Update on the emergency department diagnosis and risk stratification of acute chest pain

The first issue of the new decade is focusing on the diagnosis and risk stratification of patients presenting to the emergency department (ED) with acute chest pain, the most common cause of non-injury ED visits. Only a minority of these patients will have a final diagnosis of an acute coronary syndrome, whereas the vast majority have a non-cardiac and a low-risk cause of the chest pain for which hospitalization is unnecessary. Therefore, in order to prevent ED clutter and unnecessary hospitalizations, it is essential to use rapid but very accurate diagnostic and risk stratification pathways that allow early discharge of the many low-risk chest pain patients without missing a single acute myocardial infarction (MI). There is a growing interest in the pivotal role of coronary microvascular dysfunction in the pathogenesis of angina pectoris (1-5). Patients with microvascular angina frequently present recurrent prolonged anginal symptoms at rest that mistakenly may raise the suspicion of unstable angina when they present with these symptoms to the emergency department. In an observational study using cardiac positron emission tomography/computed tomography, nearly one-half of low-risk, mostly obese chest pain patients without evidence of myocardial infarction had coronary microvascular dysfunction (6). These findings may explain the high rates of repetitive ED visits related to chest pain frequently observed in those patients. Testing for coronary microvascular dysfunction needs, therefore, more frequent consideration certainly in patients presenting recurrently with rest anginal symptoms.