Adverse Cardiac Events in Emergency Department Patients with Chest Pain Six Months after a Negative Inpatient Evaluation for Acute Coronary Syndrome

Abstract

Objective: To evaluate the impact of the diagnostic test setting-inpatient versus outpatient-on adverse cardiac events (ACEs) after six months in emergency department (ED) patients with chest pain who were admitted to the hospital and subsequently had a negative evaluation for acute coronary syndrome (ACS). Methods: The authors retrospectively studied a consecutive sample of ED patients with chest pain over a nine-month period. All patients were admitted to the hospital and underwent negative evaluations for ACS, defined as the absence of diagnostic changes on serial electrocardiograms or cardiac markers (creatine kinase-MB and troponin T), and a negative diagnostic cardiac study. Subjects were classified according to cardiac diagnostic study setting-either inpatient or outpatient. Diagnostic testing included exercise treadmill, angiography, stress echocardiography, or stress thallium scans. Acute cardiac events at six months were defined as cardiac death, myocardial infarction, unstable angina, cardiac arrest, or emergent revascularization. Results: The six-month rate of ACEs among 157 subjects was 14%, with 2% cardiac mortality. The outpatient group had higher ACE risk when compared with the inpatient group using multivariate logistic regression, both for the entire cohort (OR 3.5, p < 0.03) and for a subgroup excluding patients with prior coronary artery disease (OR 6.7, p < 0.05). The outpatient group included 19 of 52 (37%) noncompliant subjects who did not receive a diagnostic study. Conclusions: Long-term cardiac morbidity of patients after a negative ACS evaluation may be higher than previously thought. Risk of ACE is significantly higher in subjects scheduled for outpatient diagnostic tests. Inpatient diagnostic testing is justified for subjects at risk for poor compliance. Key words: chest pain; emergency department; coronary disease; myocardial infarction; angina; long-term prognosis. ACADEMIC EMERGENCY MEDICINE 2002; 9: 896-902. In the United States, approximately five million people annually undergo evaluation in the emergency department (ED) for acute chest pain, at a cost of more than $5 billion. 1 In a study of more than 10,000 patients who presented to the ED with acute chest pain, a group with less than 1% probability of major complications could be identified

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“…Perhaps surprisingly, the women also had a higher death rate, but from non-cardiac causes. Of interest is the fact that her outcomes were in keeping with those previously reported [8], even where patients had a negative in-patient workup for chest pain [9], but worse.…”

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“…We assessed study quality numerically (1)(2)(3)(4)(5), using a modified Jadad scale for treatment studies (7 ) ( Table 1). This proposed quality score is a nonstandardized score defined for the purposes of this study because no validated quality score exists for the review of diagnostic studies.…”

Risk and chest pain evaluation: inseparable?

“…Manini et al evaluated the impact of the diagnostic test setting (inpatient vs. outpatient) on adverse cardiac events at 6 months in patients who were admitted to the hospital and had negative initial evaluations for acute coronary syndrome. They concluded that the risk of adverse cardiac events was significantly higher in patients scheduled for outpatient diagnostic testing (13).…”