See One, Do One, TEACH One: Senior Resident Tools for Teaching Low Risk Chest Pain

During a resident supervisor shift this summer a brand new intern asked me how do you know that a patient has low risk chest pain and when do we send them home? This was followed by a third year that asked a question about the utility of serial troponins. I also recently listened to the frustrations of a new medicine intern and a medical admitting resident that rolled their eyes for yet another rule out ACS admission.

What’s the recent evidence and discussion behind how we manage these patients?
What should you as the senior resident pass along to your juniors?

Spoiler alert: A person’s risk is never zero for an MI. We work in the emergency department anything is possible!

Jones and Slovis wrote a fantastic Emergency Medicine Clinics of North America article that details the history and subtleties of the low risk chest pain patient a great article to pass along to your juniors.

A sobering statistic quoted in the article is that we miss MI 2-4% of the time and its bad to be missed in the ED your mortality rate is somewhere between 10-25%.

What to do for the patient with a negative stress test or angiogram? It’s discussed in this article

After digesting this article one can surf to the NNT.com to appreciate the point of view of Dave Newman. He even produced a podcast on his site Smart EM.

Newman discusses low risk chest pain in the individual under 40 years of age (1 in 500 will have an MI) and the individual older than 40 years of age (1 in 250 will have an MI).

Give it a listen read the articles make your own interpretation. Place a comment below!

The ALiEM site has a handy paucis verbis card on this very subject (FYI all PV cards now available as an iphone/android app). A Patwari video on the topic can also be found on the ALiEM site.

Any other articles or educational media on the subject of low risk chest pain out there? How are you teaching this topic to your juniors and medical students?

As always you can follow me on twitter @melton_em

References:

Jones Ian, Slovis Corey. Pitfalls in Evaluating the Low Risk Chest Pain Patient. Emerg Med Clin N Am 28 (2010) 183–201. doi:10.1016/j.emc.2009.10.002

Walker JG, Galuska M, Vega D, et al. Significant coronary artery disease in emergency chest pain patients with recent negative cardiac stress testing [abstract].Ann Emerg Med 2008;52(4):s90.

Bugiardini R, Manfrini O, De Ferrari GM. Unanswered questions for management

of acute coronary syndrome: risk stratification of patients with minimal disease or

normal findings on coronary angiography. Arch Intern Med 2006;166(13):1391–5.

http://www.thennt.com/risk/low-risk-chest-pain-over-age-40/

http://www.thennt.com/risk/low-risk-chest-pain-under-age-40/

http://academiclifeinem.com/paucis-verbis-card-the-low-risk-acs-patient/

http://academiclifeinem.com/patwari-academy-videos-low-risk-chest-pain/

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.