Priorities in the evaluation of patients with chest pain.

tion (TIMI) score of 0 holds promise to further advance our management of low-risk patients. 4 In the current state of our knowledge, it is reasonable to call for a halt to routine cardiac testing in favor of physician discretion in selection of patients for predischarge testing. Routine use of CTA in low-risk patients with chest pain is questionable and warrants specific attention. Despite a negative predictive value of more than 99%, decreased LOS, and lower upfront ED costs in fully capable units, this method has considerable drawbacks. 5 These include ionizing radiation with its potential for future risk of cancer and a suboptimal positive predictive value that can promote follow-up invasive coronary angiography, additional radiation exposure, and use of nephrotoxic radiographic contrast medium, plus allergic reactions. Of importance, CTA is associated with elevated rates of invasive angiography and subsequent increases in revas-cularization, with the potential for increased downstream costs and no evidence of clinical benefit compared with usual care. 6,7 In this regard, it is important to appreciate that even when testing does reveal coronary artery disease, a causal relationship cannot be inferred between symptom and disease. Computed tomographic coronary angiography is a remarkable tool, but clearly it should be reserved for selected patients among the low-risk group presenting to the ED with chest pain. At the University of California, Davis, Medical Center in Sac-ramento, we practice physician discretion in selecting patients for predischarge testing. In more than 500 patients discharged directly from the unit after evaluation consisting of normal results of electrocardiograms and cardiac troponin tests, there has been only 1 adverse cardiac event (0.2%) at the 30-day follow-up. Thus, low risk is not no risk, and the crucial aspects of this strategy remain meticulous clinical history and examination, accurate electrocardiographic interpretation , and reliable and contemporary assay for cardiac troponin. The extent to which this concept will reduce the burden of unnecessary testing of low-risk patients will depend on each institution's patient mix, the readiness of clinicians steeped in the hazards of missed acute coronary syndromes to adopt new and reasonable algorithms, and the interests and influences on clinical care at their institutions. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. A. Chest pain in the emergency department: the case against our current practice of routine noninvasive testing. variation in the use of noninvasive cardiac …