Does Hospital Admission/Observation for Chest Pain Improve Patient Outcomes after Emergency Department Evaluation for Suspected Acute Coronary Syndrome?

Introduction: Evaluation for suspected acute coronary syndrome (ACS) results in millions of emergency department (ED) visits annually, and accounts for billions in health care costs. Understanding the benefits of hospitalization among patients who ruled out for an acute myocardial infarction (AMI) will inform physician decision making and future health care policies. Hypothesis: Hospital admission does not improve 30-day patient outcomes (death/AMI) compared to those discharged after ED evaluation for suspected ACS. Methods: We compared the effectiveness of hospitalization vs outpatient follow-up for a cohort of patients with chest pain presenting to one of 13 EDs within the Kaiser Permanente Southern California region between January 1, 2015 and December 1, 2017. The primary outcome was AMI or all-cause mortality, and secondary outcomes included revascularization and a composite MACE outcome within 30-days of ED visit. Adjusting for patient age, gender, race, ACS risk factors and chronic co-morbidities an instrumental variable (IV) analysis was used to evaluate the effect of hospitalization on patient outcomes Results: Of 77,562 chest pain patient encounters not identified as an AMI during the ED encounter, 322 (0.4%) went on to have an AMI (n=193, 0.2%) or died (n=137, 0.2%) within 30-days of ED visit (1.5% admitted vs 0.2% discharged). This included 200 (0.3%) patients who underwent coronary revascularization (0.7% admitted vs 0.2% discharged). IV analysis found no adjusted differences in 30-day patient outcomes between the hospitalized cohort and those discharged (risk reduction 0.002, 95% CI -0.002 to 0.007). Similarly, there were no differences in coronary revascularization (risk reduction 0.003, 95% CI -0.002 to 0.007). Conclusions: Among ED patients with chest pain who are not identified with an AMI, there does not appear to be a benefit in 30-day outcomes for patients who are hospitalized compared to those discharged with outpatient follow-up.

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Novel Cardiac Biomarkers for Emergency Department Evaluation of Acute Coronary Syndrome: The Recent Evidence on Non-troponin Biomarkers and Their Limitations

Current Emergency and Hospital Medicine Reports ◽

10.1007/s40138-016-0104-3 ◽

2016 ◽

Vol 4 (3) ◽

pp. 99-106 ◽

Cited By ~ 1

Author(s):

Taylor R. Spencer ◽

Mandeep S. Sidhu ◽

Jonathan Bisaillon ◽

C. Christopher King

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Cardiac Biomarkers ◽

Coronary Syndrome ◽

Department Evaluation

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Association of Early Stress Testing with Outcomes for Emergency Department Evaluation of Suspected Acute Coronary Syndrome

Critical Pathways in Cardiology ◽

10.1097/hpc.0000000000000068 ◽

2016 ◽

Vol 15 (2) ◽

pp. 60-68 ◽

Cited By ~ 4

Author(s):

Benjamin C. Sun ◽

Amber Laurie ◽

Rongwei Fu ◽

Maros Ferencik ◽

Michael Shapiro ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Stress Testing ◽

Coronary Syndrome ◽

Early Stress ◽

Department Evaluation

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Abstract 12162: Association of Symptom Clusters With Mode of Transportation to Emergency Department in Patients Diagnosed With Acute Coronary Syndrome

Circulation ◽

10.1161/circ.132.suppl_3.12162 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Leslie L Davis ◽

Thomas P McCoy ◽

Barbara Riegel ◽

Sharon McKinley ◽

Lynn Doering ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Delay Time ◽

Symptom Clusters ◽

Prehospital Delay ◽

Coronary Syndrome ◽

Stress Symptoms ◽

Mode Of Transportation

Background: Prompt treatment of acute coronary syndrome (ACS) has been shown to reduce mortality and morbidity; yet many patients delay seeking care. In order to receive timely care, symptoms of ACS need to be recognized, interpreted, and acted upon. Patients who experience symptoms matching their expectations and those with correct symptom attribution are more likely to use emergency medical services (EMS) as a means of transportation to the hospital. The connection between symptom type and EMS use has not been fully explored. Purpose: To assess if clusters of presenting symptoms are associated with EMS transportation to the emergency department (ED) in patients with ACS and to evaluate if EMS transportation or symptom clusters are associated with prehospital delay time. Methods: A secondary analysis was conducted from the PROMOTION trial, a randomized controlled trial to reduce patient prehospital delay in ACS. Results: Of the 3,522 subjects with coronary artery disease enrolled, 3,087 completed 2-year follow-up. Of these, 331 subjects visited an ED for ACS symptoms during follow-up. Among the 331, 84% (278) had mode of transportation documented; 44% arrived by EMS. Having classic ACS symptoms (chest pain, pressure, or discomfort) in combination with pain symptoms (AOR=2.66, p = 0.011), classic ACS symptoms in combination with stress symptoms (AOR=2.61, p = 0.007) or classic ACS symptoms in combination with both pain and stress symptoms (AOR=3.90, p = 0.012) were associated with higher odds of arriving to the ED by EMS compared to classic ACS symptoms alone. Among 260 patients with prehospital delay time available, arriving by EMS decreased median delay time by 68.5 minutes compared to those with other transportation, after accounting for symptom clusters, patient and study characteristics (p = 0.002). Symptom clusters did not predict delay time in adjusted modeling (p = 0.952). Conclusion: While chest pain was the most prevalent symptom of ACS for most (85%), these findings suggest that it is the cluster of classic ACS symptoms with other types of symptom that motivate patients to use EMS. With less than half of patients using EMS, further research is needed to better understand how symptom clusters influence care-seeking behavior.

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Predictors of myocardial damage prior to hospital admission among patients with acute chest pain or other symptoms raising a suspicion of acute coronary syndrome

Coronary Artery Disease ◽

10.1097/01.mca.0000063503.13456.0d ◽

2003 ◽

Vol 14 (3) ◽

pp. 225-231 ◽

Cited By ~ 12

Author(s):

Leif Svensson ◽

Leif Isson ◽

Christer Axelsson ◽

Rolf Nordlander ◽

Johan Herlitz

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Hospital Admission ◽

Acute Chest Pain ◽

Myocardial Damage ◽

Coronary Syndrome

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Development of a Clinical Prediction Rule for 30-Day Cardiac Events in Emergency Department Patients With Chest Pain and Possible Acute Coronary Syndrome

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2011.07.026 ◽

2012 ◽

Vol 59 (2) ◽

pp. 115-125.e1 ◽

Cited By ~ 89

Author(s):

Erik P. Hess ◽

Robert J. Brison ◽

Jeffrey J. Perry ◽

Lisa A. Calder ◽

Venkatesh Thiruganasambandamoorthy ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Prediction Rule ◽

Clinical Prediction Rule ◽

Clinical Prediction ◽

Cardiac Events ◽

Coronary Syndrome ◽

Emergency Department Patients

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Frequency of acute coronary syndrome in patients presenting to the Emergency Department with chest pain after methamphetamine use

Journal of Emergency Medicine ◽

10.1016/s0736-4679(03)00031-3 ◽

2003 ◽

Vol 24 (4) ◽

pp. 369-373 ◽

Cited By ~ 106

Author(s):

Samuel D Turnipseed ◽

John R Richards ◽

J.Douglas Kirk ◽

Deborah B Diercks ◽

Ezra A Amsterdam

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Methamphetamine Use ◽

Coronary Syndrome

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Novel Emergency Department Risk Score Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease

Critical Pathways in Cardiology ◽

10.1097/hpc.0000000000000091 ◽

2016 ◽

Vol 15 (4) ◽

pp. 138-144 ◽

Cited By ~ 1

Author(s):

Matthew T. Crim ◽

Scott A. Berkowitz ◽

Mustapha Saheed ◽

Jason Miller ◽

Amy Deutschendorf ◽

...

Keyword(s):

Coronary Artery Disease ◽

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Coronary Artery ◽

Risk Score ◽

Coronary Syndrome ◽

Artery Disease ◽

Pain Patients

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External validation of an emergency department triage algorithm for chest pain patients

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620903452 ◽

2020 ◽

Vol 9 (6) ◽

pp. 576-585

Author(s):

Òscar Miró ◽

Pedro Lopez-Ayala ◽

Gemma Martínez-Nadal ◽

Valentina Troester ◽

Ivo Strebel ◽

...

Keyword(s):

Emergency Department ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Low Risk ◽

Single Centre ◽

Coronary Syndrome ◽

Emergency Department Triage ◽

Model C ◽

Triage Algorithm ◽

Pain Patients

Background We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation. Methods In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards ‘low-risk’ required absence of all five clinical ‘high-risk’ variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C). Results The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively. Conclusion A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

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