Journal Club Recap

Thanks to everyone who came to journal club last night and thanks to Dr. Hollander for being a most generous host and for sharing his chest pain knowledge. The bottom line from the three articles discussed last evening was that there are specific clinical history points, alternative diagnoses, and cardiac risk factors which can help to risk stratify patients presenting to the ER with chest pain, but they are not good enough to reduce risk of an MI to an acceptable level (i.e. <1%). These articles support the current practice pattern of approaching most chest pain that could potentially represent ACS, as ACS until proven otherwise. That is, perform EKGs, serial troponins, and to be guideline compliant, some sort of additional provocative or anatomical testing – i.e. a stress test, coronary CT, or catheterization. Do not be thrown off and think that chest pain is definitely cardiac if it improves with nitro, is definitely not cardiac if it improves with a GI cocktail, or is definitely not cardiac if it is atypical. There is an inkling that practice guidelines may change in the future as we learn more and more that serial troponins rule out an acute MI and stress tests do not add much in the way of clinical value. Coronary CTs are valuable in that a patient with normal coronary arteries on a coronary CT almost certainly does not need an ACS workup for their chest pain during their subsequent presentation (the duration of this time period is not yet determined). Additionally, look out for high-sensitivity troponins to become available in the near future which may change the algorithm for an ACS rule-out in the ER.

Read below for some excellent and thorough resources on chest pain the ED and to read the journal club articles

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