Achieving the Holy Grail of Emergency Department Evaluation for Chest Pain.

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The emergency department (ED) sits at the interface between the inpatient and outpatient delivery arms of the US healthcare system. For each encounter, emergency providers must determine to what extent the patients in their charge would benefit from further care in the hospital. In an ideal state, those decisions are precisely determined, with patients selected to stay who would truly benefit. In reality, those decisions are complex and highly variable.1 See Article by Frisoli et al There is no clinical condition that better symbolizes this challenge in the ED than the symptom of chest pain,2 which brings with it a heterogeneous mix of patient populations and underlying diagnoses. On the one hand, most chest pain symptoms ultimately have a benign course. On the other hand, some patients with chest pain are diagnosed with serious, life-threatening conditions that require timely interventions. The combination is volatile—we annually spend substantial amounts of healthcare resources endeavoring to discriminate between these 2 groups of patients. As the authors Frisoli et al3 note in this issue of Circulation: Cardiovascular Quality and Outcomes , chest pain is common and costly. Clinicians and investigators have been hacking away at chest pain for >3 decades,4 looking for the elusive holy grail solution to this quandary: a single tool or combination of tools that perfectly sorts patients presenting to the ED with chest pain for which acute coronary syndrome (ACS) remains a consideration into those at high enough risk to require further diagnostic work versus those at low enough risk to be safely discharged.5 The consequences on both sides of the ledger are substantial. On the underdiagnosis side are missed immediate and directly downstream major adverse cardiac events, generally defined as acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, coronary angiography revealing procedurally …