The world has been obsessed over the past few years with the novelty of clinical decision rules for the early discharge of chest pain. After several years of battering the repurposed Thrombolysis in Myocardial Infarction (TIMI) score, History, Electrocardiogram, Age, Risk factors and Troponin (HEART) became ascendant, but there are several other candidates out there.
One of these is Emergency Department Assessment of Chest pain Score (EDACS), which is less well-known, but has reasonable face validity. It does a good job identifying a “low-risk” cohort, but is more complicated than HEART. There is also a simplified version of EDACS that goes ahead and eliminates some of the complicated subtractive elements of the score. This study pits these various scores head-to-head in the context of conventional troponin testing, as well.
This is a retrospective review of 118,822 patients presenting to Kaiser Northern California Emergency Departments, narrowing the cohort to those whose initial Emergency Department evaluation was negative for acute coronary syndrome. The 60-day MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) in this cohort was 1.9%, most of which were acute MI. Interestingly, these authors chose to present only the negative predictive value of their test characteristics, which means – considering such low prevalence – the ultimate rate of MACE in all the low-risk cohorts defined by each decision instrument were virtually identical. Negative predictive values of all three scores depended primarily on the troponin cut-off used, and were ~99.2% for ≤0.04 ng/mL, and ~99.5% for ≤0.02 ng/mL. The largest low-risk cohort by definition was with the original EDACS rule, exceeding the HEART score classification by an absolute quantity of about 10% of the total cohort, regardless of the troponin cut-off used.
The editorial accompanying the article goes on to laud these data as supporting the use of these tools for early discharge from the Emergency Department. However, this is an outdated viewpoint, particularly considering the data showing early non-invasive evaluations are of uncertain value. In reality, virtually all patients who have been ruled-out for ACS in the ED can be discharged home, regardless of risk of MACE. The value of these scores is probably less so in determining who can be discharged, but rather in helping triage patients for closer primary care or specialist follow-up. Then, individualized plans can be developed for optimal medical management, or for assessment of the adequacy of the coronary circulation, to prevent what MACE is feasible to be prevented.
“Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department”
http://www.onlinejacc.org/content/71/6/606
“Evaluating Chest Pain in the Emergency Department: Searching for the Optimal Gatekeeper.”
http://www.onlinejacc.org/content/71/6/617
We’ve known the lack of benefit in chest pain admissions for years. Unfortunately, most physicians refuse to accept this (to say nothing of the general public). As long as our profession persists in this delusion, emergency physicians will be forced to play along, since we see a lot of chest pain patients and a certain percentage will go on to have bad outcomes. The fact that we can’t prevent those bad outcomes with stress tests and catheterizations isn’t relevant as long as it remains a fringe belief of EBM extremists like us.
Culture change is slow!
It wasn’t so long ago that everyone was admitted – and now we generally accept early discharge strategies for the low-risk (even without a CTCA). If we keep up the good fight, eventually we can change the culture and approach.
Yes, there has been slow culture change. But so far, only in the setting of clinical prediction rules that offer a zero miss rate, or close to it, and all with the assumption that events after an ED visit could be prevented by admission and PCI. My pessimism comes from the general refusal of physicians to believe that anything is ineffective, regardless of contrary evidence. NT-proBNP, chest pain obs, PPI drips, albumin, IV tylenol, and now procalcitonin all continue their march, despite being clearly useless. I think this is one of the biggest problems in medicine, and it’s not going to change in the foreseeable future.