Few chest pain patients with negative ED status face short-term risk

The risk of short-term, life-threatening cardiac events in patients admitted to the hospital after a negative emergency department (ED) evaluation is low—really low, like one in 1,817. And that number, researchers reported, is from a conservative evaluation.

The researchers, led by Michael B. Weinstock, MD, of the Wexner Medical Center at Ohio State University in Columbus, and colleagues tapped existing databases at their three hospitals in Ohio to explore the safety benefit of hospital admission or extended observation in patients with a negative ED evaluation. They focused on patients who presented with chest pain, chest tightness, chest burning or chest pressure between 2008 and 2013.

To be included in the final cohort, the patients needed to have negative findings on two troponin tests. For the primary outcome, they selected life-threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest and death.

Of the more than 1 million ED visits, 11,230 patients fit the inclusion criteria. Of those, 0.18 percent experienced the primary outcome. After excluding for abnormal vital signs and ischemic electrocardiographic findings, the percentage of patients with these adverse events was 0.06 percent.

“We identified only 4 adverse events in 7266 patients,” they wrote. “Of these patients, 2 were ultimately deemed to have noncardiac chest pain and 2 had possible iatrogenic disease, including a periprocedural MI and STEMI during a stress test.”

They calculated that conservatively one in 1,817 such hospital admissions or observations would provide clinical benefit. They supported “judicious follow-up” in an outpatient setting as an alternative.

“[I]n the context of established risks due to hospitalization, we believe that current recommendations to admit, observe, or perform provocative testing routinely on patients after an ED evaluation for chest pain has negative findings should be reconsidered,” they proposed.

The study was published online May 18 in JAMA Internal Medicine.