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Better Chest Pain Patient Management in the ED can Deliver Significant Benefits

Chest Pain

Hospital Emergency Departments can be busy places with many anxious people crammed into a small area, all demanding attention from increasingly stretched staff.  Adopting new techniques can lead to significant reductions in the time patients must spend in the ED, the time until they get the care they need, the number of diagnostic procedures they must go through, and associated costs1.

 

In Australia, throat and chest pain is the second most common condition seen in the ED3.  In fact, often more than 5% of patients waiting in an ED list chest pain as their principal reason for visiting7, and so better chest pain management is a key area where EDs can look to improve their performance.

 

Chest pain can be caused by a number of different conditions. Some are serious and require immediate advanced care. Some are less serious and can result in a patient being discharged immediately.  Accurately and efficiently diagnosing and triaging these patients is critical.

 

Acute Myocardial Infarction (better known as “heart attack”) is one of the serious conditions requiring immediate advanced care.  In these patients every 30 minutes of delay between symptoms and treatment increases the relative risk of 1-year mortality by 7.5%6.

 

One of the defining characteristics of a heart attack is a significant change in the patient’s level of troponin. Troponins are proteins released into the blood by the heart when it is damaged and can be detected with a blood test8.

 

Until recently, troponin concentrations required a 3-6 hour wait to allow enough time for this significant change to be observed.  But new generation tests have been developed that can precisely detect troponin at far lower concentrations in the blood, so this wait is reduced to as little as 1 hour5.  

 

Some of the potential benefits of this reduced wait time include4:-

  • The time spent waiting for the ED is reduced

  • The time spent in acute care is reduced

  • Patients need fewer diagnostic tests and resources

  • The faster diagnosis does not lead to poorer outcomes than standard care

 

Over the last 30 years, Australia and the world have seen enormous improvements in the diagnosis and treatment of cardiovascular diseases reducing the overall burden2.   However, with increasing proportions of risk factors (eg: increased aging of the population, obesity, and more sedentary lifestyles) we still need to be vigilant and continually improve how we diagnose and manage these patients going forward.  As shown above, the benefits to the patient and healthcare system can be significant. 

 

Benjamin Smith

Cardiology Disease Area Lead

Roche Diagnostics Australia

References

  1. Ambavane A. et al (2017) “Economic evaluation of the one-hour rule-out and rule-in algorithm for acute myocardial infarction using the high-sensitivity cardiac troponin T assay in the emergency department.” PLoS ONE 12(11): e0187662

  2. Australian Institute of Health and Welfare 2020. “Cardiovascular disease”. Cat. no. CVD 83. Canberra: AIHW. Viewed 22 March 2021

  3. Australian Institute of Health and Welfare 2018. “Emergency department care 2017–18: Australian hospital statistics.” Health services series no. 89. Cat. no. HSE 216. Canberra: AIHW.

  4. Chew, Derek P. et al “A Randomized Trial of a 1-Hour Troponin T Protocol in Suspected Acute Coronary Syndromes.” Circulation, vol. 140, no. 19, 2019, pp. 1543-1556.

  5. Collet, JP. et al “2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation”. European Heart Journal (2021) 42, 1289-1367

  6. De Luca, Giuseppe. et al “Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts.” Circulation, vol. 109, no. 10, 2004, pp. 1223-1225.

  7. Pitts, Stephen R. et al “National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary.” National Health Statistics Reports, vol. 7, 2008, pp. 1-40.

  8. Thygesen, Kristian. et al “Fourth Universal Definition of Myocardial Infarction (2018).” Circulation, vol. 138, no. 20, 2018, pp. 618-651.