Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission

Abstract

IMPORTANCE Patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the emergency department (ED) owing to concern about adverse events. Previous studies have looked at 30-day mortality, but no current large studies have examined the most important information regarding ED disposition: the short-term risk for a clinically relevant adverse cardiac event (including inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death). OBJECTIVE To determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with 2 troponin-negative findings, nonconcerning initial ED vital signs, and nonischemic, interpretable electrocardiographic findings. DESIGN, SETTING, AND PARTICIPANTS We conducted a blinded data review of 45 416 encounters obtained from a prospectively collected database enrolling adult patients admitted or observed with the following inclusion criteria: (1) primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure and (2) negative findings for serial biomarkers. Data were collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs of 3 community teaching institutions with an aggregate census of more than 1 million visits. We analyzed data extracted by hypothesis-blinded abstractors. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization. RESULTS Of the 45 416 encounters, 11 230 met criteria for inclusion. Mean patient age was 58.0 years. Of the 11 230 encounters, 44.83% of patients arrived by ambulance and 55.00% of patients were women. Relevant history included hypertension in 46.00%, diabetes mellitus in 19.72%, and myocardial infarction in 13.16%. The primary end point occurred in 20 of the 11 230 patients (0.18% [95% CI, 0.11%-0.27%]). After excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, we identified a primary end point event in 4 of 7266 patients (0.06% [95% CI, 0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly iatrogenic. CONCLUSIONS AND RELEVANCE In adult patients with chest pain admitted with 2 negative findings for serial biomarkers, nonconcerning vital signs, and nonischemic electrocardiographic findings, short-term clinically relevant adverse cardiac events were rare and commonly iatrogenic, suggesting that routine inpatient admission may not be a beneficial strategy for this group.

Provocative testing for low-risk chest pain patients, must we continue?

“…While a historical miss rate of 2% to 4% is commonly quoted, more recent data suggest that current diagnostic strategies reduce this miss rate below 1%. [3][4][5] While this reduction in missed MIs is desirable, it comes at the cost of increased rates of hospital admissions for chest pain ''rule outs'' and additional diagnostic tests, accruing more than $3 billion in annual hospital costs in the US and subjecting many patients to testing that may not be necessary. 6,7 A subset of patients with ''low-risk'' or ''moderaterisk'' chest pain, as determined by risk assessment tools or physician clinical judgment, are often admitted to hospital observation units and subjected to additional non-invasive cardiac testing, such as a stress test or coronary computed tomographic angiogram (CCTA).…”

Physician Variability in Management of Emergency Department Patients with Chest Pain

“…We included physicians with a minimum of 30 patient encounters for chest pain and stratified physicians by age, gender, years since finishing medical school, and residency location (our institution versus other institutions). Since most of this study predates more recent literature on accelerated diagnostic pathways like the HEART score and the 2015 data on the short-term safety of patients with normal ECGs and two normal troponins, decisions in this study were made by individual discretion and not based on a particular accelerated diagnostic pathway 23,24,29…”

“…In addition, modern-generation troponins (generally with 99th percentile of the upper reference limit in a healthy population of < 0.01 μg/L, even without considering high-sensitivity troponins not yet in use in the U.S.) can reliably exclude acute coronary syndrome (ACS)when done in serial testing without additional risk stratification. 27–29 On the other hand, one recent study of Medicare patients found an association between more conservative practice (higher admission rates) and lower incidence of acute myocardial infarction (MI) and death for this patient population. 30…”

Improving care for patients with non-cardiac chest pain : Description of psychological distress and costs, and evaluation of an Internet-delivered intervention

“…Clinically relevant adverse cardiac events are rare in patients with NCCP and, therefore, they should not be admitted to hospital (140). However, patients are involved in timeconsuming and expensive assessments at the emergency departments or hospitalized and treated within cardiac units, even though the pain is not caused by a cardiac disease.…”