Societies release recommendations for diagnosing chest pain in the emergency department

New recommendations from the American College of Cardiology and American College of Radiology have established appropriate use of diagnostic imaging for patients with chest pain, one of the most common reasons for emergency department visits.

The document addresses 20 fundamental clinical scenarios for emergency imaging for chest pain and assesses when imaging is useful in each case, and if so, what information is provided by the specified imaging procedure. The clinical scenarios are broken down into leading critical diagnoses: acute coronary syndrome, pulmonary embolism and acute aortic syndrome. There is a fourth category, triple rule out computerized tomography (CT), for the minority of patients for whom a leading diagnosis is not possible.

Using the well-established modified Rand methodology, an expert panel rated each of the diagnostic procedures for the 20 clinical scenarios on a scale from 1 to 9. Each procedure has a corresponding rating of "rarely appropriate," "may be appropriate" or "appropriate."

"This document captures a wide scope of those patients who come to the emergency department with chest pain, although there will always be patients who present unique situations and no document can be a substitute for clinical judgment," said Frank J. Rybicki, MD, PhD, professor and chair of the department of radiology at the University of Ottawa, head of medical imaging at The Ottawa Hospital and co-chair of the writing committee.

The authors explain that the concept of appropriateness assesses the risks and benefits of a treatment, test or procedure and that these criteria provide imaging guidance to inform the clinician's judgment.