In the early rule-out of myocardial infarction, outcomes may be improved by accounting for the patient’s out-of-hospital experience, improving reassurance communication, and discussing future goals for cardiovascular health, according to a study published in Annals of Emergency Medicine. 

In this qualitative study, 49 emergency department (ED) patients suspected to have acute coronary syndrome but for whom myocardial infarction was ruled out were enrolled. In this cohort, 23 and 26 patients were interviewed before and after an early rule-out pathway was implemented, respectively. Recruitment took place between 2015 and 2017. Prior to implementation on February 15, 2016, participants were admitted to a separate hospital unit for serial troponin testing to diagnose myocardial infarction. After rule-out pathway implementation, high-sensitivity troponin assays were conducted in the ED, and patients with normal troponin levels could be directly released from the ED.

Participants were given semistructured interviews to assess their experience approximately 1 week after discharge. This interpretive approach was used to identify themes in interview responses, which were compared with the literature. Results were only quantified when distinct differences were observed between care pathways.

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Participant interviews yielded 5 important themes, with certain themes varying between pathways. Themes common to both pathways were: 1- participants typically contacted the health service for advice before coming to the emergency department; 2- participants’ experience of personal illness differed from the objective assessment of troponin results; and 3- reassurance after negative test results may be improved by active listening, clinician trust, and proper timing of information.

Participants requiring hospital admission reported routine care procedures as a source of frustration. There was a discordance between how the patient perceived their cardiac episode and the objective interpretation of troponin levels by a clinician, and between objective assessment and patient cardiac health goals, with participants assessed with the earlier rule-out pathway less likely to consider their future health status.

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Study limitations include the enrollment of participants from a single center, potential selection bias, and the possibility that events occurring during the recovery period and previous illness may influence participants’ responses.  

“[E]arly rule-out pathways will undoubtedly be of major benefit to healthcare providers by decreasing unnecessary hospital admissions,” Noted the study researchers. “Avoiding hospitalization and having fewer health care professionals involved in the assessment process were also viewed positively by patients.”


Ferry AV, Strachan FE, Stewart SD, et al. Exploring patient experience of chest pain before and after implementation of an early rule-out pathway for myocardial infarction: a qualitative study [published online January 23, 2020]. Ann Emerg Med. doi: 10.1016/j.annemergmed.2019.11.012