GRACE
Recurrent, Low-risk Chest Pain: A User’s Guide SAEM PULSE | SEPTEMBER-OCTOBER 2021
By D. Mark Courtney, MD, MSc and Eddy Lang, MD
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The July 2021 issue of Academic Emergency Medicine (AEM) contains two articles (Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department and Navigating Uncertainty with GRACE) that are at the same time a culmination of a multiyear effort but also the first early steps of the journal and the Society for Academic Emergency Medicine (SAEM) leadership into the science of practice guideline creation and dissemination. It is anticipated that readers could raise three basic questions about this endeavor: (1) What is the rationale for this effort and how is it unique relative to what has been
done to date? (2) What can I take to the bedside regarding chest pain? and (3) What can we learn from this first effort — to provide evidence-based guidance for undifferentiated repeat chest pain — that might inform future guidelines on other topics?
What is the Rationale for this Effort?
Emergency physicians have a love–hate relationship with clinical practice guidelines. On one end of the spectrum, guidelines in cardiopulmonary resuscitation have been at the heart of our specialty's development guiding practice and training for nearly 30 years. These guidelines developed through the International Liaison
Committee on Resuscitation (ILCOR) and adopted by seven resuscitation councils around the world are widely implemented across emergency care and CPR education systems with each update eagerly awaited by millions of end-users. On the other end of the spectrum, guideline recommendations on thrombolytic therapy for acute stroke within a 3- to 4.5-hour window has raised the ire of many emergency physicians, resulted in deep examination and debate of source research studies, and resulted in iterative modification of initial recommendations. Moreover, guidelines may not result in practice change, as suggested by an analysis of syncope care, including neuroimaging
