Please select the eligibility criteria that correspond to the clinical trial below.
Title: Randomized Investigation of Chest Pain Diagnostic Strategies
Brief Summary: Clinical decision units (CDUs) improve resource utilization and are a recommended care option by the American College of Cardiology / American Heart Association, but are underutilized in non-low risk chest pain patients due to weaknesses of traditional cardiac testing. Cardiac magnetic resonance imaging (CMR) is sensitive and specific for ischemia, can simultaneously assess cardiac function and myocardial perfusion, and could revolutionize the diagnostic process for intermediate risk patients with chest pain. The primary objective of this trial is to measure the efficiency and safety of a combined CDU-CMR care pathway compared to inpatient care among patients with non-low risk acute chest pain.


Options:
A: Inclusion Criteria:

* Age greater than or equal to 18 years
* Chest discomfort or other symptoms consistent with possible ACS
* TIMI risk score ≥ 1 or physician impression\* of intermediate or high likelihood symptoms represent ACS
* Patient requires an inpatient or observation unit evaluation for their chest pain
* The treating physician feels the patient could be discharged home if cardiac disease was excluded
* ED attending feels patient is safe for observation unit care\*\*

Exclusion Criteria:

* Initial troponin I \> 1.0 ng/ml
* New ST-segment elevation (≥1mV) or depression (≥2 mV)
* Contra-indications to MRI (listed below)
* Unable to lie flat
* Hypotension (systolic \< 90 mm Hg)
* Renal insufficiency (estimated GFR \< 45 cc/min) or end stage renal disease
* Life expectancy less than 3 months
* Patient refusal of medical record review and follow-up at 30 days
* Pregnancy
* Liver, heart, or kidney transplant
* Chronic liver disease
* Unable to speak English or Spanish
* The ED attending feels that cardiac catheterization is indicated
* The ED care provider intends to order a CT coronary angiogram

(\*)Physicians are encouraged to use the 2007 ACC/AHA guidelines for the management of patients with NSTE ACS as a framework for this assessment.(1)

(\*\*)These patients should generally not be considered for observation unit care: PCI / CAGB in past 6 months, multiple stents, multiple prior MIs

Contraindications to MRI: (Pacemaker, defibrillator, cerebral aneurysm clips, metallic ocular foreign body, implanted devices, claustrophobia)
B: Inclusion Criteria:

* Age greater than or equal to 18 years of age at the time of enrollment
* Chest discomfort or other symptoms consistent with possible Acute Coronary Syndrome (ACS) as indicated by the treating physician after obtaining an Electrocardiogram (ECG) and cardiac biomarkers for the patient's evaluation
* Patient requires an inpatient evaluation for their chest pain
* The treating physician feels the patient could be discharged home if cardiac disease was excluded
* Thrombolysis in Myocardial Infarction (TIMI) risk score ≥ 2 OR physician clinical impression of intermediate or high likelihood that the symptoms represent ACS
* Negative pregnancy test (if sexually active, female, and of childbearing age)

Exclusion Criteria:

* Initial troponin I \> 1.0 ng/ml
* New ST-segment elevation on any electrocardiogram (≥ 1 mV)
* New ST-segment depression on any electrocardiogram (≥ 2 mV)
* Unable to lie flat
* Hypotension (systolic \< 90 mm Hg)
* Contra-indications to MRI(Pacemaker, defibrillator, cerebral aneurysm clips, metallic ocular foreign body, implanted devices, claustrophobia)
* Patient refusal of medical record review and telephone follow-up at 30 days
* Terminal diagnosis with life expectancy less than 3 months
* Pregnancy per patient report or positive pregnancy test (Center for Medicare \& Medicaid Services (CMS) exclusion criteria)
* Renal insufficiency(done prior to enrollment)or end stage renal disease
* Chronic liver disease (ex. hepatitis, cirrhosis)
* History of liver, heart, or kidney transplant
C: Inclusion Criteria:

* Age greater than or equal to 21 years
* Chest discomfort or other symptoms consistent with possible ACS
* The treating physician feels the patient could be discharged home if cardiac disease was excluded

Exclusion Criteria:

* New ST-segment elevation in contiguous leads on any electrocardiogram (\>/= 1 mV)
* Unstable vitals signs: symptomatic hypotension at the time of enrollment (systolic \< 90 mm Hg), tachycardia (HR\>120), bradycardia (HR\<40), and hypoxemia (\<90% pulse-oximetry on room air or normal home oxygen flow rate)
* Terminal diagnosis with life expectancy less than 1 year
* A non-cardiac medical, surgical, or psychiatric illness determined by the provider to require admission, increase risk of objective cardiac testing, or prevent immediate discharge following negative testing.
* Prior enrollment
* Incapacity or unwillingness to provide consent and comply with study procedures
* Non-English speaking

Sub-study I \& II

Inclusion Criteria:

* ED attending physicians

Exclusion Criteria:

* ED attending physicians who decline to participate
D: Inclusion Criteria:

* Age greater than or equal to 21 years of age at the time of enrollment
* Chest discomfort or other symptoms consistent with possible ACS as indicated by the treating physician after obtaining an ECG and cardiac biomarkers for the patient's evaluation
* Thrombolysis in myocardial infarction (TIMI) risk score \>/= 2 or physician impression of intermediate or high likelihood symptoms represent ACS
* Patient requires an inpatient or CDU evaluation for their chest pain
* The treating physician feels the patient could be discharged home if cardiac disease was excluded
* The treating physician feels the patient is safe for CDU care

Pretest probability assessment The assessment of intermediate risk for developing ACS will be based on a TIMI risk score \>/= 2 and / or a board certified / board eligible emergency physician clinical impression of intermediate or high likelihood that the symptoms represent ACS. Physicians are encouraged to use the 2007 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines as a framework for this assessment.

Exclusion Criteria:

* Elevated cardiac biomarkers
* New ST-segment elevation on any electrocardiogram (\>/= 1 mV)
* New ST-segment depression on any electrocardiogram (\>/= 2 mV)
* Known inducible cardiac ischemia without subsequent revascularization
* Unable to lie flat
* Symptomatic hypotension at the time of enrollment (systolic \< 90 mm Hg)
* Contra-indications to MRI (examples: Pacemaker, defibrillator, cerebral aneurysm clips, metallic ocular foreign body, implanted devices, severe claustrophobia)
* Patient refusal or inability to comply with medical record review and follow up
* Terminal diagnosis with life expectancy less than 3 months
* Currently Pregnant
* Creatinine clearance \< 45 ml/min at the time of enrollment or clinical concern for acute kidney injury
* Chronic liver disease with a creatinine clearance of \<60 ml/min at the time of enrollment
* Hepato-renal syndrome
* History of liver, heart, or kidney transplant
* Confirmed angioplasty, stent placement, or coronary artery bypass grafting (CABG) within the last 6 months

Answer: D