Very Low Risk for Clinically Relevant Adverse Cardiac Events in Low-Risk Patients With Chest Pain | Journal Scan

Study Questions:

What is the incidence of short-term life-threatening events among patients hospitalized for chest pain with two troponin-negative findings, nonconcerning initial emergency department (ED) vital signs, and nonischemic and interpretable electrocardiographic findings?

Methods:

This was a retrospective review of an existing database at three hospitals in the US Midwest. Eligible patients presented at a study ED with chest pain from 2008 through 2013. Participants had to have been admitted to the hospital (admission or observation) following negative serial biomarker testing in the ED (with the second test performed 60-420 minutes from the initial test). The primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infraction (STEMI), cardiac or respiratory arrest, and death during hospitalization.

Results:

Of 45,416 ED visits with chest pain, 11,230 met the inclusion criteria and comprised the analytic sample. The primary endpoint occurred in 20 of the 11,230 patients (0.18%; 95% confidence interval [CI], 0.11%-0.27%). After excluding from the primary outcome those patients unlikely to have been sent home from the ED (abnormal vital signs or electrocardiogram findings that either showed ischemic changes or were unevaluable for ischemia), the primary endpoint occurred in 4 of 7,266 patients (0.06%; 95% CI, 0.02%-0.14%). Of these events, two were noncardiac and two were possible iatrogenic (periprocedural MI and STEMI during stress test).

Conclusions:

In adult patients with chest pain admitted following two negative findings for serial biomarkers, short-term clinically relevant adverse cardiac events were rare.

Perspective:

This is an important study that draws attention to the marginal benefit (and perhaps risk of adverse iatrogenic events) of hospitalization for low-risk patients presenting with chest pain. The authors conservatively estimate that the risk of a clinically relevant adverse cardiac event (which did not include non-STEMI) in their cohort was low, at 1 in 1,817. Such a risk should prompt us to reconsider a strategy of hospitalization or observation in the ED in low-risk patients presenting with chest pain and with negative cardiac biomarkers. Perhaps, further testing in this low-risk group is best deferred to the outpatient setting following discharge from the ED.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Prevention, ACS and Cardiac Biomarkers, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Biological Markers, Chest Pain, Electrocardiography, Emergency Service, Hospital, Exercise Test, Hospitalization, Iatrogenic Disease, Incidence, Inpatients, Myocardial Infarction, Outpatients, Patient Discharge, Retrospective Studies, Secondary Prevention, Troponin


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