outcome – patients discharged from the ED within 6 hours – non-significantly favored the ADAPT group, 34.4% vs 32.3%.

To me, this represents a few things.

We are still have an irrational, cultural fear of chest pain.  Only 11.6% of their total cohort had STEMI or NSTEMI, and another 5.7% received a diagnosis of “unstable angina”.  Thus, potentially greater than 50% of patients were still hospitalized unnecessarily.  Furthermore, this cultural fear of chest pain was strong enough to prevent acceptance of the more-aggressive EDACS decision instrument being tested in this study.  A full 15% of low-risk patients by the EDACS instrument failed to be discharged within 6 hours, despite their evaluation being complete following 2-hour troponin testing.

But, even these observations are a digression from the core hypothesis: ADPs are a flawed approach.  Poor outcomes are such the rarity, and so difficult to predict, that our thought process ought be predicated on a foundation that most patients will do well, regardless, and only the highest-risk should stay in the hospital.  Our decision-making should probably be broken down into three steps:

  • Does this patient have STEMI/NSTEMI/true UA?  This is the domain of inquiry into high-sensitivity troponin assays.
  • Does the patient need any provocative testing at all?  I.e., the “No Objective Testing Rule”.
  • Finally, are there “red flag” clinical features that preclude outpatient provocative testing?  The handful of patients with concerning EKG changes, crescendo symptoms, or other high-risk factors fall into this category.

If we are doing chest pain close to correctly, the numbers from this article would be flipped – rather than ~30% being discharged, we ought to be ~70%.

“Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice”

3 thoughts on “Perpetuating the Flawed Approach to Chest Pain”

  1. Great post!

    Curious what your opinion is on how chest pain rule outs compare financially to other big name, low yield admissions. I'd imagine that cellulitis, for instance, probably doesnt require an admission yet the "need for IV antibiotics" probably takes a toll on the system. or PE work ups. or unneeded blood cultures.

    Or is it by the sheer volume of chest pain that we see make it far and away the lowest hanging fruit to tackle?

  2. We also work in New Zealand, but have attempted to have a more pragmatic approach to chest pain in the ED. We send home 70% of all patients within 6 hours. Admittedly we live in an area with pretty good primary care followup. The big difference is we substituted a scoring system for an ED physician gestalt, which we applied at the end of the evaluation as a safety net for patients with a great story for unstable angina despite a negative ECG & troponins. We used a much higher absolute troponin cutoff, with 0 and 2 hour tests and deltas. We also flipped the risk stratification to be high risk or non high risk, where all non high risk patients went home. No one died or had an MI at 30 day followup in our non high risk group (although some subsequently and safely had outpatient PCI)

    Here's a link to our study for anyone interested

    https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2015/vol-128-no-1408/6416

    Cheers

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