Vancouver Chest Pain Rule

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.

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.