Patient Without ECG Should Be Referred to the Emergency Room
Yes, a patient without an electrocardiogram (ECG) should be referred to the emergency room for evaluation if they present with chest pain or symptoms concerning for acute coronary syndrome. 1
Rationale for Emergency Room Referral
- According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guidelines, an ECG should be acquired and reviewed within 10 minutes of arrival for all patients presenting with acute chest pain, regardless of the setting 1
- If an ECG is unavailable in the office setting, the patient should be referred to the emergency department so one can be obtained 1, 2
- Patients with clinical evidence of acute coronary syndrome (ACS) or other life-threatening causes of chest pain seen in the office setting should be transported urgently to the ED, ideally by emergency medical services (EMS) 1
Importance of ECG in Chest Pain Evaluation
- The ECG is central to the evaluation of chest pain to ensure that ACS is not missed 1, 2
- Even a normal ECG does not rule out ACS - studies show that 1-4% of patients with normal ECGs still have acute myocardial infarction 3
- Patients with normal or nonspecific ECGs during symptoms have similar rates of adverse cardiovascular events as those without symptoms at the time of ECG acquisition 4
Risks of Delayed or Missed Diagnosis
- Delayed transfer to the hospital for determination of cardiac troponin or other diagnostic testing beyond the ECG in the office setting can be harmful and should be avoided 1
- Failure to hospitalize patients with ACS is associated with increased mortality 5
- Patients with a normal or nondiagnostic ECG have 3.3 times higher odds of being mistakenly discharged with ACS 5
Recommended Transport Method
- Transfer by EMS from the office setting is recommended because of important advantages including:
- Acquisition of a prehospital ECG, which can facilitate reperfusion if ST elevation is present
- Presence of trained personnel who can provide treatment for chest pain and arrhythmias
- Shorter travel time to the ED 1
Special Considerations
- Even young adults with chest pain require ECG evaluation - while they have lower overall risk, those without cardiac risk factors still have a small but significant risk of ACS 6
- The absence of ECG abnormalities during symptoms should not be relied upon to exclude ACS 4
- For patients with suspected pericarditis, an ECG is essential as part of the diagnostic criteria 7
Common Pitfalls to Avoid
- Attributing chest pain solely to non-cardiac causes without obtaining an ECG 2
- Relying on a single normal ECG to rule out ACS when clinical suspicion is high 2, 3
- Overreliance on a normal or nonspecifically abnormal ECG in a patient with a classic description of anginal chest pain is dangerous 3
In conclusion, if a patient presents with chest pain and an ECG cannot be obtained in the current setting, prompt referral to the emergency department is necessary to ensure proper evaluation and to avoid potentially life-threatening delays in diagnosis and treatment.