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Few Life-Threatening Events Seen in ED Patients With Chest Pain but No Abnormalities

By L.A. McKeown


The vast majority of patients who receive a negative evaluation after presenting to an emergency department (ED) with symptoms of chest pain can safely be discharged home and undergo further outpatient evaluation at a later time, according to a study published online May 18, 2015, ahead of print in JAMA Internal Medicine. In fact, the researchers say, admitting such patients may do more harm than good. 

Next Step: Few Life-Threatening Events Seen in ED Patients With Chest Pain but No Abnormalities

“Our findings support the notion that adverse iatrogenic events as a result of admission may eclipse potential benefits in low-risk patients,” write Michael B. Weinstock, MD, of Mount Carmel St. Ann’s (Westerville, OH), and colleagues. 

The investigators looked at data on 45,416 ED visits at 3 community teaching hospitals from July 2008 through June 2013. All had a primary presenting symptom of chest pain, tightness, burning, or pressure. Among them, 11,230 patients (mean age 58 years; 55% women) met inclusion criteria, which included 2 negative troponin tests performed 60-420 minutes apart. 

Risk Low in Absence of Abnormal Clinical Findings

Short-term life-threatening events (the primary endpoint) occurred in 20 patients (0.18%). These included:

  • 6 life-threatening arrhythmias 
  • 5 inpatient STEMIs 
  • 4 cardiac arrests 
  • 1 respiratory arrest 
  • 9 in-hospital deaths 

After further excluding patients with abnormal vital signs or ischemic findings, or those unable to undergo evaluation for ischemia and therefore considered unlikely to be sent home from an ED, the study cohort shrank to 7,266. Within this group, only 4 patients (0.06%) experienced short-term, clinically relevant adverse events:

  • A man in his 80s who died in the hospital from massive GI tract bleeding secondary to warfarin coagulopathy, with secondary comorbidities of chronic obstructive pulmonary disease, pulmonary hypertension, and renal failure 
  • A man in his 60s who underwent catheterization and CABG for CAD and MI before being discharged to a skilled nursing facility 
  • A man in his 40s who underwent catheterization and stenting for acute inferior MI then was discharged home 
  • A woman in her 60s who required pacemaker implantation for bradyasystolic cardiac arrest and was discharged home

Possible or definite MI (defined by final diagnosis or by an elevated level of troponin at the third or subsequent testing) occurred in 0.55%.

No Admission Does Not Mean No Evaluation

According to Dr. Weinstock and colleagues, previous studies have shown that about 1 in 164 hospitalized patients suffer a preventable adverse event that contributes to their death. Assuming that data from the current study are correct, only 1 patient in 3,634 who is hospitalized for chest pain with negative biomarker tests stands to benefit from the hospitalization.

“Our study does not demonstrate that patients derive no utility from further management or diagnostic workup after the ED evaluation,” they note. “We believe that judicious follow-up is in the best interest of most such patients. However, 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.”

Additionally, Dr. Weinstock and colleagues suggest 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” in the context of the established risks that patients are exposed to from hospitalization.

Physician Biases Drive Clinical Decisions

In an accompanying editorial, Grace A. Lin, MD, MAS, and JAMA Internal Medicine Editor Rita F. Redberg, MD, MSc, both of the University of California San Francisco (San Francisco, CA), say looking at “day-to-day clinical decision-making processes can reveal how patterns of overuse develop.”

In this study, they add, “many… low-risk patients are admitted to the hospital for observation and further testing, leading to unnecessary expenditure of resources and exposure of the patient to the potential harms of hospitalization, which may be higher than the actual event rate.” More importantly, they say, the findings highlight the fact that “physician decision-making processes are a driver of increased use.”

They cite their own research via physician focus groups, which demonstrated that anticipated regret by clinicians over a missed diagnosis as well as a tendency toward action rather than inaction are responsible for recommendations for both more testing and invasive treatment of CAD.

“In fact, physicians said that they would feel more regret about patients experiencing adverse events if they did not perform a procedure (cardiac catheterization with possible stent placement) than if the patient experienced harm from undergoing a procedure,” Drs. Lin and Redberg write.

The solution, they argue, is for physicians and their patients to be fully informed about the risks vs benefits of procedures and tests and for structural changes to be made to reimbursement that promote “greater evidence-based clinical decision making.”

Sources:

1. Weinstock MB, Weingart S, Orth F, et al. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015;Epub ahead of print.
2. Lin GA, Redberg RF. Addressing overuse of medical services one decision at a time [editorial]. JAMA Intern Med. 2015;Epub ahead of print.  

Disclosures:

  • Dr. Weinstock reports receiving royalties for 3 books.  
  • Drs. Lin and Redberg report no relevant conflicts of interest. 

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