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Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial

BMJ 2016; 355 doi: (Published 05 December 2016) Cite this as: BMJ 2016;355:i6165

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Is low risk chest pain equivalent to a low risk patient with chest pain?

Dear Editor,
I read with interest the article. An attempt to solve this common dilemma is praiseworthy. However, the low risk chest pain and the chest pain in a low-risk patient is qute different. To clarify, a true vignette: a 32- year old Bangaladeshi male manual labour patient presents to emergency department with burning in epigastrium for last 36 hours. He has no identifiable major coronary risk factor. He came to emergency as he finds it difficulty to work effectively, even though he can work slowly . His ECG and hs- troponin I (two sets 3-hour apart) are non-contributory. As per the criteria used in the study he has low-risk symptom. He was discharged from emergency, only to be readmitted in another hospital, following a out-of-hospital (resucitated) cardiac arrest at workplace.
While evaluating chest pain, it should be mentioned pain/discomfort from jaw- to- umbilicus, located both anteriorly, posteriorly and on either side (not only anterior chest pain, as commonly perceive) and not only characteristics of pain (typical/atypical/non-anginal) along with ECG and cardaic enzyme are taken into account, but overll assessment of the patient background, race, eductional status, accessibility to the nearest heathcare services, and coverage with medical insurance schemes are to be figured into decision making/conveying to the patient to impart comprehensive heathcare.
We have encountered enough blunders based on conventional decision making in our patients: a lesson worth memorizing.

Competing interests: No competing interests

24 December 2016
Rajeev Gupta
Consultant Cardiologist
Al Noor-Al Jowhara-Medicilinc hospital, Al Ain, UAE
Al Noor-Al Jowhara-Medicilinc hospital, Al Ain, UAE