By Stacey Kusterbeck
Not all patients who present to EDs with acute chest pain can be, or should be, admitted; not all can receive an immediate cardiology consult, either. Yet, emergency physicians (EPs), understandably, worry about liability risks if they discharge these patients.
“The reality of life is that for the majority of patients who show up in EDs with various kinds of chest pain syndromes, there are no cardiologists around at that moment,” says H.V. “Skip” Anderson, MD, chair of the writing committee for updated American College of Cardiology chest pain guidelines and an accompanying decision pathway for acute chest pain in EDs.1,2
It is not possible for a cardiology consult to happen with every chest pain patient in the ED. The pathway authors recommend implementing high-sensitivity cardiac troponins and clinical decision pathways to safely discharge low-risk patients without additional testing. However, the decision pathway is not meant to replace the EP’s clinical judgment. “It is a methodical, logical approach to deal with this enormous crush of patients who show up in EDs and help them sort through what’s important and not important, and what to do with the patients who are considered higher-risk and more critical,” Anderson explains.
For EDs, these tools offer a structured approach to safely discharge most patients who are considered low risk. “For ED providers, uncertainty leads to hesitancy, which leads to increased dwell times in EDs,” Anderson notes.
EPs often wait for a cardiology consult before feeling comfortable enough to discharge a chest pain patient. That could result in patients waiting in EDs for many hours unnecessarily.
At some EDs, cardiologists are more readily available, and rapid consults can be easy to arrange. In other EDs, it is harder. “If cardiologists are not far away physically, and you can get one to come to the ED quickly and participate in the decision-making, especially for more difficult and complicated patients, then by all means you should do that,” Anderson offers.
If cardiologists are harder to come by, and cannot arrive at the ED rapidly, the decision pathway can help EPs in that situation pick who to discharge or admit confidently.
“It provides some level of reassurance and comfort that this is what the cardiology community considers appropriate,” Anderson adds.
REFERENCES
1. Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC expert consensus decision pathway on the evaluation and disposition of acute chest pain in the emergency department: A report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022;80:1925-1960.
2. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021;78:e187-e285.
Guideline authors recommend implementing high-sensitivity cardiac troponins and clinical decision pathways to safely discharge low-risk patients without additional testing. However, the decision pathway is not meant to replace the emergency physician's clinical judgment.
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