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Chest Pain Management


A patient walks into your emergency department complaining of chest pain. You order an EKG and cardiac enzymes – both negative. This patient is not having an MI. This type of patient walks into the emergency room all the time! In fact over 90% of patients who walk into the ED are NOT having a myocardial infarction.

It’s true that about 1.5% of patients suffering ACS are missed – this has led to fear and is why so many low risk patients are sent for advanced cardiac testing which ultimately leads to increased costs ($3-10 billion annually) and false positive results.

So, what do we do with this patient?

Keep them in the ED? Admit? Refer for more invasive testing? Have them follow up with their primary care?


There are many options and routes that can be taken. I have always said medicine is not a dictatorship. The patient is there for help and guidance – they are not their to be told what to do.

The Mayo Clinic developed a four part 1 page decision making tool (chest pain choice aid) to help tackle this very dilemma.

First, you risk stratify the patient. Then, you choose the appropriate decision making tool based on the risk you calculated. Very simple! This process took about 1.3 minutes for most ED clinicians.

The Mayo Clinic conducted a trial run with their new tool at six emergency departments in five states (899 patients). Patients who were going to be admitted for further testing were either given the standard care or the new decision making tool.

The tool isn’t an algorithm, instead it clearly shows the risks and options in a very easy to understand format so the patient is more informed/knowledgable.

Erik Hess, M.D (lead author of the study) states:

“What we heard from our patients and patient advisory group when designing the tool is what they fear the most is not knowing what’s going on or why they’re getting various tests. “When that happens, your imagination often blows the problem out of proportion and increases fear and anxiety. I think this tool helps patients better connect with their physician and calibrates their degree of anxiety to their objective level of risk — and in this way they are more knowledgeable of what’s going on and can feel more in control.”

Chest Pain Choice was associated with no major adverse cardiovascular events and led to a significantly lower proportion of patients receiving a stress test. The patients also left happier and with a better understanding as to why they received the care they received.

You can find the risk stratification calculator and the CPC tool here.

Having a conversation with your patient and including them in the decision making process might seem trivial or “annoying” – but it’s the right thing to do. After all, it’s their life you’re dealing with.

As Theodore Roosevelt says,

“nobody cares how much you know, until they know how much you care”