GRACE-1 – Chest Pain Frequent Flyers

Written by Clay Smith

Spoon Feed
GRACE-1 offers eight evidence based guidelines to determine which adult patients with recurrent chest pain are low risk and can be safely sent home from the ED.

Why does this matter?
Up to 40% of patients return to the ED with recurrent chest pain, and it’s hard to know what to do. We don’t want to blow them off and miss an MI, but we also don’t want to keep doing expensive tests with high-dose radiation exposure. It would be nice if we could all agree on what constitutes low risk so we could send more patients home. This is a first stab at that. By the way, low risk in this guideline is defined as a HEART score <4 or low risk determination by other validated score, such as the HEART pathway.

Give some GRACE
The authors made eight evidence based recommendations to determine low risk status for patients who have recurrent ED visits for chest pain. For each, I will quote the guideline and add a comment.

Recommendation 1: In adult patients with recurrent, low-risk chest pain, for >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].”
Comment: I am looking forward to getting hs-Tn where I work. This is a quick way to rule out ACS if you have it.

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].”
Comment: If the patient is already low risk, we really shouldn’t feel pressed to do a stress test anyway, right?

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].”
Comment: This is an evidence free zone. If a patient repeatedly returns to the ED with chest pain, and there has been no prior stress test or CCTA, it is reasonable to consider admission in my opinion.

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].”
Comment: This helps clarify a common question about what to do with a prior cath with minor abnormalities.

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].”
Comment: This clarifies another perennial question – what is the warranty period after a clean cath?

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].”
Comment: A recent clean CCTA is helpful – hs-Tn and done.

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].”
Comment: Careful with this. This assumes you have already taken the chest pain seriously and worked it up. Don’t assume anxiety prior to doing your due diligence. That said, chest pain is a common way for anxiety to manifest physically. Just be careful.

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].”
Comment: Well, there you go. If your patient screens positive for depression/anxiety, referral can help them.

Source
Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med. 2021 Jul 6. doi: 10.1111/acem.14296. Online ahead of print.

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