All of us have looked a patient’s past medical history, his/her triage note, chief complaint of chest pain, and instantly knew that patient was headed for admission despite a normal EKG and negative troponins. But are we doing more harm than good in admitting low risk chest pain patients with 2 negative biomarkers, stable vital signs, and nonischemic EKG?
In a practice-changing multi-center study from our very own David Newman (1), the authors reviewed 45,416 patient encounters that presented with chest pain over 5 years–11,230 met inclusion criteria. Of those 11,230, only 20 met a primary outcome of death, life-threatening arrythmia, inpatient STEMI, or cardiac/respiratory arrest. If you exclude certain factors such as abnormal vitals/EKG in the ED, only 4 out of 7266 met the primary outcome.
What does this mean? Well, given it’s estimated that 1 in 164 hospitalized patients (2) have a preventable adverse outcome that contributes to death, risk the of the patient dying from a cardiac event from that low risk chest pain admission is much lower than another iatrogenic or hospital related cause.
The verdict: consider early outpatient follow-up for your chest pain patient that has a nonischemic EKG, stable vital signs, and 2 negative troponins.
1) Primary article: JAMA (July 2015)
2) Estimate of risks of hospital admissions (2013)
3) Decision to admit affected by medicolegal reasons (2015)
4) Physician communication about risks is poor (2015)