Recurrent, low-risk chest pain care in the ED: SAEM publishes GRACE guidelines

Chest pain is the second most common chief complaint in the emergency department (ED), with only five percent of patients diagnosed with an acute, life-threatening condition. There are significant physician and institutional variations in diagnostic testing and admission of these patients, creating a need for clinical practice guidelines to aid in the evaluation and treatment specific to the ED population. The first SAEM GRACE team was assembled to address this critical need for evidence-based and expert-driven recommendations for the care of complaints associated with recurrent chest pain.

A multidisciplinary panel of experts assessed the certainty of evidence and strength of recommendations regarding eight priority questions for adults presenting to the ED with recurrent, low-risk chest pain. They then developed recommendations for testing, treatment, hospital admission, and screening tools and referrals for mental health management. To write this clinical practice guideline, the panel used Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology, a framework for rating the quality of the best available evidence and developing clinical practice recommendations.

"In patients with recurrent, low-risk chest pain and a normal stress test in the prior 12 months, it is not recommended to employ further routine stress testing to reduce subsequent 30-day Major Adverse Cardiac Events (MACE). In our opinion, the other important statement is that there is insufficient evidence to recommend hospitalization (either inpatient admission or observation) versus discharge as a strategy to mitigate 30-day MACE. Further recommendations including screening and referral for anxiety and depression, previously unexplored topics in the context of chest pain, should also be noted in this novel work."

"Endorsement and dissemination by multi-stakeholder organizations and societies could catapult these recommendations into decision support within electronic health records and implementation for millions of chest pain visits across the US and beyond, transforming them into shared decision-making with patients at the point of care."

The SAEM GRACE program addresses the best practices for the care of the most common chief complaints that can be seen on the tracking board of any emergency department in the country, based upon research and expert consensus. These guidelines are designed with de-implementation as a guiding principle to reasonably reduce wasteful testing, provide explicit criteria to reduce foreseeable risk, and define sensible and prudent medical care. In addition to GRACE for chest pain, SAEM research and writing teams will create guidelines for recurrent abdominal pain, acute dizziness, and non-opioid substance dependence.

"GRACE emerged to address the critical need for evidence-based and expert driven, trustworthy, and transparent recommendations for the clinical care of common chief complaints and syndromes, prioritizing those with demonstrable practice variability and significant malpractice angst that often elicit decisional conflict or treatment uncertainty."

"It is vital for (emergency medicine) EM organizations to foster EM-specific guidelines, created by EM clinical/academic experts, to serve ED patient needs. GRACE will accelerate the creation of new evidence-based recommendations for our specialty, with involvement and focus on patient-important outcomes and consideration of patients' values and preferences. Above all, GRACE aims to transparently report the decision process, as the focus on transparency facilitates understanding and implementation, and should empower patients and clinicians to make informed choices."

RECOMMENDATIONS

Recommendation 1: In adult patients with recurrent, low-risk chest pain, for greater than 3 h duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude ACS within 30 days. (Conditional, For) [Low level of evidence].

Recommendation 2: In adult patients with recurrent, low-risk chest pain, and a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of MACE at 30 days. (Conditional, Against) [Low level of evidence].

Recommendation 3: In adult patients with recurrent, low-risk chest pain, there is insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days. (No evidence, Either).

Recommendation 4: In adult patients with recurrent, low-risk chest pain and non-obstructive (<50% stenosis) CAD on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation. (Conditional, For) [Low level of evidence].

Recommendation 5: In adult patients with recurrent, low-risk chest pain and no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation. (Conditional, For) [Low level of evidence].

Recommendation 6: In adult patients with recurrent, low-risk chest pain and prior CCTA within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, high-sensitivity troponin below a validated threshold to exclude ACS within that 2-year time frame. (Conditional, For) [Moderate level of evidence].

Recommendation 7: In adult patients with recurrent, low-risk chest pain, we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return ED visits. (Conditional, Either) [Very low level of evidence].

Recommendation 8: In adult patients with recurrent, low-risk chest pain, we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits. (Conditional/Either) [Low level of evidence].