When to Rule Out ACS: 3 Simple Recommendations

Amal Mattu, MD


July 05, 2012

In This Article


"I hate chest pain!"

A young attending voiced his frustration after hearing a lecture on chest pain at a recent risk management conference, and I had no doubt that his feelings were shared by many others in the audience, including me. He continued, "Essentially, any sign or symptom involving the waist up can be an acute coronary syndrome (ACS)! Nothing can rule out ACS, and we're on thin ice medicolegally if we ever miss ACS. So, what are we supposed to do?"

The evaluation of patients with chest pain and possible ACS is fraught with difficulty and frustration. While the disposition of patients with a "classic" or "typical" history seems easy, determining a disposition for patients with "atypical" features is more challenging.

Traditional teaching is that 2%-5% of cases of ACS are discharged home from emergency department (EDs), despite the wealth of technology and testing to which we have access. Furthermore, concerns about litigation for missed ACS lead to an enormous number of hospital admissions with negative inpatient work-ups, contributing to increased costs and hospital overcrowding.

Part of the problem we face in evaluating these patients is that there are a multitude of symptoms that we've been taught that are considered "classic" or "typical" for ACS: chest pressure with radiation to the left neck, jaw, shoulder, or arm, dyspnea; diaphoresis; nausea; vomiting; and lightheadedness. Yet, many of the patients who present with typical symptoms end up having negative work-ups for ACS. We've also been taught that "atypical" pain (pleuritic, sharp, positional, or reproducible) can also be consistent with ACS.

A well-publicized article from JAMA concluded, "Although certain elements of the chest pain history are associated with increased or decreased likelihoods of a diagnosis of ACS or AMI [acute myocardial infarction], none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing."[1] One wonders whether the authors of this article had any realistic concept of hospital costs or overcrowding. Regardless, publications such as this one raise further medicolegal concerns about the safety of ever discharging a patient with chest pain.

Fortunately, however, studies published in recent years have more closely evaluated the accuracy of both typical and atypical symptoms and signs at predicting ACS. These studies can be used to better predict the likelihood that these features rule in ACS, and they might also help in defending physicians in some missed cases. We'll begin with a brief discussion of the most recent of these studies, then review 2 other publications that all acute care providers should know about.


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