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Routine Inpatient Admission Usually Unnecessary for Chest Pain

COLUMBUS, OH – Routine inpatient admission may not be the best option for patients presenting with chest pain but who have negative findings and non-concerning vital signs after an emergency department evaluation.

A study recently published in JAMA Internal Medicine suggests that those patients rarely had adverse cardiac events.

Background in the report, led by Ohio State University researchers, notes that patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the ED because of fear of adverse events. Until now, however, no large trials had examined the short-term risk for a clinically relevant adverse cardiac event, including inpatient ST-segment elevation myocardial infarction (STEMI), life-threatening arrhythmia, cardiac or respiratory arrest, or death, according to the study.

"We wanted to determine the risk to help assess whether this population of patients could safely go home and do further outpatient testing within a day or two," said Michael Weinstock, MD, a professor of emergency medicine at The Ohio State University College of Medicine and chairman of the Emergency Department at Mount Carmel St. Ann's Hospital.

For the study, researchers reviewed data collected from EDs at three community teaching hospitals on adults who were admitted to the hospital or observed after presenting with chest pain, chest tightness, chest burning or chest pressure and with negative findings for serial biomarkers. The primary outcome measurement was a composite of life-threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest, or death.

Of the 45,416 encounters examined by the authors, 11,230 patients – average age 58 and 55% female – met the criteria to be included in the study. One or more of the primary outcomes occurred in 20 of the 11,230 patients, for a rate of 0.18%.

The authors point out that, after excluding from the 20 patients those patients who were not likely to be sent home from the ED because of abnormal vital signs or other concerning findings, a primary outcome event occurred in only four patients, 0.06% of the total.

"Our study does not demonstrate that patients derive no utility from further management or diagnostic workup after the ED evaluation,” the authors write. “We believe that judicious follow-up is in the best interest of most such patients. However, our findings suggest that further evaluation may be best performed in the outpatient rather than the inpatient setting, and that this information should be integrated into shared decision-making discussions regarding potential admission.”

The researchers also called for a reconsideration of “current recommendations to admit, observe or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings.”

"We'd like to see more emergency medicine physicians having that bedside conversation to ensure the chest pain patient knows the risks and benefits of hospitalization compared to outpatient evaluation,” Weinstock emphasized. “We think continuing evaluation in an outpatient setting is not only safer for the patient, it's a less costly approach for the healthcare system."