Which of the following is the most appropriate next step in management for this patient’s condition?
- A) Cardiology consultation
- B) Discharge home with prompt outpatient follow-up
- C) Prescribe a benzodiazepine
- D) Admission for cardiac stress testing
This patient presents to the emergency department after an atypical, brief episode of chest pain. The list of potential diagnoses that may have caused the pain episodes is extensive. The focus of the Emergency Medicine practitioner should not be to determine the diagnosis per say, but rather to be to identify the presence of any life-threatening conditions (i.e. Myocardial infarction, Aortic dissection, Esophageal Rupture, Pulmonary embolism, Tension pneumothorax, Cardiac tamponade, etc.). Many of these serious diagnoses can be evaluated with a detailed history, physical exam, and basic imaging and lab work if needed. Many risk stratification tools have been developed to evaluate the likelihood a patient has chest pain due to Acute Coronary Syndrome. One well-supported tool with international validation is the HEART score tool. The HEART score categorizes a patient as low (0-3), moderate (4-6), or high risk (7-10) for a Major Adverse Cardiac Event (MACE) based on the patient’s history, EKG, age, risk factors, and troponin level. The below chart from Wieters et al. (2020) outlines the HEART score categories and how to make clinical decisions based on a patient’s score.
HEART score for cardiac risk assessment of major adverse cardiac event (MACE).
| Category | Score | Explanation | Risk Features |
|---|---|---|---|
| History | High-risk features • Middle- or left-sided chest pain • Heavy chest pain • Diaphoresis • Radiation • Nausea and vomiting • Exertional • Relief of symptoms by sublingual nitrates Low-risk features • Well localized • Sharp pain • Non-exertional • No diaphoresis • No nausea and vomiting |
||
| Slightly Suspicious | 0 | Mostly low-risk features | |
| Moderately Suspicious | +1 | Mixture of high-risk and low-risk features | |
| Highly Suspicious | +2 | Mostly high-risk features | |
| ECG | |||
| Normal | 0 | Completely Normal | |
| Non-specific Repolarization Disturbance | +1 | Non-specific repolarization disturbance | • Repolarization abnormalities • Non-specific T wave changes • Non-specific ST wave depression or elevation • Bundle branch blocks • Pacemaker rhythms • Left ventricular hypertrophy • Early repolarization • Digoxin effect |
| Significant ST Depression | +2 | Significant ST depression | • Ischemic ST-segment depression • New ischemic T wave inversions |
| Age | |||
| <45 | 0 | ||
| 45-64 | +1 | ||
| ≥ 65 | +2 | ||
| Risk Factors | • Obesity (Body-Mass Index ≥ 30) • Current or recent (≤ 90 days)smoker • Currently treated diabetes mellitus • Family history of coroner artery disease (1st degree relative < 55 year old) • Hypercholesterolemia OR Any history of atherosclerotic disease earn 2 points: • Know Coroner artery Disease: Prior myocardial infarctions, percutan coronary intervention (PCI) or coronary artery bypass graft • Prior stroke or transient ischemic attack • Peripheral arterial disease |
||
| No known risk factors | 0 | ||
| 1-2 risk factors | +1 | ||
| ≥ 3 risk factors or history of atherosclerotic disease | +2 | ||
| Initial Troponin | |||
| ≤ normal limit | 0 | ||
| 1-3 x normal limit | +1 | ||
| > 3x normal limit | +2 |
Score 0–3 = 2.5 % MACE over next 6 wk: Discharge home
Score 4–6 = 22.3% MACE over next 6 wk: Admit for observation
Score 7–10 = 72.7% MACE over next 6 wk: Admit with early invasive strategies
The patient’s HEART score in this question would be 2 (1 point for age and 1 point for hypertension as a risk factor). This categorizes the patient as low risk for a MACE over the next six weeks. The appropriate course of action for this patient would be discharge home with prompt outpatient follow-up (Choice B). Admission for cardiac testing (Choice D) would be warranted for a moderate-high risk HEART score. Prescribing a benzodiazepine (Choice C) would not be warranted as this patient is asymptomatic and the pain episode is vague and atypical. Benzodiazepines are sometimes useful in patients with chest pain due to anxiety. Cardiology consultation (Choice A) would not be warranted as the patient has a low HEART score, is currently asymptomatic with normal imaging, blood work and troponin, and a normal EKG. Correct Answer: B
Which of the following is the most appropriate next step in management for this patient’s condition? – See answer @ 23:00 UK @ https://t.co/c911V4uOBl
— iem-student (@iem_student) September 18, 2020
References
Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=219641169
Wieters J, McDonough J, Catral J. Chest Pain. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2172§ionid=165059275
