Outcomes of Patients Admitted for Observation of Chest Pain | Cardiology | JAMA Internal Medicine | JAMA Network
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 Statistics for U.S. community hospital stays: most common diagnoses for the top 100 DRGs, 2008. Agency for Healthcare Research and Quality Web site. http://hcupnet.ahrq.gov/. Accessed March 17, 2011
Anderson JL, Adams CD, Antman EM,  et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction); American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic Emergency Medicine.  ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine.  J Am Coll Cardiol. 2007;50(7):e1-e15717692738PubMedGoogle ScholarCrossref
Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease.  N Engl J Med. 1979;300(24):1350-1358440357PubMedGoogle ScholarCrossref
Gibbons RJ, Balady GJ, Bricker JT,  et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines).  ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines).  Circulation. 2002;106(14):1883-189212356646PubMedGoogle ScholarCrossref
Thygesen K, Alpert JS, White HD,  et al; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction.  Universal definition of myocardial infarction.  Circulation. 2007;116(22):2634-265317951284PubMedGoogle ScholarCrossref
Zou G. A modified poisson regression approach to prospective studies with binary data.  Am J Epidemiol. 2004;159(7):702-70615033648PubMedGoogle ScholarCrossref
Greenland S. Model-based estimation of relative risks and other epidemiologic measures in studies of common outcomes and in case-control studies.  Am J Epidemiol. 2004;160(4):301-30515286014PubMedGoogle ScholarCrossref
Selvin S. Practical Biostatistical Methods. Palo Alto, CA: Duxbury/Wadsworth Press; 1995
Vittinghoff E, Glidden DV, Shiboski SC, McCulloch C. Regression Methods in Biostatistics. Berlin, Germany: Springer Science & Business Media; 2005
Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM. Cost-effectiveness of mandatory stress testing in chest pain center patients.  Ann Emerg Med. 1997;29(1):88-988998087PubMedGoogle ScholarCrossref
Biviano AB, Bergmann SR, Tenenbaum J,  et al.  Design of a comprehensive chest pain initiative in an academic urban hospital.  Crit Pathw Cardiol. 2003;2(2):113-11718340328PubMedGoogle ScholarCrossref
Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department–based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO).  J Am Coll Cardiol. 1996;28(1):25-338752791PubMedGoogle ScholarCrossref
Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit.  J Nucl Cardiol. 2008;15(2):186-19218371589PubMedGoogle ScholarCrossref
Pope JH, Aufderheide TP, Ruthazer R,  et al.  Missed diagnoses of acute cardiac ischemia in the emergency department.  N Engl J Med. 2000;342(16):1163-117010770981PubMedGoogle ScholarCrossref
Newby LK, Christenson RH, Ohman EM,  et al.  Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. The GUSTO-IIa Investigators.  Circulation. 1998;98(18):1853-18599799204PubMedGoogle ScholarCrossref
Than M, Cullen L, Reid CM,  et al.  A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study.  Lancet. 2011;377(9771):1077-108421435709PubMedGoogle ScholarCrossref
Kirk JD, Turnipseed S, Lewis WR, Amsterdam EA. Evaluation of chest pain in low-risk patients presenting to the emergency department: the role of immediate exercise testing.  Ann Emerg Med. 1998;32(1):1-79656941PubMedGoogle ScholarCrossref
Chan GW, Sites FD, Shofer FS, Hollander JE. Impact of stress testing on 30-day cardiovascular outcomes for low-risk patients with chest pain admitted to floor telemetry beds.  Am J Emerg Med. 2003;21(4):282-28712898483PubMedGoogle ScholarCrossref
Zalenski RJ, Selker HP, Cannon CP,  et al.  National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia.  Ann Emerg Med. 2000;35(5):462-47110783408PubMedGoogle Scholar
Rusnak RA, Stair TO, Hansen K, Fastow JS. Litigation against the emergency physician: common features in cases of missed myocardial infarction.  Ann Emerg Med. 1989;18(10):1029-10342802275PubMedGoogle ScholarCrossref
Katz DA, Williams GC, Brown RL,  et al.  Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia.  Ann Emerg Med. 2005;46(6):525-53316308068PubMedGoogle ScholarCrossref
Pines JM, Isserman JA, Szyld D, Dean AJ, McCusker CM, Hollander JE. The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain. Am.  Am J Emerg Med. 2010;28(7):771-77920837253PubMedGoogle ScholarCrossref
Bekmezian A, Chung PJ, Yazdani S. Staff-only pediatric hospitalist care of patients with medically complex subspecialty conditions in a major teaching hospital.  Arch Pediatr Adolesc Med. 2008;162(10):975-98018838651PubMedGoogle ScholarCrossref
Roy CL, Liang CL, Lund M,  et al.  Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes.  J Hosp Med. 2008;3(5):361-36818951397PubMedGoogle ScholarCrossref
Original Investigation
June 11, 2012

Outcomes of Patients Admitted for Observation of Chest Pain

Author Affiliations

Author Affiliations: Divisions of Cardiology (Drs Penumetsa and Hiser) and General Medicine (Drs Mallidi and Rothberg), Department of Medicine, and Division of Academic Affairs (Ms Friderici), Baystate Medical Center, Springfield, and Tufts University School of Medicine, Boston (Drs Penumetsa, Mallidi, Hiser, and Rothberg), Massachusetts.

Arch Intern Med. 2012;172(11):873-877. doi:10.1001/archinternmed.2012.940

Background Low-risk chest pain is a common cause of hospital admission; however, to our knowledge, there are no guidelines regarding the appropriate use of stress testing in such cases.

Methods We performed a retrospective cohort study of patients 21 years and older who were admitted to our tertiary care center with chest pain in 2007 and 2008. Using electronic records and chart review, we sought (1) to identify differences in the use of stress testing based on patient demographics and comorbidities, pretest probability of coronary artery disease, and house staff coverage and (2) to describe the results of stress testing and patient outcomes, including revascularization procedures and 30-day readmissions for myocardial infarction.

Results Of 2107 patients, 1474 (69.9%) underwent stress tests, and the results were abnormal in 184 patients (12.5%). Within 30 days, 22 patients (11.6%) with abnormal test results underwent cardiac catheterization, 9 (4.7%) underwent revascularization, and 2 (1.1%) were readmitted for myocardial infarction. In a multivariable model, stress test ordering was positively associated with age younger than 70 years (RR [relative risk], 1.12; 95% CI, 1.02-1.23), private insurance (vs Medicare/Medicaid: RR, 1.19; 95% CI, 1.11-1.27), and no house staff coverage (RR, 1.39; 95% CI, 1.28-1.50). Of patients with low (<10%) pretest probability, 68.0% underwent stress testing, but only 4.5% of these had abnormal test results.

Conclusions Most patients who are admitted with low-risk chest pain undergo stress testing, regardless of pretest probability, but abnormal test results are uncommon and rarely acted on. Ordering stress tests based on pretest probability could improve efficiency without endangering patients.