Chest Pain in the ED: Is there an opportunity to ease the burden?

October 12, 2021

The hard part is implementing the decision, not making it.

Guy Kawasaki

The current pandemic has provided a forceful reminder of the central role emergency departments play in the assessment and delivery of urgent critical care to patients. The responsibility to differentiate quickly and efficiently the high-risk from the routine, with care and respect, has always been a herculean task. This has now been compounded in complexity as emergency departments (EDs) have adapted to serve and accommodate COVID-19 patients in addition to the constant flow of patients who come to EDs with presentations unrelated to the pandemic.

Assessing patients with chest pain has always been, and continues to be, a frequent and vital undertaking by ED clinicians. Chest pain is the second most common reason for presentation to the ED, amounting to more than 7 million annual visits in the US. History and physical exam often are insufficient to rule in or rule out coronary disease as a cause of chest pain, and hence the task of differentiating a patient with acute coronary syndrome (ACS) from one with less pressing cardiac or non-cardiac issues remains a challenge.

We know that only a small percentage of chest pain presentations to EDs in fact represent ACS, but if this diagnosis is missed mortality rates are doubled. The liability of a missed ACS diagnosis can be substantial; in fact, misdiagnosis or delayed diagnosis for patients presenting with chest pain are among the top reasons for medical malpractice claims against ED clinicians.

So how do clinicians maximize their ability to make the right treatment decisions in such a time-strapped, high-stakes scenario?

ED clinicians have long relied on non-invasive testing options such as electrocardiograms (ECG) or blood levels of cardiac enzymes to diagnose or rule out ACS. When these tests appear normal in patients presenting with suspected ACS, non-invasive cardiac stress testing may be used as a second step. Unfortunately, stress testing often requires hospitalization or prolonged ED stays, and has notoriously low sensitivity and specificity.

This ineffectiveness of current approaches is exactly the reason that many EDs are shifting toward coronary CTA rather than stress testing for chest pain patients. With a sensitivity near 99%, clinicians can confidently rule out CAD in many patients. Interestingly, hospitals increasing their use of coronary CTA in the ED setting are reporting that the majority of these ED-acquired coronary CTAs are free of concerning findings. This assessment enables clinicians to confidently discharge such patients, rather than admitting them for unnecessary inpatient care.

When CAD is found by the coronary CTA, sites are using FFRCT to further inform clinical decisions. With an ED-compatible turnaround time of less than 2 hours for STAT cases, the FFRCT assessment of lesion-specific physiology can be utilized within an ED’s existing workflow.

Determining the right test and treatment for a patient presenting with chest pain in an ED setting is difficult. Risks are high, yet the percentage of cases warranting further intervention due to proven ACS is low. While choosing CTA + FFRCT makes clinical, operational, and financial sense, implementing and optimizing that practice change in the ED will require concerted efforts to ensure each patient has access to the most informative and complete treatment pathway.

It is time to move beyond the current standard. Any familiarity, and perhaps misplaced comfort, with a sub-optimal pathway should be replaced with a drive to change clinical practice and provide the best cardiac care available to patients. In this case, that is coronary CTA + FFRCT.

— A perspective from HeartFlow Chief Medical Officer, Campbell Rogers, MD
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