![]() This review paper discusses the merits and limitations of validated clinical decision aids used by emergency providers to risk-stratify patients with acute chest pain. However, the most frequently sited acceptable miss rate is less than 1%, 4 so most decision aids aim for a negative predictive value (NPV) >99%. Kline et al 3 calculated that a 2% miss rate should be acceptable based on the testing threshold at which the risk of harm from further testing equals or exceeds the chance of benefit from confirming ACS. ![]() In their often cited study from more than a decade and a half ago, Pope et al 2 concluded that it would be difficult to achieve a reduction in their reported 2%–4% miss rate for acute myocardial infarction and unstable angina. However, the acceptable miss rate for ACS is a matter of considerable debate. The ideal risk stratification tool is sensitive and specific enough to identify a subset of patients who present with chest pain who can be discharged from the ED after an abbreviated and cost-effective workup, while maintaining an acceptable miss rate for short-term adverse cardiac events. In an attempt to more accurately risk-stratify patients with chest pain, physicians and researchers have sought out objective tools to better risk-stratify patients determining who needs further emergent workup and who can be safely discharged home. As a result, in order to avoid missing the diagnosis of ACS, the workup for ED patients with acute chest pain is often prolonged and costly. 2 Adding complexity to the problem, the symptoms of ACS are frequently atypical, and traditional risk factors for coronary artery disease have little diagnostic utility in the acute care setting. Some estimates suggest double the likelihood of death for patients who are discharged from the ED with myocardial infarction. 1 While the majority of these cases do not result in a diagnosis of acute coronary syndrome (ACS), missing the diagnosis has potential to result in significant morbidity and mortality. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting.Ĭhest pain is one of the most common presenting complaints in the emergency department (ED), accounting for 9%–10% of annual visits. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT) Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT) North American Chest Pain Rule (NACPR) and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. ACS presentations can be atypical, and their workups are often prolonged and costly. However, missing the diagnosis has potential for significant morbidity and mortality. Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS).
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