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This month’s update is from the Academic Department of Military Emergency Medicine and University Hospitals Plymouth NHS Trust. We used a multimodal search strategy, drawing on free open-access medical education resources and literature searches. We identified the five most interesting and relevant papers (decided by consensus) and highlight the main findings, key limitations and clinical bottom line for each paper.
The papers are ranked as
Worth a peek—interesting, but not yet ready for prime time.
Head turner—new concepts.
Game changer—this paper could/should change practice.
Can ED chest pain patients with intermediate heart scores be managed as outpatients? by Moustapha et al
Topic: chest pain
Rating: worth a peek
This Canadian multicentre retrospective study examined outcomes of patients with intermediate-risk HEART (history, electrocardiogram, age, risk factors, troponin) scores directly referred from ED for outpatient rapid access chest pain clinic (RACPC) management, which allows cardiologists follow-up of patients with chest pain of possible cardiac origin.1 The primary outcome was a major adverse coronary event (MACE) at 6 weeks from presentation, defined as ‘death, ACS, stroke, coronary angiogram, or revascularisation’ (for which the American College of Emergency Physicians gave an acceptable missed diagnosis rate of 1%–2%).
Of 2018 RACPC referrals, 817 patients had intermediate-risk HEART scores calculated either by the treating physician (57.6%) or retrospectively by the investigators from charts (42.4%.) RACPC review took place a median of 8 days (IQR 5.0–12.5) after the ED visit. Of these patients, 6.1% re-presented to the ED before evaluation, and 21.3% did not attend RACPC. A MACE within 6 weeks occurred in 9.3% (n=76) of patients, with 1.1% (n=9) of events before clinic. Excluding angiography from the composite outcome, the MACE incidence was 0.73% before evaluation, which the authors felt supported the RACPC model.
Agreement on HEART scores between emergency physicians and cardiologists was far from …
Contributors All authors have contributed in line with the International Committee of Medical Journal Editors guidelines.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.