{"id":3439,"date":"2014-05-02T13:00:00","date_gmt":"2014-05-02T13:00:00","guid":{"rendered":"http:\/\/www.emlitofnote.com\/?p=3439"},"modified":"2014-05-02T13:00:00","modified_gmt":"2014-05-02T13:00:00","slug":"burn-the-accaha-low-risk-chest-pain-guidelines","status":"publish","type":"post","link":"https:\/\/www.emlitofnote.com\/?p=3439","title":{"rendered":"Burn the ACC\/AHA Low-Risk Chest Pain Guidelines"},"content":{"rendered":"

Management of low-risk chest pain is, by reasonable conjecture, one of the greatest failings of Emergency Medicine and the medical profession in general.  Whether driven by true altruism or by risk-management and zero-miss strategies based on the ACC\/AHA guidelines<\/a>, many, many, many patients are admitted and subjected to provocative testing.<\/p>\n

And almost none of those patients are ultimately, correctly, diagnosed with the feared disease \u2013 acute coronary syndrome.<\/p>\n

This is a prospective, observational evaluation of patients admitted for chest pain observation at a single academic center in Rhode Island.  Over the course of ~2 years, 3,543 patients were admitted for an initial evaluation of chest pain after initial negative cardiac biomarkers in the Emergency Department.  Approximately half of patients underwent stress testing.<\/p>\n

Of 1,754 stress tests, there were 29 positives.  Of those, 9 were false positives.  Stratified by pretest probability, none of the patients with a “low probability” Diamond & Forrester Score had a true positive test.  Only 1% of patients admitted and stressed with “intermediate probability” D&F Score ultimately proved to have true positive tests.  Even with “high probability”, 5% of all stress tests performed were true positives.<\/p>\n

The author of this article means to specifically reduce stress testing in the “low probability” cohort.  this is a reasonable proposal to skim off a small percentage of tests.  However, he misses asking the better question \u2013 how do we reduce use in our “intermediate probability” cohort, which constituted 85% of admissions with just a 1.7% yield for ACS?  We need to seriously address the outdated and inefficient notion admission and testing for these patients is the ideal strategy \u2013 and that probably starts by tossing our current guidelines out the window.<\/p>\n

\u201cThe Association Between Pretest Probability of Coronary Artery Disease and Stress Test Utilization and Outcomes in a Chest Pain Observation Unit\u201d
http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/24730402<\/a><\/p>\n\n

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Management of low-risk chest pain is, by reasonable conjecture, one of the greatest failings of Emergency Medicine and the medical profession in general.  Whether driven by true altruism or by risk-management and zero-miss strategies based on the ACC\/AHA guidelines, many, many, many patients are admitted and subjected to provocative testing. And almost none of those … Continue reading “Burn the ACC\/AHA Low-Risk Chest Pain Guidelines”<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2},"jetpack_post_was_ever_published":false},"categories":[7,11],"tags":[],"class_list":["post-3439","post","type-post","status-publish","format-standard","hentry","category-chest-pain","category-quality"],"jetpack_publicize_connections":[],"jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p7KesJ-Tt","jetpack_featured_media_url":"","_links":{"self":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/posts\/3439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3439"}],"version-history":[{"count":0,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=\/wp\/v2\/posts\/3439\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3439"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3439"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.emlitofnote.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}