Less is more: chest pain pathways in clinical care

The significant benefits for patients and hospitals of reduced testing can be achieved without compromising safety

Public awareness of the importance of early treatment for chest pain has contributed to improved outcomes for patients with acute coronary syndromes (ACS), but also to the large and growing number of people with chest pain attending emergency departments (EDs). Some have threatening pathology, but in most cases the underlying cause is benign. Clinicians’ desire for diagnostic accuracy, minimal risk, and low personal liability has led to high rates of low value admission and investigation, draining resources from already strained services; in the United States, 10% of ED visits are motivated by chest pain, costing US$12 billion annually.1 The rapid growth in the numbers of clinical pathways and risk scores for chest pain is one response to this unsustainable demand, each aiming to integrate clinical information, assess risk, uphold consistency and quality, and minimise diagnostic error. Successful trials of a range of pathways have been reported, but questions remain about their content and local applicability, impact on outcomes, implementation, and financial benefits.1 Two articles published in this edition of the MJA investigate these questions.