Chest pain/protocols and algorithms. Not everyone needs an EST!

30 May

[I know the video isn’t immediately relevant but it’s still awesome…]

From the blogs and podcasts, it seems that everyone in the US with a chest and some pain in it will get a rule out in the ED followed by some provocative testing. Amal Mattu (who I’m stalking, seeing at an advanced ECG course pre-ICEM2012) falls into the category of Very Smart People, and I’ve heard him say that we need provocative testing. It has not been my (limited) experience that EDs in the UK and Ireland do provocative testing on everyone.

This study seeks to show that a protocol of not stress-testing everyone is a good and fine thing to do.


  • observational data on the protocol used in St.Paul BC, Canada
  • got in on the basis of triage criteria
  • pts got the usual ECG and assessment (and this “assessment” is probably the most important part and the most difficult to quantify and reproduce.)
  • trops at 2 and 6 hrs
  • if considered low risk, pt could be discharged
  • if considered higher they could get EST (or other appropriate stress) within 48 hrs
  • fairly low threshold for referral to cardiology it seems
  • telephone follow up and they checked death registry if needed
  • primary outcome was AMI or confirmed unstable angina within 30 days (the second part is a bit of a problem as admission and tests formed part fo the diagnosis and it’s always hard to know if everything the cardiologists do is gold)


  • 1255 pts of whom they removed 55 from the protocol (remember this is a nurse initiated one so this is pretty damn good)
  • 50% discharged with no planned provocative testing
  • didn’t miss a single ACS by 30 days (oevrall rule in rate was 10% and most picked up in ED, only a few by provocative testing after the initial assessment)
  • 2% lost to FU who didn’t attend ED or die in the region
  • of note of the 10% rule ins; 10% of these had a TIMI of 0 (but hopefully you’re all clear by now that the TIMI isn’t a clinical decision instrument that we can use as EPs)


  • this is all about patient selection – if we can work out who goes into this protocol then we can rest safe
  • reassures us that low risk patients probably are just that
  • fairly compelling that we can keep doing what we’re doing – in my experience in Norn Iron we only did provocative testing on a select bunch of our chest pains. There were some who got rule out trops who we did no further testing on.
  • It’s useful to know that a 6 hr trop is a useful rule out. Where I’ve previously worked we’ve based things around a 12 hr troponin as our rule out (though I confess it may have changed since I left a couple of years ago.)

Scheuermeyer, F X, G Innes, E Grafstein, M Kiess, B Boychuk, E Yu, D Kalla, and J Christenson. “Safety and Efficiency of a Chest Pain Diagnostic Algorithm with Selective Outpatient Stress Testing for Emergency Department Patients with Potential Ischemic Chest Pain.” Annals of Emergency Medicine 59, no. 4 (April 1, 2012): 256–264.e3. PMID 10.1016/j.annemergmed.2011.10.016 PMID 22221842

3 Replies to “Chest pain/protocols and algorithms. Not everyone needs an EST!

    • I confess to stealing most of my ideas from David Newman or Jerry Hoffmann…

      Though in my experience in UK setting, we have never pursued stress testing on every chest pain patient

  1. Hi Andy, this does seem to be a controversial area at the moment and on this side of the pond we often think that the Americans ‘don’t get it’, but in reality they do, it’s just that we seem to asking different questions depending on which side of the Atlantic we are practicing.

    In the UK we have taken the ED approach that the purpose of testing in chest pain is to identify myocardial damage and patients at risk of early complications if sent home. This has led to numerous strategies that do not necessarily require provocative testing (though some would argue that the walk back to the multi-storey after discharge is an uncontrolled version).

    Having spoken to US colleagues then their perspective seems to be different as many are pursuing the question of whether the patient in front of them has underlying ischaemic heart disease. This is clearly a different question and will require provocative testing or more in many patients.

    In the UK we have taken the position that the diagnosis of stable IHD is not really an EM issue on the day and that it can be followed up as an out patient once we have ruled out badness on the day. It seems like a sensible approach to us but we do not work within the legal restrictions of our chums over in the States.

    So, are Amul and chums wrong? Certainly not. They are answering a question that is pertinent to them. We are doing the same, it’s just that the question is different.

    As you know Rick Body’s paper on HsTnT has caused quite a stir in the blogosphere with a fair bit of criticism, and also a lot of support. HsTnT exemplifies the differences in perspective. Depending on the question you are asking HsTnT is, or is not helpful. It is up as EPs to first understand the question before we go seeking the answers.

    Love your blog. Wish we could do as well.



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