Low-risk chest pain? Turn the negative into a positive

Emergency room presentations are opportunities to discuss cardiovascular risk factors while increasing patient awareness of their importance

One of the most common presentations in the emergency department is those of people with chest pain. Current practice ensures that people at high risk of acute myocardial infarction (AMI) are quickly identified and treated. Aside from heart disease biomarkers,1 a number of algorithms aid in the risk stratification of patients without AMI. The current move to rapidly rule out AMI based on highly sensitive cardiac biomarkers, often followed by patient discharge without further investigation or management, is based on the perceived low risk of adverse events in the near future.

In this issue of the MYAGreenslade and colleagues report their study on the safety and reliability of excluding AMI in Indigenous Australians presenting to an emergency department with chest symptoms based on a single highly sensitive cardiac troponin I (hs‐cTnI) measurement.2 Since people from different ethnic groups may have different disease patterns and even different responses to therapies,34 it is important to ensure that care guidelines apply to all patients. Although the patients in the study by Author and colleagues had a high burden of cardiovascular risk factors – 31 of 110 (28%) had previously experienced AMI – none of the 30 people with single hs‐cTnI levels less than 4 ng/ L cardiovascular events in the 30 days after discharge. This important observation provides direct evidence that a single hs‐cTnI outcome-based approach is just as safe for Indigenous patients as it is for other Australians.

However, this finding should be interpreted with caution. hs‐cTnI assays are not always easily accessible. A large proportion of Indigenous Australians live in rural and remote areas where less accurate, rapid bedside troponin testing is used. While useful for early detection of a risk of cardiovascular events, the results or sensitivity of these tests should not be assumed to be equivalent to those of hs‐cTnI assays. This raises questions about how broadly relevant single hs‐cTnI testing could be for many Indigenous patients: do the potential benefits to the patient and healthcare system require hs‐cTnI assays to become the standard of care, including in rural and remote Australia?

Furthermore, cardiac troponin is not the only biomarker of acute, active ischemia. When patients have other high-risk features or their clinical history is of particular concern, they should not be treated as low-risk patients based on a single hs‐cTnI assay result alone.

Reasons for rapidly identifying patients at low cardiovascular risk, in addition to excluding AMI, include the desire to shorten emergency department hospitalization and avoid unnecessary testing. However, the presence of cardiovascular risk factors at a young age in indigenous peoples is not uncommon,5 as reflected in the Australian Heart Foundation’s updated guidelines,6 and a negative hs‐cTnI result is less likely to indicate low cardiovascular risk over a period of more than 30 days than in other Australians. Many patients discharged from the emergency department with negative cardiac biomarker results have coronary artery disease,7 with the potential for fragile plaques to develop and rupture. The fact that this does not happen during the index presentation does not mean that this is not possible in the future. Rather than quickly dismissing patients with “non-cardiac pain,” the emergency department presentation should be viewed as an opportunity to assess and manage cardiovascular risk factors while sensitizing the patient to their importance. Early discharge of low-risk patients is possible, but it is also appropriate and important to discuss their cardiovascular risk both immediately and during primary care follow-up.

Perhaps we should rethink the emergency department’s paradigm regarding troponin-negative chest pain. A proactive strategy that identifies patients and helps change risk can prevent future heart disease. This may involve quantifying plaque with computed tomography coronary angiography (CTCA) or educating patients about modifying risk factors.

The greater the risk burden in the population a person comes from, the greater the potential for improving their health outcomes. Is this the role of an emergency department? It is the role of all clinicians to promote good health! Some patients discharged with low-risk chest pain feel like they’ve wasted hospital time. If instead they felt that they had avoided heart disease on this occasion, but could take steps to further reduce their risk, the experience could have a more positive impact on their health and increase the likelihood that they would seek treatment for it. future events.

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