Low-Risk Chest Pain Admissions: A Waste of Time?
Low-Risk Chest Pain Admissions: A Waste of Time?
Weinstock MB, Weingart S, Orth F, et al
JAMA Intern Med. 2015 May 18. [Epub ahead of print]
The term "low-risk chest pain" has for many years been considered one of the great oxymorons in the specialty of emergency medicine. Patients with this entity, although considered to be at low risk for acute coronary syndrome (ACS), nevertheless cause a great deal of stress to emergency care providers and have been considered "high risk" from a medical malpractice standpoint.
Providers have typically worried that these patients will experience myocardial infarction (MI) and sudden cardiac arrest (SCA) if discharged too quickly. In the United States, patients who are discharged from emergency departments after evaluation for low-risk chest pain and then go on to have MI or SCA account for a large percentage of malpractice dollars that are paid out to plaintiffs from our specialty.
Let's briefly discuss what traditional practice has been for patients with potential ischemic chest pain in recent years in the United States, and perhaps many other countries as well.
When a patient presents with symptoms that are concerning for ACS, an ECG is obtained. If the ECG clearly shows an injury or ischemic pattern, the patient is admitted to the hospital for an urgent workup and treatment. If the ECG is nondiagnostic, troponin levels are obtained. If the troponin levels are elevated, the patient is admitted for an urgent workup and treatment. In general, there's little dispute about what's been described so far.
In contrast, there is significant variability in how patients with a nonischemic ECG and normal troponin levels are managed. The current recommendation from the American Heart Association is that these patients should receive provocative testing to rule out ACS within 72 hours. A tremendous number of these patients are admitted to the hospital or placed in observation units while awaiting provocative tests, presumably for close monitoring for malignant dysrhythmias or development of MI.
This approach has contributed to hospital overcrowding and significant financial costs. It's unclear whether all of these routine admissions are associated with prevention of MIs or with lives saved. Anecdotally, we've had our doubts for many years, yet we continue admitting patients or observing them anyway, for fear of violating national recommendations and being wrong. Are we actually saving lives, or are we wasting resources?
Weinstock and colleagues sought to determine the short-term risk for adverse cardiac events (ACEs), including life-threatening dysrhythmias, MI, SCA, and death, in low-risk patients admitted to the hospital for presumed ACS.
Among three large Midwestern hospitals, they evaluated patients > 18 years of age presenting with chest pain between 2008 and 2013 who were admitted or placed in an observation unit for evaluation of ACS. "Low-risk" patients were defined by nonischemic ECGs, two negative serial troponin tests, and stable vital signs. Patients with unevaluable ECGs, pacemakers, and left bundle branch block were excluded.
The investigators were left with 7266 admissions, among which only four patients (0.06%) had adverse outcomes while in the hospital. On further evaluation, one of these patients died of gastrointestinal bleeding, leaving only three of 7266 cases of ACEs. This leaves an overall risk for an ACE of 1 in 2422 admissions.
The investigators discuss this risk in relation to the reported risk for adverse events during a routine hospitalization that contributes to a patient's death: 1 in 164. Stated in more simple terms, the risk that an adverse event will occur purely by virtue of being admitted to a hospital is 15 times higher than the short-term risk for an ACE after a negative workup in the emergency department. These low-risk patients appear to be safer at home than in the hospital.
This study adds to the mounting data in the past few years indicating that patients with potential ACS who undergo a negative workup in the emergency department probably do not need an urgent provocative test, or even admission.
Rather, these patients can be discharged home to receive further risk stratification and workups as outpatients. This practice appears to be safe, reasonable, and cost-effective, and it is often favored by patients. It will help to reserve inpatient beds for patients who are truly sick. Current national guidelines that have recommended expedited workups, at great cost to the healthcare system, must be changed on the basis of the best evidence that is now finally emerging.
Introduction
Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission
Weinstock MB, Weingart S, Orth F, et al
JAMA Intern Med. 2015 May 18. [Epub ahead of print]
The term "low-risk chest pain" has for many years been considered one of the great oxymorons in the specialty of emergency medicine. Patients with this entity, although considered to be at low risk for acute coronary syndrome (ACS), nevertheless cause a great deal of stress to emergency care providers and have been considered "high risk" from a medical malpractice standpoint.
Providers have typically worried that these patients will experience myocardial infarction (MI) and sudden cardiac arrest (SCA) if discharged too quickly. In the United States, patients who are discharged from emergency departments after evaluation for low-risk chest pain and then go on to have MI or SCA account for a large percentage of malpractice dollars that are paid out to plaintiffs from our specialty.
Let's briefly discuss what traditional practice has been for patients with potential ischemic chest pain in recent years in the United States, and perhaps many other countries as well.
When a patient presents with symptoms that are concerning for ACS, an ECG is obtained. If the ECG clearly shows an injury or ischemic pattern, the patient is admitted to the hospital for an urgent workup and treatment. If the ECG is nondiagnostic, troponin levels are obtained. If the troponin levels are elevated, the patient is admitted for an urgent workup and treatment. In general, there's little dispute about what's been described so far.
In contrast, there is significant variability in how patients with a nonischemic ECG and normal troponin levels are managed. The current recommendation from the American Heart Association is that these patients should receive provocative testing to rule out ACS within 72 hours. A tremendous number of these patients are admitted to the hospital or placed in observation units while awaiting provocative tests, presumably for close monitoring for malignant dysrhythmias or development of MI.
This approach has contributed to hospital overcrowding and significant financial costs. It's unclear whether all of these routine admissions are associated with prevention of MIs or with lives saved. Anecdotally, we've had our doubts for many years, yet we continue admitting patients or observing them anyway, for fear of violating national recommendations and being wrong. Are we actually saving lives, or are we wasting resources?
Weinstock and colleagues sought to determine the short-term risk for adverse cardiac events (ACEs), including life-threatening dysrhythmias, MI, SCA, and death, in low-risk patients admitted to the hospital for presumed ACS.
Among three large Midwestern hospitals, they evaluated patients > 18 years of age presenting with chest pain between 2008 and 2013 who were admitted or placed in an observation unit for evaluation of ACS. "Low-risk" patients were defined by nonischemic ECGs, two negative serial troponin tests, and stable vital signs. Patients with unevaluable ECGs, pacemakers, and left bundle branch block were excluded.
The investigators were left with 7266 admissions, among which only four patients (0.06%) had adverse outcomes while in the hospital. On further evaluation, one of these patients died of gastrointestinal bleeding, leaving only three of 7266 cases of ACEs. This leaves an overall risk for an ACE of 1 in 2422 admissions.
The investigators discuss this risk in relation to the reported risk for adverse events during a routine hospitalization that contributes to a patient's death: 1 in 164. Stated in more simple terms, the risk that an adverse event will occur purely by virtue of being admitted to a hospital is 15 times higher than the short-term risk for an ACE after a negative workup in the emergency department. These low-risk patients appear to be safer at home than in the hospital.
Viewpoint
This study adds to the mounting data in the past few years indicating that patients with potential ACS who undergo a negative workup in the emergency department probably do not need an urgent provocative test, or even admission.
Rather, these patients can be discharged home to receive further risk stratification and workups as outpatients. This practice appears to be safe, reasonable, and cost-effective, and it is often favored by patients. It will help to reserve inpatient beds for patients who are truly sick. Current national guidelines that have recommended expedited workups, at great cost to the healthcare system, must be changed on the basis of the best evidence that is now finally emerging.
