Value of Cardiology Follow-up of Acute Chest Pain Patients
Abstract & Commentary
By Michael H. Crawford, MD, Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco.
This article originally appeared in the June 2013 issue of Clinical Cardiology Alert. It was peer reviewed by Ethan Weiss, MD, Assistant Professor of Medicine, Division of Cardiology and CVRI, University of California, San Francisco. Dr. Crawford reports no financial relationships relevant to this field of study, and Dr. Weiss is a scientific advisory board member for Bionovo.
Source: Czarnecki A, et al. Association between physician follow-up and outcomes of care after chest pain assessment in high risk patients. Circulation 2013;127:1386-1394.
Patients seen in emergency departments (ED) for acute chest pain who are deemed low risk for acute coronary syndrome (ACS) and relatively safe for discharge are often referred to their primary care physician (PCP) for follow-up. However, little is known about the effectiveness of follow-up care. Thus, Czarnecki and colleagues performed a retrospective database review of patients seen in the ED for chest pain who were evaluated, discharged, and survived at least 30 days. They focused on those at higher risk because of diabetes or known cardiovascular disease. They specifically evaluated whether there was a follow-up visit within 30 days and whether it was by a PCP or cardiologist. The primary outcome was all-cause mortality and hospitalization for acute myocardial infarction (MI) at 1 year. After excluding ineligible patients, 56,767 were included in the study and the duration of follow-up averaged 4 years. Follow-up visits were with a cardiologist in 17%, a PCP in 58%, and no visit in 25%. Median time to follow-up was 7 days for a PCP and 12 days for a cardiologist. Patients seeing a cardiologist had the highest rates of previous cardiac conditions and more tests, procedures, and medications than the other groups. The primary endpoint occurred in 5.5% of those seen by a cardiologist, 7.7% seen by a PCP, and 8.6% in the no follow-up group. After adjustment for confounders, the cardiology follow-up group had the lowest hazard ratio (0.85, 95% CI, 0.78-0.92) as compared to PCP and 0.79 as compared to no visit. The authors concluded that patients referred to a cardiologist after an ED visit for chest pain had a decreased risk of mortality or hospitalization for an MI at 1 year.
This large database study from a Canadian health system raises several important issues. First, what should be the follow-up of patients seen in the ED for chest pain who are deemed low risk for ACS, but at higher risk of having underlying coronary artery disease? The results suggest that a visit with a cardiologist as opposed to no visit or a visit with a PCP improves the primary endpoint of all-cause death and hospitalization for acute MI at 1 year. Even after adjustments for many confounders, these data remain robust. It doesn’t suggest that all patients with chest pain seen in the ED need a cardiology follow-up, only the higher risk subset.
Second, cardiologists used more tests, medications, and procedures than the PCPs, and better followed evidence-based guidelines. Whether this is what made the difference is unclear since this is a database study and there are no details on the appropriateness of the tests and procedures used. So this study cannot be used to support routine testing in all patients. However, this is the practice of most cardiologists who see such referrals and the study does not refute this practice.
Third, provision of rapid outpatient follow-up for these patients is a challenge in many health systems. One-quarter of their patients had no visits within 30 days despite the fact that 95% had an identified PCP they had seen in the last 3 years. They used the 30-day time frame because most patients were seen between 14-30 days, but 15% were excluded who had a visit in 30-90 days. The ideal post-ED follow-up time is unknown, but many believe within 14 days is ideal. I doubt we are doing much better than the Canadians in this regard, but it appears that we need to for the patient’s sake.