March 27, 2019

From the Chair

Hey all.

I hope everyone had a great holiday.

Back in November, ACEP released its clinical policy on the care of patients with suspected NSTEMI. I strongly advise everyone to take a look at it if you haven’t already as there are some key recommendations that should help us streamline our approach to low risk chest pain.

  1. There is an excellent discussion on the concepts of risk tolerance, troponin measurement as well as the concept of MACE and what it really measures.
  2. Use of the HEART Score to predict patients at low risk of 30 day MACE (Level B).
  3. Use of 0 and 3 hour conventional troponin measurement (Level B).
  4. No use for further diagnostic testing (cCTA/Stress) in low-risk patients (Level B).
  5. Recommendations to arrange follow-ups 1-2 weeks for low risk patients in whom MI has been ruled out. Further testing can be considered if no follow-up is available. (Level C).

These recommendations are huge as ACEP is recognizing what recent literature has been saying about lack of benefit and the potential of harms associated with over-testing in this population. Based on this, we can encourage our colleagues to use the observation units at our shops for moderate risk patients.

Many of us have seen a gradual decline in the use of our observation units for low-risk chest pain in recent years and have filled those beds with more complex cardiac patients and patients on new protocols. If you are struggling with how to expand your unit in the face of fewer chest pain cases, please look at the sample protocols on the section website or reach out to the section members via the engagED portal.

Matthew Wheatley, MD, FACEP