Clinical question: Do stable, low-risk patients hospitalized for chest pain after negative ED evaluation experience adverse cardiac events in the hospital?
Background: Chest pain results in more than seven million ED visits annually, with a cost of over $11 billion to hospitalize these patients for closer monitoring. It is not well known to what extent these low-risk patients experience in-hospital adverse cardiac events after a negative ED evaluation.
Study design: Blinded data review from a prospectively collected, multicenter database.
Setting: Three community teaching hospitals in the U.S.
Synopsis: Researchers identified 11,230 patients, aged 18 and older, hospitalized with chest pain symptoms after negative serial troponin, from July 2008 through June 2013. Demographics included mean age 58 years, 55% female, with several co-morbid medical illnesses. One hundred ninety-seven patients met the primary outcomes of in-hospital life-threatening arrhythmia, ST segment elevation MI, cardiac or respiratory arrest, and death.
Blinded reviewers further stratified these patients and excluded any patients with initial abnormal vital signs, with ECG evidence of ischemia, or with an uninterpretable ECG. This resulted in four patients who experienced the primary outcome in hospital after presenting with chest pain, stable vital signs, and no evidence of ischemia. By verifying inclusion data from 5% of the primary cohort and extrapolating, they calculated a primary outcome incidence of 0.06% [95% CI, 0.02%-0.14%].
Results were in hospital only and were not time specific. Authors were unable to control for confounders, prevent data collection bias, or verify inclusion criteria for more than 5% of the initial sample.
Bottom line: Risk for in-hospital adverse cardiac events is low in patients hospitalized from the ED with chest pain and normal vital signs, negative serial troponin, and non-ischemic ECG.
Citation: Weinstock MB, Weingart S, Orth F, et al. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015;175(7):1207-1212. doi: 10.1001/jamainternmed.2015.1674.