Low-risk Chest Pain Research Articles

Abstract 173: Reducing the Burden of Low Risk Chest Pain Admissions; Role of the Expedited Outpatient Stress Testing Quality Improvement Initiative

Background: Chest pain is a frequent cause for emergency department (ED) presentation and is associated with significant costs. A pathway for expedited outpatient stress testing and follow-up for low risk chest pain patients in the ED was established in our institution. We present patients’ demographics and evaluate the efficacy, safety and overall performance of this quality improvement (QI) initiative. Methods: All patients referred to the program were retrospectively identified from the first year of experience. Rates of MACE and readmissions were determined at both 30 and 60 days of follow-up. Average time to testing and clinic assessment were measured. Rates of Cardiology consultations and admissions for chest pain were determined before and after program implementation. Results and discussion: A total of 425 patients were identified who were referred to the program. Forty patients were excluded from analysis as they failed to attend or declined testing, were inappropriately referred, or were lost to follow-up. Patient characteristics, outcome data, and adverse events are shown in table 1. A rate of over 75% stress testing within 5 days of ED visit and 68% of clinic visit within 6 weeks of a positive test was observed. Trends towards a reduction in admissions and consultations occurred in the year following program implementation(Figure 1). Conclusion: This local program for rapid out-patient testing for low risk chest pain patients in the ED is feasible, safe, and effective. Lack of patient adherence to follow-up is a concern with this out-patient approach. Improving time to stress testing and clinic waiting times have been identified as institutional priorities on the basis of this QI project.

Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain.

BackgroundApproximately 80% of patients presenting to emergency departments (ED) with chest pain do not have any true cardiopulmonary emergency such as acute coronary syndrome (ACS). However, psychological contributors such as anxiety are thought to be present in up to 58%, but often remain undiagnosed leading to chronic chest pain and ED recidivism.MethodsTo evaluate ED provider beliefs and their usual practices regarding the approach and disposition of patients with low risk chest pain associated with anxiety, we constructed a 22-item survey using a modified Delphi technique. The survey was administered to a convenience sample of ED providers attending the 2016 American College of Emergency Physicians Scientific Assembly in Las Vegas.ResultsSurveys were completed by 409 emergency medicine providers from 46 states and 7 countries with a wide range of years of experience and primary practice environment (academic versus community centers). Respondents estimated that 30% of patients presenting to the ED with chest pain thought to be low risk for ACS have anxiety or panic as the primary cause but they directly communicate this belief to only 42% of these patients and provide discharge instructions to 48%. Only 39% of respondents reported adequate hospital resources to ensure follow-up. Community-based providers reported more adequate follow-up for these patients than their academic center colleagues (46% vs. 34%; p = 0.015). Most providers (82%) indicated that they wanted to have referral resources available to a specific clinic for further outpatient evaluation.ConclusionEmergency Department providers believe approximately 30% of patients seeking emergency care for chest pain at low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety. This highlights an opportunity for patient centered communication.

A MIXED METHODS STUDY OF AN ENHANCED DECISION AID FOR EMERGENCY DEPARTMENT PATIENTS WITH LOW-RISK CHEST PAIN

Cardiac stress testing is often recommended for patients presenting to the ED with low-risk chest pain. We used an explanatory mixed-methods design to assess correlation between real-life ED patients' intent to undergo cardiac stress testing and their general preference for medical care after

Implementation of an Early Discharge Protocol and Chest Pain Clinic for Low-Risk Chest Pain in the Emergency Department.

Most of the patients presenting to emergency department with chest pain are at low risk of adverse events. Identifying high-risk patients can be challenging and resource intensive. We created a protocol to assist early discharge of low-risk adults with chest pain from emergency department. Also a chest pain clinic (CPC) was started for cardiology follow-up within 72 hours. In a retrospective cohort study, primary outcome of major adverse cardiac events (MACEs) of death, myocardial infarction, or revascularization was compared between CPC patients and those hospitalized for observation. In addition, rate of observation admissions and MACE were compared in the pre- and postintervention periods using piecewise regression and multiple logistic regression, respectively. A total of 1422 patients were admitted for observation, and 290 were seen in CPC in the 1-year postintervention period. Thirty-day MACE was very low (0.7% in observation and 0.3% in CPC) postintervention. A total of 3637 patients were admitted for observation over the 2-year preintervention period. Thirty-day-adjusted MACE rate was not significantly different between pre- and postintervention periods (0.4% vs. 0.6%, P = 0.3), also monthly observation admissions did not change significantly; however, utilization of stress testing (57.2% vs. 41.0%, P < 0.001) and cardiac catheterization (2.3% vs. 1.6%, P = 0.036) was reduced. Chest pain patients admitted for observation and risk stratification are at very low risk of 30-day MACE. An intervention based on a chest pain protocol and availability of early cardiology follow-up did not change the admission rate of these patients. This intervention was not associated with increased risk of adverse outcomes.

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study

BackgroundChest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. ObjectiveTo compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). MethodsWe conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. ResultsThe admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7–68.2%), vs. 48.3% (95% CI 43.7–53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7–21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33–0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. ConclusionsThe HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.

Fostering Choice Awareness for Shared Decision Making: A Secondary Analysis of Video-Recorded Clinical Encounters.

ObjectiveTo assess the extent to which (1) clinicians, using or not using conversation aids, foster choice awareness during clinical encounters and (2) fostering choice awareness, with or without conversation aids, is associated with greater patient involvement in shared decision making (SDM).Patients and MethodsWe randomly selected 100 video-recorded encounters, stratified by topic and study arm, from a database of 10 clinical trials of SDM interventions in 7 clinical contexts: low-risk acute chest pain, stable angina, diabetes, depression, osteoporosis, and Graves disease. Reviewers, unaware of our hypothesis, coded recordings with the OPTION-12 scale to quantify the extent to which clinicians involved patients in decision making (SDM, 0-100 score). Blinded to OPTION-12 scale scores, we used a self-developed coding scale to code whether and how choice awareness was fostered.ResultsClinicians fostered choice awareness in 53 of 100 encounters. Fostering choice awareness was associated with a higher OPTION-12 scale score (adjusted [for using vs not using a conversation aid] predicted mean difference, 20; 95% CI, 11-29). Using a conversation aid was associated with a higher, nonsignificant chance of fostering choice awareness (N=31 of 50 [62%] vs N=22 of 50 [44%]; adjusted [for trial] P=.34) and with a higher OPTION-12 scale score, although adjusting for fostering choice awareness mitigated this effect (adjusted predicted mean difference 5.8; 95% CI, −1.3-12.8).ConclusionFostering choice awareness is linked to a better execution of other SDM steps, such as informing patients or discussing preferences, even when SDM tools are not available or not used.

Are Geriatric Patients Placed in an Emergency Department Observation Unit on a Chest Pain Pathway More Likely Than Non-Geriatric Patients to Re-Present to the Hospital within 30 Days?

BackgroundEmergency department observation units (EDOUs) are used frequently for low-risk chest pain evaluations. ObjectiveThe purpose of this study was to determine whether geriatric compared to non-geriatric patients evaluated in an EDOU for chest pain have differences in unscheduled 30-day re-presentation, length of stay (LOS), and use of stress testing. MethodsWe conducted an exploratory, retrospective, cohort study at a single academic, urban ED of all adult patients placed in an EDOU chest pain protocol from June 1, 2014 to May 31, 2015. Our primary outcome was any unscheduled return visits within 30 days of discharge from the EDOU. Secondary outcomes included EDOU LOS and stress testing. We used Wilcoxon non-parametric and χ2 tests to compare geriatric to non-geriatric patients. ResultsThere were 959 unique EDOU placements of geriatric (n = 219) and non-geriatric (n = 740) patients. Geriatric compared to non-geriatric patients had: no significant difference in unscheduled 30-day return visits after discharge from the EDOU (15.5% vs. 18.5%; p = 0.31); significantly longer median EDOU LOS (22.1 vs. 20.6 h; p < 0.01) with a greater percentage staying longer than 24 h (42% vs. 29.1%; p < 0.01). Geriatric patients had significantly fewer stress tests (39.7% vs. 51.4%; p < 0.01), more of which were nuclear stress tests (78.2% vs. 39.5%; p < 0.01). ConclusionsIn this exploratory retrospective study, geriatric EDOU chest pain patients did not have an increased rate of re-presentation to the hospital within 30 days compared to non-geriatric patients. Geriatric patients had a longer EDOU LOS than non-geriatric patients. Geriatric patients in the EDOU had fewer stress tests, but more of those were nuclear stress tests.

Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial.

Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system. The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days. This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital-level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45-day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures. Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient-reported health care utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI]= 40.8-149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI= 15.5-23.3). When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI= 29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI= 3.74-47.9) in the intervention arm. Shared decision making in low-risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.

Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study

BackgroundEvaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays. ObjectiveOur aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP. MethodsLow-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0–1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6 months. ResultsWe enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6 months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; p = 0.89). Median time from triage to discharge was significantly shorter with IESE (572.6 min vs. 1466.0 min), resulting in significantly lower cost ($4380.50 vs. $6191.70). There were no adverse events related to IESE or early discharge. ConclusionsIn our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.

Thirty-Day Readmission Rate and Costs After Percutaneous Coronary Intervention in the United States: A National Readmission Database Analysis.

The association of short-term readmissions after percutaneous coronary intervention (PCI) on healthcare costs has not been well studied. The Healthcare Cost and Utilization Project National Readmission Database encompassing 722 US hospitals was used to identify index PCI cases in patients ≥18 years old. Hierarchical regression analyses were used to examine the factors associated with risk of 30-day readmission and higher cumulative costs. We evaluated 206 869 hospitalized patients who survived to discharge after PCI from January through November 2013 and analyzed readmissions over 30 days after discharge. A total of 24 889 patients (12%) were readmitted within 30 days, with rates ranging from 6% to 17% across hospitals. Among the readmitted patients, 13% had PCI, 2% had coronary artery bypass surgery, and 3% died during the readmission. The most common reasons for readmission included nonspecific chest pain/angina (24%) and heart failure (11%). Mean cumulative costs were higher for those with readmissions ($39 634 versus $22 058; P<0.001). The multivariable analyses showed that readmission increased the log10 cumulative costs by 45% (β: 0.445; P<0.001). There was no significant difference in cumulative costs by the type of insurance. In a national sample of inpatient PCI cases, 30-day readmissions were associated with a significant increase in cumulative costs. The majority of readmissions were because of low-risk chest pain that did not require any intervention. Ongoing effort is warranted to recognize and mitigate potentially preventable post-PCI readmissions.

BET 2: Sharing decisions for patients with suspected cardiac chest pain in the emergency department

A short-cut review was carried out to establish whether shared decision making used alongside a decision aid can lead to greater patient satisfaction, lower healthcare resource use and non-inferior clinical...

32 Do low-risk patients with non-cardiac chest pain prefer early discharge after rapid rule-out in the emergency department?

BackgroundThere has been a recent drive to implement rapid rule-out strategies which allow the early discharge of low-risk patients with suspected cardiac chest pain directly from the Emergency Department (ED)....

45 Effectiveness of Modified HEART Score Versus Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol for Low Risk Chest Pain: A Prospective Observational Study

45 Effectiveness of Modified HEART Score Versus Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol for Low Risk Chest Pain: A Prospective Observational Study

40 Development of a Health-Literate Decision Instrument for Low-Risk Chest Pain in the Emergency Department

40 Development of a Health-Literate Decision Instrument for Low-Risk Chest Pain in the Emergency Department

How Do We Balance the Long-Term Health of a Patient With the Short-Term Risk to the Physician?

BackgroundThere is a wide variation in practice patterns among emergency medicine physicians; many factors weigh into the medical decision-making process including the health of the patient as well as short-term risk to the physician. ObjectiveThe objective of our discussion is to illustrate specific scenarios where medical decisions are focused on the physician’s short-term risk, then to propose an approach to shifting the balance to the patient’s long-term health. MethodsUsing recent data on the evaluation, disposition, and outcomes of patients with low-risk chest pain in the emergency department, we calculate the risk of outpatient evaluation compared to the common practice of admission or observation. ResultsPatients with low-risk chest pain and negative initial evaluation in the emergency department with 2 normal cardiac biomarkers, normal vital signs, and non-ischemic, interpretable ECGs, have an extremely low-risk of a short term clinically relevant adverse cardiac event. There is a suggestion of a higher patient risk from admission, prompting consideration that continued evaluation of the chest pain as an outpatient may be safer than admission or observation. ConclusionA test/intervention should be done if the risk of a missed diagnosis or adverse outcome is greater that the risk of the test/intervention. Involving the patient in the decision-making process may help to shift the management balance from the physician’s short-term concern of their own risk, to the patient’s long-term health.

Evidence That Provocative Testing in Low-Risk Chest Pain Patients Does Not Prevent MI

There is no evidence to support the recommended practice of provocative testing or computed tomographic coronary angiography (CTCA) in low-risk chest

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain.

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1–V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20–40% of misdiagnosed myocardial infarctions.

LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain.

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

The Utility of Screening for Pre-Diabetes and Diabetes Mellitus with Hba1c in Patients who are Admitted to the Hospital with Low or Intermediate Risk Chest Pain for Rule Out Myocardial Infraction

The Utility of Screening for Pre-Diabetes and Diabetes Mellitus with Hba1c in Patients who are Admitted to the Hospital with Low or Intermediate Risk Chest Pain for Rule Out Myocardial Infraction