Led by Frank J. Rybicki, MD, PhD; James E. Udelson, MD, FACC; and W. Frank Peacock, MD, co-chairs of the Emergency Department Patients With Chest Pain Writing Panel, two panels of cardiology and radiology specialists reviewed evidence-based medicine, existing guidelines and practice experience to address appropriate use criteria in 20 fundamental clinical scenarios for emergency imaging in patients who present to the emergency department with chest pain. Each recommendation assesses when imaging is useful in a given scenario, as well as what information is provided by the specified imaging procedure.
According to the authors, “imaging appropriateness explicitly considers two questions: [one] is any imaging justified for 20 clinical scenarios that categorize patients after history, physical examination and ancillary testing? And [two] if justified, what meaningful incremental information will an imaging procedure provide?”
The clinical scenarios are divided into leading clinical diagnoses, acute coronary syndrome, pulmonary embolism and acute aortic syndrome, and rated from one through nine using the well-established modified Rand methodology. A fourth category – triple rule-out computerized tomography – was included for the minority of patients for whom a leading diagnosis is not possible. Each procedure also received indications of rarely appropriate, may be appropriate or appropriate.
Rybicki concludes that “this document captures a wide scope of those patients who come to the emergency department with chest pain, although there will always be patients who present unique situations and no document can be a substitute for clinical judgment.”