Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    Vancouver Chest Pain Rule

    Identifies chest pain patients who are low risk and safe for early discharge.
    Favorite
    When to Use
    Pearls/Pitfalls
    Why Use

    The Vancouver Chest Pain Rule can be applied to patients ages 25-49 with chest pain and can help risk stratify those patients who are very low risk of adverse event and can be safely discharged from the emergency department without serial biomarkers.

    • Patients were included if they were 25 or older and did not have trauma or other radiologic cause (like pneumothorax, pleural effusion, pneumonia) for the chest pain
    • Calculated a goal for the rule’s sensitivity of 98%
    • Used troponin T testing for biomarker
    • EKG could not have “ischemic changes” (STE, ST depr > 0.5mm), Q waves, LVH, paced rhythm, LBBB
      • Were rated by two separate, blinded physicians and rated as “ischemic” or “non-ischemic”
    • Adverse events were broadly defined: tachycardia or bradycardia requiring medical intervention; respiratory failure requiring assisted ventilations; pulmonary embolism; aortic dissection or aneurysm; new congestive heart failure requiring intravenous medications; hypotension requiring vaso-active agents or an intra-aortic balloon pump; chest compressions; percutaneous coronary intervention; or coronary artery bypass grafting.
    • Primary outcome: Diagnosis of ACS (acute MI or unstable angina) within 30 days
      • Unstable angina: “Coronary angiogram with 70% lesion, revascularization with either percutaneous coronary intervention or coronary artery bypass grafting”
      • Acute MI: Troponin positive, EKG consistent with acute MI, death without any other cause or event
    • The incidence of disease may be higher in the countries where the rule was developed and tested (Canada, Australia, New Zealand) compared to the United States

    Patients requiring serial blood testing (serial troponin markers typically at 0 and 6-hours to rule out myocardial infarction) and further risk stratification require an extended emergency department evaluation, leading to crowding and bed allocation problems. The authors of this study were able to find a low-risk group of patients (~22%) that could safely be discharged from the ED after one biomarker, EKG, and history and physical exam.

    Step One
    Step Two
    Step Three

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    Barring other concerning features for acute coronary syndrome or other life-threatening causes of chest pain (pneumothorax, pulmonary embolism, cardiac tamponade, aortic dissection, esophageal rupture, etc.), patients that meet the low-risk criteria can be considered for discharge with close follow-up with their primary care physician.

    Patients who do not meet the low-risk criteria should be ruled-out for myocardial infarction with serial EKGs and biomarkers and risk stratified as per normal chest pain guidelines and protocols.

    Management

    • For low-risk patients: consider other causes of chest pain due to aortic, esophageal, pulmonary, cardiac, and abdominal, and muskuloskeletal sources prior to discharge.
    • For non-low-risk patients: Treat as per usual chest pain protocols, including but not limited to consideration of aspirin, nitroglycerin, and serial EKGs and biomarkers at minimum.

    Formula

    Step-wise analysis of EKG, biomarker, history and physical exam; if all questions are answered “No,” the patient is low-risk by the Vancouver Chest Pain Rule.

    Facts & Figures

    First Step: If no to all, move to step two. Otherwise proceed with standard chest pain evaluation:

    • Abnormal initial EKG?
    • Positive troponin at 2 hours?
    • Prior ACS or nitrate use?

    Second Step: If yes, proceed to early discharge. If no, move to step three.

    • Does palpation reproduce pain?

    Third Step: If no to all, proceed with early discharge. Otherwise proceed with standard chest pain evaluation.

    • Age ≥ 50?
    • Does pain radiate to neck, jaw, or left arm

    Evidence Appraisal

    • The Vancouver Chest Pain Rule was 99.2-100% sensitive, 18.6-23.4% specific in its internal validation cohort and 99.1% sensitive and 16.1% specific.
    • It was a prospective study for the derivation and validation cohorts.
    • As mentioned above, about 15-20% of patient with chest pain can be deemed safe for early discharge using this protocol in the two studies below.
    • Note: A prior Vancouver Chest Pain rule was created using CK-MB instead of troponin but not validated. This rule only used troponin as its biomarker.
    • 19% lost to followup, but none found in death records nor 30-day ER visit
    • In the original study, the derivation cohort had a high incidence of disease (including acute coronary syndrome and adverse event) of 30%, but in the validation cohort this was a lower incidence of 15.5%.
    • In the external validation study by Cullen et. al., this incidence was 20%.
    Dr. Frank Scheuermeyer

    From the Creator

    Why did you develop the Vancouver Chest Pain Rule? Was there a clinical experience that inspired you to create this tool for clinicians? Was it directly related to the “old” Vancouver Chest Pain Rule that used older enzyme assays?
    The Vancouver Chest Pain Rule (VCPR) was developed in response to work by Pope (NEJM 2000) and Christenson (CMAJ 2004) that demonstrated a 2 - 5% of emergency department patients with an acute coronary syndrome were inappropriately discharged with a minimizing diagnosis and no further follow-up. The initial VCPR decribed by Christenson (Ann Emerg Med 2006), which used creatinine kinase as a key decision point, was clinically appropriate, but the disuse of CK ensured that an additional rule had to be derived.
    Overall, the declining prevalence of ACS in chest pain patients (likely due to better community control of risk factors such as cholesterol and hypertension), as well as the diversion of STEMI patients directly to the catheterization laboratory, ensures that emergency physicians will likely be faced with an increased proportion of low risk chest pain patients with clinically vague presentations. In these cases, a 2-hour risk stratification approach may be welcomed, since it can result in safe discharge of 20 - 40% of chest pain patients within 2 hours, rather than subjecting these patients to prolonged observation, repeated investigations, and potential hospital admissions.
    What pearls, pitfalls and/or tips do you have for users of the Vancouver Chest Pain Rule? Are there cases in which it has been applied, interpreted, or used inappropriately?
    Many clinicians will be tempted to use the VCPR in patients they have already decided are low-risk - for example, patients that are younger, have lower Framingham risk factors, etc. - but the rule is designed to perform in any ED patient with potential ischemic chest pain. It cannot be used to “rule-in” an ACS diagnosis, but works better as a “rule out” test. Rare but lethal causes of chest pain including aortic dissection, pneumothorax, and pericarditis, cannot reliably be identified with the VCPR.
    A few questions about definitions: how are “prior ACS” or “nitrate use” defined. For the former, was this any anginal symptom in the past? For the latter, was this any prior prescription for nitrates?
    Prior acute coronary syndrome was defined as a history of acute myocardial infarction or unstable angina, or prior percutaneous coronary intervention or coronary artery bypass grafting. Prior nitrate use (or any prior nitrate prescription) was a proxy marker for stable angina, since many patients could not remember they had angina, but patients COULD remember that they inhaled liquid from a reddish bottle that gave them a headache.
    What recommendations do you have for health care providers once they have applied the Vancouver Chest Pain Rule? Are there any adjustments or updates you would make to the rule given recent changes in medicine?
    One advantage of the VCPR is that no additional investigations are required - the patient does not need to be admitted for provocative testing, cardiac CT angiography, or echocardiography - and the patient can simply be discharged home. However, the use of rapid ED-based advance imaging may affect the VCPR. Currently, chest pain outcomes are typically studied until 30 days, but a normal cardiac CT, for instance, could provide reassurance that no ACS event is likely in the next several years.
    Any other comments? Any new research or papers on this topic in the pipeline? Any thoughts on comparisons to other risk scores like the HEART or GRACE Scores?
    Currently other scores like HEART and GRACE appear to be appropriate as well, although the variables in GRACE may be difficult to obtain in the ED. The team led by Drs Martin Than and Louise Cullen have a practical approach with the ADAPT and EDACS, which are other 2-hour ACS rule-out tests. These different techniques have so far not been compared to one another.

    About the Creator

    Frank Xavier Scheuermeyer, MD, is an assistant professor of emergency medicine at the University of British Columbia in Vancouver, Canada. He also practices at St. Paul's and Mount St. Joseph's Hospital Emergency Departments. Dr. Scheuermeyer conducts research on atrial fibrillation and other cardiac emergencies.

    To view Dr. Frank Scheuermeyer's publications, visit PubMed