SGEM#337: Amazing GRACE-1 How Sweet the Guidelines – Recurrent, Low Risk Chest Pain in the Emergency Department

Date: July 1st, 2021 Guest Skeptic #1: Dr. Chris Carpenter is Professor of Emergency Medicine at Washington University in St. Louis and a member of their Emergency Medicine Research Core. He is a member of the SAEM Board of Directors and the former Chair of the SAEM EBM Interest Group and ACEP Geriatric Section. He is Deputy Editor-in-Chief of Academic Emergency Medicine. He is also Associate Editor of Annals of Internal Medicine’s ACP Journal Club and the Journal of the American Geriatrics Society, and he serves on the American College of Emergency Physician’s (ACEP) Clinical Policy Committee. Dr. Carpenter also wrote the book on diagnostic testing and clinical decision rules. Reference: Musey et al. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. AEM July 2021 This is an extra special SGEM. It is a combo of an SGEM Xtra and an SGEMHOP. The Society of Academic Emergency Medicine (SAEM) has decided to publish its own clinical practice guidelines (CPGs). They are called Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE). This episode will review the GRACE-1 guideline looking at low-risk recurrent chest pain. Because this is a new initiative by SAEM, I interviewed Dr. Chris Carpenter about these new GRACE guidelines. Dr. Chris Carpenter Listen to the SGEM podcast to hear him answer five background questions about these new CPGs. Who came up with the idea of doing CPGs? Why do we need more guidelines? Walk us through the GRACE process? Why pick recurrent, low-risk chest pain to be the first CPG? What do you hope to achieve with these CPGs Guest Skeptic #2: Dr. Suneel Upadhye is an Associate Professor of Emergency Medicine & Clinical Epidemiology at McMaster University. He is a founding member of the Best Evidence in Emergency Medicine (BEEM) program. Suneel is also the inaugural Research Lead for the EM Researchers of Niagara, which is a novel community-based EM research group within Niagara region, Canada. He is also a Guidelines Methodologist within CAEP and the SAEM GRACE groups. Case: You are seeing a patient who has returned to the emergency department (ED) with recurrent chest pain. It is their fourth visit in the last twelve months.  He has had his chest pain for approximately three to four hours now and is not classic for ischemic symptomatology.  His initial high-sensitivity (hs) troponin is negative, and his ECG is unremarkable.  In reviewing his records, you note that he has undergone significant cardiac testing in the recent past, which was unremarkable. This included a normal exercise stress test and CCTA 18 months ago.  You also note that he has an underlying anxiety disorder, which is being treated and followed by his family physician.   Background: This new SAEM GRACE initiative is committed to using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system, GRADE was pioneered at McMaster University, in creating rigorous, transparent, and trustworthy guidelines on common clinical problems for emergency medicine (EM) physicians that are not always directly studied in EM research activities. The steering group/panelists explored many different potential questions, and voted on the top eight, that were then reviewed in systematic fashion; evidence was rated using GRADE methods, and then final recommendations were made using the GRADE Evidence-to-Decision framework (Upadhye et al CJEM 2021 and Courtney and Lang AEM 2021).  The Methods team sought initial GRADE training, then shared that learned expertise with the question groups, many of whom were relative novices in guideline methodology. After two years, a comprehensive document is being published that answers the key diagnostic dilemmas in recurrent chest pain patients who have had recent normal cardiac investigations,