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Invited Commentary
Less Is More
August 2017

Cardiac Testing After Emergency Department Evaluation for Chest Pain: Time for a Paradigm Shift?

Author Affiliations
  • 1Center for Policy Research–Emergency Medicine, Department of Emergency Medicine, Oregon Health and Science University, Portland
  • 2Division of Cardiology, University of California–San Francisco, San Francisco
  • 3Editor, JAMA Internal Medicine, Chicago, Illinois
JAMA Intern Med. 2017;177(8):1183-1184. doi:10.1001/jamainternmed.2017.2439

Cardiovascular disease is the leading worldwide cause of mortality and morbidity. The evaluation of chest pain for suspected acute coronary syndrome (ACS) typically occurs in an emergency department (ED). Chest pain is the second most common reason for an ED visit and accounts for 7 million annual encounters in the United States. Identifying the minority of patients who have ACS is challenging with high stakes, as timely treatment can prevent future cardiac events.1 Missed ACS is also the top reason for malpractice claims against emergency physicians. Consequently, most emergency physicians are unwilling to accept an ACS “miss” rate of less than 1%.2 Thus, the current ED approach to suspected ACS is to err on the side of more testing and more admissions, and results in more than $3 billion in annual hospital costs.3

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