Early discharge with next day stress testing in low risk chest pain patients presenting to the emergency department is feasible [abstract]
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Study Objectives: Chest pain (CP) is a common presenting complaint in the emergency department (ED). Several clinical decision rules have been developed to help risk stratify a group of patients at very low risk for acute coronary syndrome and bad outcomes. Central to the care of most ED patients with CP is close clinical followup and appropriate risk stratification testing. We sought to determine if a protocol could be effectively implemented to help assure timely stress testing (stress echocardiogram or stress nuclear) of patients with undifferentiated CP. Methods: We instituted a low-risk CP protocol that provided reliable stress testing with 72 hours of ED presentation at an inner-city tertiary care hospital with annual census of 80,000. Patients were eligible if they had a thrombolysis in myocardial infarction (TIMI) score of 0 or 1, a normal or unchanged EKG and a negative troponin I biomarker at 6 hours after onset of CP. Alternatively, patients could be enrolled if the treating ED clinician deemed the patient to be otherwise low-risk. The study was approved by the IRB. Data was abstracted from patient electronic medical records. Patients who did not show up for their scheduled stress test were surveyed by phone. Results: A total of 340 patients were initially enrolled. The average age was 50 and 51% were female (age range 22-82). Two hundred nine patients had a TIMI score of 0 while 29 patients had a TIMI score of 3 or 4. Common risk factors included smoking (30%), hypertension (39%), hyperlipidemia (30%) and diabetes (12%). Median ED length of stay was 223 minutes. 265 (78%) patients followed up as scheduled and had stress testing performed. Median time to follow-up was 2.4 days (range 0-48 days) with 187 (55%) of the cohort completing their stress test within 72 hours. 75 (22%) failed to have stress testing performed. Of the 75 who did not attend their stress test appointment, 32 provided clinical follow-up data through a phone survey, 32 had electronic medical record clinical follow-up data beyond their emergency department visit, and the remaining 11 (3%) had no follow-up. Of the 329 patients with some form of follow-up available including scheduled stress testing, there were 17 (5%) with equivocal or abnormal stress test, 12 (4%) patients who had a subsequent coronary angiogram, 4 (1%) patients that underwent percutaneous revascularization, and 2 patients who suffered a myocardial infarction (0.05%). There were no deaths. Conclusion: A majority of ED patients presenting with CP identified to be at low risk for ACS followed up for scheduled stress testing utilizing an ED low-risk CP protocol. However, a substantial minority did not show up for stress testing. The reasons for this are unknown. Observed rates of angiography, coronary intervention, and myocardial infarction were very low: 4%, 1%, and 0.05%.