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.
Read more important recent literature by Newman on why we admit (3) and by Newman and Kaushal Shah on how poorly we are communicating risk of ACS (4).
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)