Chest pain in the emergency department: In search of the Holy Grail

Abstract

The current approach to patients presenting to the emergency department (ED) with possible acute coronary syndrome lacks the discrimination to optimize both the safety and efficiency of clinical care. Prior studies suggest that 2% of ED patients who present with acute myocardial infarction and another 2% who present with unstable angina are inadvertently discharged home after their ED evaluation. Conversely, more than half of patients admitted from the ED for further evaluation of possible acute coronary syndrome are ultimately diagnosed with a noncardiac condition. Because the intensity of the ED evaluation of patients presenting with chest pain is proportional to the clinician’s estimate of patient risk, it is particularly important to understand the clinical course of patients deemed to have a low likelihood of acute coronary syndrome. In the study by Miller et al in this issue of Annals, the investigators asked emergency physicians to assess the likelihood that a given patient was experiencing an acute coronary syndrome after completing a history, physical examination, and review of the ECG. ED providers recorded their diagnostic impression as definite acute coronary syndrome, high-