Strategy may lead to early chest pain discharges

Identifying patients with low-risk chest pain who can safely be discharged early may be possible using a new set of diagnostic procedures, leading to lower costs and better patient outcomes. A study published online Oct. 7 in JAMA: Internal Medicine found that an experimental strategy nearly doubled the amount of patients discharged from the emergency department (ED) to outpatient care within six hours.

Researchers led by Martin Than, MBBS, of Christchurch Hospital in Christchurch, New Zealand, randomized 542 patients admitted with acute chest pain characteristic of acute coronary syndrome to either the control group, who received the hospital’s standard chest pain care, or the experimental group, who received care based on the experimental accelerated diagnostic protocol (ADP).

The experimental group patients received an electrocardiogram (ECG) and had their blood tested for troponin I levels. Their Thrombolysis in Myocardial Infarction (TIMI) score was also calculated. To be considered low risk and eligible for an early discharge, patients had to meet several ADP criteria, including a modified TIMI score of 0, a negative troponin test at 0 and two hours and no ECG changes reflecting ischemia. Patients who met these criteria based on ADP were scheduled to return to the hospital on an outpatient basis for a stress test. Patients who did not meet ADP criteria received standard chest pain care.

The main outcome was discharge within six hours of arriving in the ED and no major adverse cardiac events within the first 30 days. They chose six hours because it is the maximum time a patient can stay in the ED without contributing to overcrowding or adverse outcomes.

Successful discharges occurred in 19.3 percent of the experimental group compared with 11 percent of patients in the control group. There were 35 patients in the experimental group who were subsequently admitted to an inpatient cardiac unit, but none were ultimately diagnosed with acute coronary syndrome.

This strategy, the authors argued, can decrease overcrowding and lower costs and could be especially beneficial to hospitals in the U.S., where EDs receive more than 6 million patients with chest pain annually.

Additionally, “[t]his diagnostic strategy could be easily replicated in other centers because no extra resources are required,” the researchers wrote.

In an accompanying editorial, Peter S. Rahko, MD, of the University of Wisconsin School of Medicine and Public Health in Madison, wrote that this type of rapid diagnostic strategy holds great promise and in the future, discharges may be even quicker.

“New data suggest that a single blood sample of high-sensitivity troponin and a new biomarker copeptin obtained at entry into the ED might allow immediate triage of patients, further reducing the number of patients needing prolonged observation or admission,” he wrote.