{"id":733,"date":"2015-06-01T19:40:24","date_gmt":"2015-06-01T19:40:24","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=733"},"modified":"2017-08-21T11:45:34","modified_gmt":"2017-08-21T11:45:34","slug":"primary-care-corner-with-geoffrey-modest-md-low-risk-chest-pain-dangerous-to-admit","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/06\/01\/primary-care-corner-with-geoffrey-modest-md-low-risk-chest-pain-dangerous-to-admit\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Low risk chest pain, dangerous to admit"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

A prospective observational study looked at a large number of low-risk\u00a0patients admitted for chest pain and their outcomes (See\u00a0doi:10.1001\/jamainternmed.2015.1674<\/strong>). Data was\u00a0collected from July 2008 until July 2013 from the emergency depts (EDs)\u00a0of \u00a03 academic\u00a0mid-Western\u00a0US\u00a0hospitals. Details:<\/p>\n

–45,416 patients were\u00a0seen\u00a0for chest pain,\u00a0and\u00a022,457 (49.5%) were admitted,\u00a0of whom 11,230 met inclusion criteria of: primary presenting symptom of chest pain, chest tightness, chest burning or chest pressure; and two\u00a0negative serial troponins, 60-420 minutes apart<\/p>\n

–Primary outcome was short-term (ie, during the hospitalzation)\u00a0development of life-threatening arrhythmias, inpatient ST-segment elevation MI (STEMI), cardiac or respiratory arrest, or death during hospitalization (ie,\u00a0CRACE, or clinically relevant adverse cardiac events).<\/p>\n

–Mean age 58, 44.8% arrived by ambulance, 55% women. hypertension in 46%, diabetes in 20%, prior MI in 13%.<\/p>\n

–Results (based on 5% randomized sample of the 11230 patients):<\/p>\n

–primary endpoint was found in\u00a020 of 11230 patients (0.18%, 0.11%-0.27%), where mean age was 71, 50% women<\/p>\n

–excluding patients with abnormal vital signs, EKG-ischemia, LBBB, or pacemaker rhythm, the\u00a0primary endpoint was found\u00a0in only\u00a04 of 7266 (0.06%, 0.023%-0.14%). [they excluded these patients from the analysis because admission would have been appropriate, and they were looking at really low risk people to see if they really needed admission]<\/p>\n

\u200b–of these 4 events: 2 were noncardiac (one with a GI bleed from over-anticoagulation; another was a patient with a\u00a0nitroglycerin-associated bradyasystolic cardiac arrest who responded to CPR and had totally normal cardiac\u00a0stress test, troponins, echo)\u00a0and 2 were\u00a0possibly iatrogenic (one was\u00a0MI post-cardiac cath; another with acute MI while doing\u00a0the\u00a0stress test in the hospital)<\/p>\n

–secondary outcome (includes non-STEMI events not resulting in CRACE)<\/p>\n

–62 of 11230 patients had\u00a0final diagnosis of possible or definite MI (0.55%, 0.42%-0.71%)<\/p>\n

–decreased to\u00a028 patients, if exclude those with abnormal initial vital signs, or nonischemic ECG findings<\/p>\n

–none of these 28 patients developed a CRACE, though \u00a026 had a cath at least one day after admission, 18 had PCI, 4 CABG, and 4 were\u00a0medically managed.<\/p>\n

As we know, chest pain is quite\u00a0common: 7 million ED visits annually for chest pain in US in 2010, 5.4% of the total ED visits. In 2006, US charges for admission for nonspecific chest pain was $11 billion. And most patients are discharged with a non-cardiac diagnosis. This study was somewhat\u00a0limited by looking at only a 5% sample of the 11230 patients. Also, they did not include patients with\u00a0non-STEMIs in the primary analysis, which they justified by the data suggesting that those with\u00a0non-STEMIs do not benefit from aggressive invasive intervention.<\/p>\n

So, what are the implications of this observational study? The most obvious one is that\u00a0admitting these low-risk patients (normal vital signs, no STEMI, negative troponins\u00a0x2)\u00a0revealed that\u00a0there were very few CRACEs, the most important clinical\u00a0outcomes, leading to\u00a0their assessment that\u00a0the maximum hospitalization benefit\u00a0was on the order of 1 in 1817 patients (if you add in all of\u00a0these 4 cases, 2 of whom had noncardiac major\u00a0events). And this number is pretty dramatically eclipsed by the current estimate of 1 in 164 patients who have hospitalization-associate preventable adverse events that contribute to their death, and with serious harm being 10- to 20-fold more common. I\u00a0agree with their conclusion: many of these patients who go to the ED with chest pain are sick, at high risk of potentially bad outcomes, and need very close followup. But they may be better served by aggressive\u00a0outpatient than inpatient care…\u200b<\/p>\n","protected":false},"excerpt":{"rendered":"

By: Dr. Geoffrey Modest A prospective observational study looked at a large number of low-risk\u00a0patients admitted for chest pain and their outcomes (See\u00a0doi:10.1001\/jamainternmed.2015.1674). Data was\u00a0collected from July 2008 until July 2013 from the emergency depts (EDs)\u00a0of \u00a03 academic\u00a0mid-Western\u00a0US\u00a0hospitals. Details: –45,416 patients were\u00a0seen\u00a0for chest pain,\u00a0and\u00a022,457 (49.5%) were admitted,\u00a0of whom 11,230 met inclusion criteria of: primary presenting […]<\/p>\n

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