Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Abstract

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE‐1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low‐risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low‐risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high‐sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non‐obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high‐sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

Using HEART2 score to risk stratify chest pain patients in the Emergency Department: an observational study

“…However, no modified HEART score was derived from the study. A similar recommendation was also shown in a recently published guideline for reasonable and appropriate care of recurrent low-risk chest pain patients in the ED (GRACE) [ 15 ]. Taken together, it might be worthwhile to modify the current HEART scoring system.…”

“…Chest pain is one of the common chief complaints that present to Emergency Departments (ED) [ 24 ]. Among all chest pain patients, a significant number of patients have recurrent chest pain with frequent ED visits [ 15 , 25 ]. In this study, we focused on a special population of chest pain patients who presented to the ED with previous cardiac imaging tests performed.…”

“…At present, ED chest pain patients with the previous CIT performed are over-investigated. Though not accounting for the majority of ED chest pain patients, such a cohort may use significant healthcare resources [ 15 ]. Frequent ED visits, higher hospital readmissions, and repetitive cardiac imaging tests significantly increased health care costs [ 10 , 26 , 27 ].…”

Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review

“…While the National Institute of Care and Excellence (NICE) has published extensive guidelines on epilepsy diagnosis and management, it does not provide further guidance on this specific topic 10 . It is possible that guidelines from the Society for Academic Emergency Medicine, similar to those published for recurrent chest pain, may become available for patients presenting with recurrent seizures 38 …”

A candle in the dark: The role of indirect evidence in emergency medicine clinical practice guidelines

“…The GRACE‐2 writing team deliberated to select topics and questions and to explicitly define a clinically meaningful population, ultimately settling on definitions of recurrence within 30 days and adults with “low‐risk” abdominal pain. Identifying no well‐accepted or validated definition of “low risk” (as opposed to a risk model like the HEART score for chest pain 4 ), the GRACE‐2 writing team devised a definition of “low risk” that resonated with our clinical intuition and excluded populations that emergency physicians would routinely identify as moderate or high risk. Subsequently, the GRACE‐2 writing team worked with medical librarians to focus searches based on the patient‐intervention‐control‐outcome‐time (PICOT) template 5 and completed systematic reviews for each question before developing the recommendations 6,7 .…”