Chest pain syndromes are associated with high rates of recidivism and costs in young United States Veterans

Abstract

BackgroundRecurrent chest pain is common in patients with and without coronary artery disease. The prevalence and burden of these symptoms on healthcare is unknown.ObjectivesTo compare chest pain return visits (recidivism) in patients with unexplained chest pain (UCP) against reference group of patients with coronary artery disease (CAD) and estimate the annual cost of recurrent chest pain.MethodsIn a retrospective cohort study, a Veteran Affairs (VA) administrative and clinical database of Veterans who were deployed to or served in support of the wars in Iraq or Afghanistan was queried for first disease specific ICD-9 code to form two cohorts (UCP or CAD). Patients were followed between 09/2001-09/2010 for the first and cumulative return visits for UCP or cardiac pain (ACS or angina) to clinic, emergency department or admission; or for all-cause death. Time to return was analyzed using Cox regression and negative binomial models and adjusted for age, gender, race, marital status, and risk factors (hypertension, hyperlipidemia, diabetes, smoking and obesity). Direct total costs included inpatient, outpatient and fee basis (non-VA) costs.ResultsOf 749,036 patients, 20,521 had UCP and 5303 had CAD. UCP patients were young and had a lower burden of risk factors than CAD cohort (p < .01). Yet, these patients were likely to return earlier with any chest pain (adjusted Hazard Ratio [aHR] = 1.76; 95 % CI 1.65-1.88); or unexplained chest pain than CAD patients (aHR: 1.89; 95 % CI 1.77-2.01). UCP patients were also likely to return more frequently for any chest pain (aRate Ratio = 1.54; 95 % CI 1.43-1.64) or UCP than CAD patients (aRR =2.63; 95 % CI 2.43-2.87). Per 100 patients, the 1-year cumulative returns were 37 visits for reference group and 45 visits for UCP cohort. The annual costs for chest pain averaged $69,009 for CAD and $57,336 for UCP patients (log geometric mean ratio=1.25; 95 % CI 1.18-1.32).ConclusionChest pain recidivism is common and costly even in patients without known CAD. We need evidence-based guidelines for these patients to minimize returns.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0287-9) contains supplementary material, which is available to authorized users.

Prevalence and characteristics of coronary microvascular dysfunction among chest pain patients in the emergency department

“…First, our findings suggest that CMD could account for many cases of unexplained chest pain, which have been linked to recurrent symptoms, high rates of return visits and poor functional outcomes in both the ED and outpatient settings. 21,22 Similar to observed rates of CMD in higher-risk cohorts (21-63%), 6,23-25 we found a surprisingly high rate of CMD in low to moderate risk patients (42%). We also found that one third of patients with CMD reported prior episodes of chest pain, many of whom sought ED care but were discharged home with a diagnosis of unexplained chest pain.…”

Coronary Physiology in the Cardiac Catheterization Laboratory

“…Chest pain is one of the most common presenting complaints in outpatient visits and to the emergency department [47,48]. Of the patients who are referred for coronary angiography, with or without ischemia on non-invasive stress testing, 20–50% are found to have angiographically normal coronary arteries [3,49,50].…”

“…Of the patients who are referred for coronary angiography, with or without ischemia on non-invasive stress testing, 20–50% are found to have angiographically normal coronary arteries [3,49,50]. Despite the absence of epicardial coronary artery disease by angiography many patients suffer recurrent presentations for chest pain [48,50]. There is increasing awareness of pathologies beyond obstructive coronary stenosis that can cause myocardial ischemia, including diffuse epicardial coronary artery disease, occlusion of small secondary branches, microvascular disease, or low baseline resting flow [51,52].…”

Ranolazine and Microvascular Angina by PET in the Emergency Department: Results From a Pilot Randomized Controlled Trial

“…7 It is also associated with persistent chest pain, repeat health services utilization, and poor patient function, with disease-related costs that mount to $13 billion. [10][11][12] Thus, early diagnosis and optimal management of symptomatic CMD is critical.…”