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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Feb 19, 2015

Something very cool is happening in emergency medicine, specifically low risk chest pain. What I mean by that is figuring out who is low risk and what to do about it. This is one of the biggest areas of CYA, for the uninitiated, cover your ass, medicine. And for good reason, it’s a big cause of lawsuits and if we get it wrong, people can die. We just had two episodes on cardiac CT addressing this very topic and one thing that came up in the last show with Rory Spiegel, was that the Cardiac CT did not perform any better than just using risk assessment and cardiac enzymes. But what does that mean? What is risk assessment in the ED? Is it, “Holy moly, that sounds like cardiac chest pain for sure, bang, you’re admitted.” Or is it, “C’mon, that’s not cardiac chest pain.” Well, that’s indeed a small part of it, but there has been improvement on assessing risk using enzymes and risk scores. The TIMI score has been out there for a while but it’s not as nuanced an instrument as we’d like. The HEART score may be a better and more usable tool in the ED.

Links for this episode

Amal Mattu's full explanation of Chest Pain ADP, Low risk chest pain, medico-legal aspects of chest pain, chest pain guidelines

University of Maryland Low Risk Chest Pain ADP

Shared Decision Making Graphic

Heart Score Calculator 

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We are hungry for a sensible, safe and consistent pathway for evaluating chest pain. A new chest pain ADP has emerged from from the primordial soup, and it comes from none other Dr. Amal Mattu. Here is a link to Amal’s full explanation of the ADP and chest pain risk assessment and I recommend you to listen to it to get the full flavor of what he’s talking about. But for now, a  recap….

Many chest pain pathways have relied on the TIMI score, but that is a somewhat cumbersome tool for our needs. The HEART score shows promise as a decision instrument with more utility in the emergency department. The HEART score uses 5 criteria: history, EKG, age, risk factors, and troponin to determine risk of a 6 week major adverse cardiac event. Each one of these pieces has three parts. For example, risk factors: no risk factors, zero points; 1-2 risk factors, 1 point; 3 or more risk factors, 2 points. If a patient has everything, everything positive in the heart score, that’s 10 points -high risk. Low risk is 3 points or less. A low risk score gives a 1.7% 30 day risk of major adverse event. Add in a second negative (delta) troponin, and the risk goes down to under 1%.