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    Vancouver Chest Pain Rule

    Identifies chest pain patients who are low risk and safe for early discharge.
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    When to Use
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    Why Use
    • Use in adult patients ≥25 years old presenting to the ED with chest pain.
    • Should not be used in patients with trauma or other radiographically-identified cause for chest pain such as pneumothorax, pleural effusion, and/or pneumonia.
    • Should not be used in patients with any of the following findings on EKG: ST elevation, ST depression >0.5mm, Q waves, left ventricular hypertrophy, paced rhythm, left bundle branch block.
    • Original derivation study was intended to derive a prediction rule allowing for safe discharge of ED chest pain patients within 2 hours and without the need for further provocative testing.
    • The original derivation study tested with troponin T, but an external validation study showed no difference in the performance of the rule with high-sensitivity troponin.
    • 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.
    • Primary outcome was diagnosis of ACS (acute MI or unstable angina) within 30 days. Acute MI was defined as positive troponin, EKG consistent with acute MI, or death without any other cause or event, and unstable angina was defined as coronary angiogram showing 70% lesion or revascularization with either percutaneous coronary intervention or coronary artery bypass grafting”
    • Adverse events include: tachycardia or bradycardia requiring medical intervention, respiratory failure requiring assisted ventilation, pulmonary embolism, aortic dissection or aneurysm, new congestive heart failure requiring intravenous medications, hypotension requiring vasoactive agents or an intra-aortic balloon pump, chest compressions, percutaneous coronary intervention, or coronary artery bypass grafting.

    The Vancouver Chest Pain Rule identifies low-risk chest pain patients that can be safely discharged from the ED after the standard initial evaluation of history and physician exam, EKG, and one cardiac biomarker (normal sensitivity troponin).

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    Step Two
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    Step Three
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    Advice

    • Patients with an abnormal EKG, positive troponin at 2 hours, or history of prior ACS or nitrate use do not qualify for early discharge.
    • Patients with a normal EKG, negative 2-hour troponin, no prior history of ACS or nitrate use, and reproducible pain to palpation can be discharged from the ED without further provocative testing.
    • Patients with a normal EKG, negative 2-hour troponin, no prior history of ACS or nitrate use, with non-reproducible chest pain who are age <50 years and have chest pain that does not radiate to the neck, jaw, or arm, can be discharged from the ED without further provocative testing.

    Critical Actions

    • Low-risk patients can be considered for discharge from the ED without further provocative testing for ACS.
    • Consider other etiologies of chest pain, including aortic, esophageal, pulmonary, cardiac, abdominal, and musculoskeletal sources.
    • Patients who are not low risk should be managed as per usual chest pain protocols, including but not limited to consideration of aspirin, nitroglycerin, and serial EKGs and biomarkers.
    About the Creator
    Dr. Frank Scheuermeyer
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