10 Questions
What is the typical negative predictive value of exercise testing in low-risk patients?
99%
When can patients with low clinical risk for complications undergo exercise testing?
After their second negative troponin test and no evidence of myocardial ischemia
What is the primary goal of exercise testing in the ED setting?
To rule out ACS in low-risk patients
What is the typical positive predictive value of exercise testing in low-risk patients?
Less than 50%
Which of the following is a requirement for exercise electrocardiographic testing in the ED?
No evidence of myocardial injury by serial troponin
What is the purpose of obtaining an ECG at the time of arrival in the ED?
To exclude significant electrocardiographic abnormalities
Which of the following patients should be excluded from early or immediate exercise testing?
Patients with electrocardiographic findings consistent with ischemia
What is the primary purpose of serial troponin testing in the ED?
To rule out ACS in low-risk patients
Which of the following is a contraindication to exercise electrocardiographic testing in the ED?
Presence of rest electrocardiographic abnormalities
What is the purpose of the Bruce or modified Bruce treadmill protocol in exercise testing?
To simulate physical activity and assess cardiac response
Study Notes
Acute Chest Pain
- Acute chest pain is one of the most common reasons for seeking care in the emergency department (ED), accounting for almost 10% of non-traumatic visits in the United States.
- Only 10% to 15% of patients with acute chest pain actually have acute coronary syndrome (ACS).
Causes of Acute Chest Pain
- Myocardial ischemia or infarction
- Pericardial disease
- Vascular disease
- Pulmonary conditions
- Gastrointestinal conditions
- Musculoskeletal and other causes
Differentiating ACS from Non-ACS
- Diagnosis of ACS is missed in approximately 2% of patients, leading to substantial consequences.
- Patients with a lower risk for complications must be balanced against the cost and inconvenience of admission and the risk of complications from tests and procedures.
Clinical Evaluation
- Clinical evaluation involves taking a thorough medical history and performing a physical examination.
- Decision aids are used to stratify patients according to their risk of complications.
- Early non-invasive testing, such as exercise testing, is used to evaluate low-risk patients.
Chest Pain Protocols and Units
- Chest pain units and critical pathways are used for efficient and rapid evaluation of lower-risk patients.
- These units have been shown to reduce hospitalization rates and costs while maintaining patient safety.
Immediate Management
- Immediate management involves making a rapid diagnosis and initiating treatment to prevent further complications.
- Patients with ACS or other life-threatening conditions must be identified and treated promptly.
Atypical Descriptions of Chest Pain
- Atypical descriptions of chest pain reduce the likelihood of myocardial ischemia or injury.
- Examples of atypical descriptions include:
- Pleuritic pain
- Pain that may be localized by the tip of one finger
- Pain reproduced with movement or palpation of the chest wall or arms
- Constant pain that persists for many hours
- Pain that radiates into the lower extremities
Exercise Testing
- Exercise testing is safe and has a negative predictive value of typically greater than 99%.
- In low-risk patients, exercise testing has a positive predictive value of frequently less than 50%.
- Patients with low clinical risk for complications can safely undergo exercise testing after their second negative troponin test and no other evidence of myocardial ischemia.
This quiz covers the approach to diagnosing and managing patients with chest pain, including causes, immediate management, and protocols. It is based on the content of Part V Atherosclerotic Cardiovascular Disease.
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