Three Must-Read Emergency Medicine

Articles From 2018

Amal Mattu, MD
DISCLOSURES 
January 16, 2019

Three Must-Read Emergency Medicine

Articles From 2018
Amal Mattu, MD
DISCLOSURES 
January 16, 2019

The 2018 calendar year was once again rife with outstanding additions to the
emergency medicine literature from numerous journals in many specialties. In
selecting this year's three "must-read" articles, I focused on what I believe is
practice-changing and once again chose to avoid articles that I've covered in
prior Viewpoints.

These are excellent reads with take-home points that go beyond my simple
summaries. I hope all acute care physicians will take some time to read them.
Until then, enjoy these synopses.
Clinical Policy: Critical Issues in the Evaluation and Management of ED
Patients With Suspected Non-ST-elevation Acute Coronary Syndrome
The evaluation of patients with potential acute coronary syndrome (ACS) has
been the bane of emergency medicine for decades. For many years, we have
been overadmitting patients for potential ACS, leading to costly negative
workups. A major reason for the excessively conservative approach to these
patients has been fear of litigation in the event that we miss ACS. Litigation
would often be based on failure to follow guidelines, which have, for many
years, stated that all of these patients need to receive a provocative test after
being ruled out for myocardial infarction (MI).[1] The result is that an inordinate
number of low-risk patients would be sent for provocative testing, which
typically would also be negative.
A fact that we tended to ignore, however, was that a significant number of
these patients would have false-positive results, leading to unnecessary
cardiac catheterization and even bypass surgery.[2] What, then, is the
appropriate threshold for risk in potential ACS below which mandating further
workup potentially can induce more harm than benefit?
The American College of Emergency Physicians Clinical Policies
Subcommittee stepped up to address this challenge and has indicated in its
Clinical Policy that after a patient has been ruled out for MI, if the patient's risk
for ACS is less than 2%, there is likely to be greater harm than benefit by
mandating further provocative stress testing or coronary CT angiography.[3]
Is there a way to decide when a patient's risk of ACS is less than 2%? The
answer is a resounding yes! Recently developed accelerated diagnostic
protocols, the most popular of which is the HEART score,[4] have allowed us to
risk-stratify patients to sufficiently low risk so as to bypass further testing.
Specifically, if a patient's HEART score is ≤ 3, the estimated rate of major
adverse cardiac events (MACE) is less than 2% at 1 month. This MACE is
based on clinical factors, ECG interpretation, and a conventional troponin at
the time of the patient's arrival. Physicians can opt to obtain a second troponin
3 hours after arrival, and if this is normal, the patient's risk for 1-month MACE
is less than 1%. In either case, the Clinical Policy recommends that physicians
should "not routinely use further diagnostic testing (coronary CT angiography,
stress testing, myocardial perfusion imaging) prior to discharge" but instead
simply "arrange outpatient follow-up in 1-2 weeks for low-risk patients in whom
MI has been ruled out."[3]
This Clinical Policy goes into greater detail regarding accelerated diagnostic
protocols, conventional and highly sensitive troponins, and use of antiplatelet
medications, and the reader is encouraged to review the policy for some
additional great practice recommendations.[3] But the key point here for all of
us is that we finally have a formal endorsement from a major national
organization stating that we no longer have to "stress" about getting
provocative tests on our patients who are at low risk for ACS.
TRaducere.