Routine Admission Not Beneficial for Many Chest Pain Patients

Diana Phillips

May 20, 2015

Patients with chest pain and negative findings on emergency department evaluation have a less than 1% short-term risk for adverse cardiac events, according to a multicenter study. The low incidence of clinically relevant events suggests routine inpatient admission may not be beneficial for many patients who present to the emergency department (ED) with chest pain, investigators conclude in an article published online May 18 in JAMA Internal Medicine.

Michael B. Weinstock, MD, from the Department of Emergency Medicine, Wexner Medical Center, Ohio State University, Columbus, and colleagues examined a prospectively collected database from three hospitals in the Midwest to determine the incidence of short-term, adverse cardiac outcomes among patients with chest pain admitted to the hospital after ED evaluation showed negative serial biomarkers, nonconcerning vitals, and nonischemic electrocardiographic findings.

Overall, 11,230 patient encounters between July 1, 2008, and June 30, 2013, met the criteria for inclusion in the study, including two troponin-negative test results, with the second test performed 60 to 420 minutes from the initial test. Of those, the investigators identified 20 cases that met their primary endpoint of life-threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest, or death during hospitalization (0.18%; 95% confidence interval [CI], 0.11%-0.27%). Specifically, there were six cases of life-threatening arrhythmia, five inpatient ST-segment elevation myocardial infarctions, four cardiac arrests, one respiratory arrest, and nine deaths.

On closer examination of the records, the investigators excluded 16 patients because they were unlikely to be sent home from the ED because of abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm.

Of the remaining four cases, two were ultimately deemed to be noncardiac, two of which were possibly iatrogenic disease (periprocedural myocardial infarction and ST-segment elevation myocardial infarctions during a stress test), translated to a primary outcome event percentage of 0.06% (95% CI, 0.02% - 0.14%), the authors observe.

"Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits in low-risk patients," the authors write. Further, the risk for a clinical relevant cardiac adverse event in this cohort after a negative result of ED evaluation, "using the most conservative estimate," was 1 in 1817, they note, "suggesting this rate to be a maximum potential rate of clinical benefit from hospitalization."

The authors stress that the rare occurrence of adverse cardiac events in this study "does not demonstrate that patients derive no utility from further management or diagnostic workup after the ED evaluation." Rather, "our findings suggest that further evaluation may be best performed in the outpatient rather than the inpatient setting, and that this information should be integrated into shared decision-making discussions regarding potential admission," they write. "Moreover, in the context of established risks due to hospitalization, we believe that current recommendations to admit, observe or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered."

Dr Weinstock receives royalties for the books Bouncebacks!, Bouncebacks! Medical and Legal, and Bouncebacks! Pediatrics. One coauthor has served as a speaker and on the advisory board for Astra Zeneca. Another coauthor is the chief clinical advisor and serves on the clinical advisory board for Callibra, Inc. The other authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online May 18, 2015. Abstract

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