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Societies issue recommendations for diagnostic imaging in ED for chest pain
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The American College of Cardiology and American College of Radiology have issued a joint document establishing appropriate use of diagnostic imaging for patients presenting to the ED with chest pain.
“This document captures a wide scope of those patients who come to the [ED] with chest pain, although there will always be patients who present unique situations and no document can be a substitute for clinical judgment,” 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, said in a press release.
The panel rated each diagnostic procedure for 20 clinical scenarios. The scenarios were broken down into four broad categories: suspected ACS, suspected pulmonary embolism, suspected acute aortic syndrome, and patients for whom a leading diagnosis is difficult or impossible.
The possible diagnostic procedures for each scenario were rated on a scale of 1 through 9, with 7, 8 or 9 signifying that is an appropriate procedure whose benefits outweigh its risks; 4, 5 or 6 signifying that it is at times an appropriate option because of inconclusive benefit/risk ratio or shows potential benefit on the basis of practice experience; and 1, 2 or 3 signifying that it is rarely an appropriate option because of the lack of clear evidence that benefits outweigh risks, and exceptions should have their clinical reasons documented.
The panel wrote that when a patient first presents to the ED with chest pain, the physician should perform an initial history and physical exam. If a non-CV illness without long-term consequences is identified, then the patient should be treated for that and/or discharged. If one is not, then biomarker and other initial ancillary testing should be performed. If an actionable diagnosis of chest pain is established from that, then treatment should be initiated. If not, then diagnostic imaging is needed and the recommendations for the clinical scenarios outlined in the document should be followed.
“When more than one imaging study is considered appropriate for a clinical scenario, the methods do not consider preferred individual modalities among all those rated appropriate,” Rybicki and colleagues wrote. “Clinicians should include all factors including costs as well as local availability and expertise when ordering imaging studies.” – by Erik Swain
Disclosure: Rybicki reports receiving a research grant from Toshiba Medical Systems. Please see the full document for a list of the relevant financial disclosures of the other authors, reviewers and rating panel members.
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