Triage of acute onset chest pain: now a biochemical rule-out test?

The management of coronary disease has moved forward with the application of more sensitive blood biomarkers for early detection alongside more structured symptom assessment, examination and serial ECG measures. However every episode of exertional chest pain isn’t symptomatic coronary disease and given massive public awareness campaigns we now face a different management issue with undiagnosed chest pain sent as a ‘rule-out’ activity. These urgent referrals are often justified based on the management of the minority with unstable coronary disease without preliminary medical review or examination. Avoiding delay which is valuable in coronary patients may be irrelevant to the majority. The overall effectiveness of this pathway is unclear where the patient does not have coronary disease but also where superficial interpretation can be misleading through non-specificity. Do biomarker assays become the answer to every chest pain patient and has the basic assessment of the individual patient and a prior probability of disease no role to play? Does this activity represent a burden or an irrelevant dead end for non-coronary patients? We have asked for comment from two leading authorities on the evolving role and application of cardiac biomarker technologies in managing this considerable and common clinical dilemma.