Patients with Negative ED Evaluations for Chest Pain Rarely Have In-Hospital Adverse Cardiac Events

July 17, 2015

Patients with Negative ED Evaluations for Chest Pain Rarely Have In-Hospital Adverse Cardiac Events

  1. Ali S. Raja, MD, MBA, MPH, FACEP

Among admitted patients with two negative troponin measurements, nonischemic ECGs, and normal vital signs, fewer than 0.1% had clinically relevant events.

  1. Ali S. Raja, MD, MBA, MPH, FACEP

Many patients treated for chest pain in U.S. emergency departments (EDs) are admitted to observation or inpatient units for monitoring of potential adverse cardiac events and provocative testing. In a review of medical records from three hospitals, researchers quantified the risk for such events — a composite of inpatient ST-segment elevation myocardial infarction, serious arrhythmia, cardiac or respiratory arrest, and death — in ED patients who presented with chest pain/pressure/tightening/burning and had serial negative troponin measurements (1 to 7 hours apart).

Of 11,230 patients, 20 (0.2%) had clinically relevant adverse cardiac events. After exclusion of patients with abnormal vital signs, ischemic electrocardiogram findings, left bundle branch block, and pacemakers, only 4 of the 20 patients remained, and adverse events in these 4 patients were deemed potentially iatrogenic or noncardiac.

Comment

Patients with negative ED evaluation for cardiac chest pain who have access to appropriate follow-up care should be discharged home. This study provides the necessary evidence to inform shared patient–physician decision making around this treatment plan. With a low rate of adverse events and high proportion of such events that may have been iatrogenic, the findings suggest we may be doing more harm than good by admitting these patients for observation.

Editor Disclosures at Time of Publication

  • Disclosures for Ali S. Raja, MD, MBA, MPH, FACEP at time of publication Speaker's bureau Airway Management Education Center Leadership positions in professional societies Society for Academic Emergency Medicine (Constitution and Bylaws Committee Chair, Program Committee Chair, and Trauma Interest Group Chair); American College of Emergency Physicians (Trauma and Injury Prevention Section Chair)

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