Vancouver, Canada, to be specific. The 37th most expensive city in the world to live in (ahead of New York and Los Angeles), a jewel on the coast of British Columbia, with breathtaking scenery, evergreens, rugged coasts, and mountains.
This is an observational series of their chest pain algorithm, and it falls into the category of "we do this and we like it" types of articles. So, they do this, and they like it, and I can see why.
And the first thing you notice is that it is nothing like the United States. Of the 1,116 patients they enrolled for this follow-up, they send home 25% of their potentially cardiac chest pain after an EKG and a single troponin. These are patients whose mean age is 43 years old, and have TIMI scores of 0 or 1. No outpatient stress test is arranged. None of them had ACS within 30 days.
Another 20% had a negative 2-hour troponin and EKG and were sent home without outpatient stress testing, average age 49 years old and TIMI scores mostly 0 and 1. None of them had ACS within 30 days.
Finally, at six hours, they were left with a group of 60 year old folks, 30% of their cohort, whose TIMI scores were >1. They sent them all home, 25% of without an outpatient stress test and 75% with - and none of the no-stress cohort had ACS within 30 days.
Essentially, they send home over half their patients, aged 40 to 60 years old, and a couple cardiac risk factors - and they do fine. We don't really know what sort of coronary disease the patients discharged without a follow-up stress test had, and it means they probably have some false negatives in their outcomes at 30 days simply because they don't receive any sort of additional diagnostic testing. But, none of them had an unprovoked adverse coronary event, which counts for something.
About 20% of their patients referred for outpatient stress failed, and about half of those ultimately received a diagnosis of ACS - so, even then, in the patients they were most concerned about after negative ED testing, only 10% had ACS. Seems like there's room to improve here, as well.
It's not crazy, it's Canada.
"Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain"