Vancouver Chest Pain Rule
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.