Vague Chest Pain

What, in my definition, is a vague chest pain?
– It’s a chest pain that happens in a seemingly healthy, middle age patient, without a lot of risk factors (maybe just mild dyslipidemia, well, who doesn’t have cholesterol elevated nowadays?)

Ok, this may not apply to all countries. Im just sharing what I have read. This is quite a good one.

Question 1: Do all patients with vague chest pain need stres test?

Judd Hollander’s 2003 study of 962 hospital admissions for chest pain (patients received inpatient, outpatient or no stress test; the medical team decided who got what and which type of stress test) showed that:

  • There was no statistical difference in 30 days CV outcomes among patients who received inpatient, outpatient or no stress test.
  • Note that, in this study, they use tomographic imaging of the heart (stressed with exercise or drugs) as the stress test modality.

Shown here are the sens and spec of common methods of cardiac imaging.

  • As shown, sens ranges between 60-100 percent and spec ranges between 36-100 percent depending on what type of nuclear cardiac imaging you use.
  • Sens is better in pharmacological stress cardiac imaging but will still miss probably about 10-20 percent of patients with CAD.
    chart-11

Bottom line: patients with vague CP admitted may not be requiring any stress prior to discharge, provided that they can be followed closely in outpatient.

Question 2: Do all patients with vague chest pain need to be admitted?

Weinstock et al (JAMA 2015) studied patients with negative troponins X2 and excluded patients who were hypotension/hypoxic/abnormal EKG (those that we would want to manage aggressively) and looked at the bad outcomes of those patients admitted.

  • Only 4 over 5 years over 7266 patients.

Bottom line: Not all patients with vague CP need to be admitted. If you think they have low enough risk, it maybe okay to just follow them closely in outpatient.

Question 3: Any rule to help in admitting/discharging patients with vague CP?

Yes, for example HEART Score, EDACS and Vancouver Chest Pain Rule.

  • The rules are quite okay, pick one and combine with clinical judgements.
  • If needed, repeat troponin 6 hours after the first one may increase the specificity further.

HEART Score
http://www.heartscore.nl/resources/table.pdf

References:
Graham Walker, MD. Trust your Gut When It Comes To Vague Chest Pain. Emergency Medicine News August 2015;37(8):30-32

Grace Wu Chan, MD, Frank D Sites, RN, BSN, Frances S Shofer, PhD, Judd E Hollander, MD. Impact of stress testing on 30-day cardiovascular outcomes for low-risk patients with chest pain admitted to floor telemetry beds.
Am J Emerg Med 2003;21(4):282

Michael B. Weinstock, MD; Scott Weingart, MD; Frank Orth, DO; Douglas VanFossen, MD; Colin Kaide, MD; Judy Anderson, MS, MAS; David H. Newman, MD. Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission. JAMA Intern Med. 2015;175(7):1207-1212

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