Outcome of chest pain patients discharged from a French emergency department: a 60-day prospective study

Background

Chest pain (CP) is a common complaint among patients presenting to the emergency department (ED). Previous studies suggest that between 2% and 5% of ED patients who present with CP and are sent home develop an acute coronary syndrome within 30 days. In France, no prospective data are available concerning the outcome of CP patients discharged from the ED.

Objective

The objective of our study was to determine the rate of adverse cardiac events (ACE) within a period of 60 days after discharge from the ED.

Methods

From October 2007 to February 2008, consecutive patients aged 25 years or more who presented to the ED with CP were prospectively included. Patients discharged from the ED were contacted by phone at 60 days to determine their clinical course and the occurrence of an ACE.

Results

There were 322 CP patients enrolled, representing 3.9% of all medical admissions to the ED; 40.4% of these patients were hospitalized and 59.6% were discharged. Three patients (1.6%) could not be contacted for follow-up, leaving 189 patients eligible for the study. The rate of ACE was 3.7%: one ST-segment elevation myocardial infarction and six non-ST-segment elevation myocardial infarctions. Follow-up revealed that 39.1% of patients saw a cardiologist and that 14.2% were readmitted for CP.

Conclusion

We found that CP is a frequent complaint in patients who present to our ED, and that a small proportion (3.7%) is mistakenly discharged and presents with an ACE during the 60-day follow-up period.     

Prognosis and gender differences in chest pain patients discharged from an ED

A large proportion of patients evaluated for chest pain in the emergency department (ED) will be sent home because the probability of acute myocardial infarction, unstable angina, or other severe disease processes is determined to be sufficiently low. Patients who came to the ED at Sahlgrenska Hospital in Göteborg during a 21-month period because of chest pain were registered and followed up for one year. Survivors after one year were asked to complete a mailed questionnaire regarding different kinds of symptoms. Of 5,362 patients evaluated in the ED, 2,175 were sent home on their first visit. Fifty-four percent were men and 46% were women. The one-year mortality rate was 3% in men and 3% in women. Recurrent chest pain, dyspnea, and psychological symptoms were more frequently reported by patients with known cardiac disease than by patients without cardiac disease. Female patients with and without cardiac disease reported significantly more frequent recurrent chest pain, dyspnea, and psychological and psychosomatic complaints than male patients with and without cardiac disease. These data suggest that there are specific gender differences between men and women who are discharged from the ED after being evaluated for chest pain. In particular, psychological gender differences may exist and need to be addressed when evaluating patients with chest pain.     

Outcome from a rapid-assessment chest pain clinic

Chest pain accounts for much of the rising numbers of emergency admissions, but in-patient assessment is not necessarily the best way of dealing with these patients. We ran a 'rapid-assessment chest pain clinic' to provide an alternative route of assessment, and audited its outcome. General practitioners referred patients with recent-onset chest pain, increasing chest pain, chest pain at rest, or other chest pain of concern, on the understanding that they would be seen within 24 h. During 8 1/2 months, 334 patients were referred and 317 patients were seen, most of whom had exercise electrocardiography. A median of 6 months later, 278 patients were personally contacted to determine outcome. Of these, 18% had been admitted immediately with acute coronary syndromes, and 49% had been diagnosed as non-coronary chest pain (none of whom subsequently infarcted or died). Continuing symptoms were infrequent, and satisfaction was high, although 13% of patients had been revascularized. A significant number of patients required immediate admission and/or ultimate revascularization, but many more did not. The majority of these patients had non-coronary chest pain, and this diagnosis was substantiated by their excellent outcome and (in some cases) by further investigation.      

Investigating six-month health outcomes of patients with angina discharged from a chest pain service

Hospital admissions for patients with suspected cardiac chest pain are increasing. The development of a chest pain service allows rapid diagnosis, investigation and treatment. Since the in-patient stay is often short, there is limited time for education and risk factor management. Little is known about the patients' recovery post discharge. This study was completed to investigate the 6-month health outcomes of 57 patients discharged from the chest pain service by measuring cardiovascular symptoms and risk profiles, mood and quality of life, adherence to secondary prevention, morbidity and mortality. The results of this study showed that 58% of the sample still suffered angina, 72% reported breathlessness, and 79% reported lethargy. Assessment of mood showed that 76% suffered from anxiety and 78% depression. Quality of life was impaired. A reduction of cholesterol level was the only significant change in risk factors. Secondary prevention measures showed that there was still room for improvement. Twenty-five percent of the sample was readmitted to hospital due to their cardiac condition. Patients had an average of eight contacts with their general practitioner, four of which were cardiac related. The ongoing symptoms, anxiety and depression and uncorrected risk factors can impact on their recovery. Currently, however, no programme of rehabilitation is available for angina patients, despite the potential for up to 30% of patients suffering a subsequent cardiac event (Ghandi et al., British Heart Journal 73 (1995) 193-198). This study suggests the need to develop, implement and evaluate a CR programme in this client group.     

Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain.

BACKGROUND: Chest pain is the second most common presenting complaint seen in the emergency department. Following evaluation in the emergency department, many of these patients are discharged with a diagnosis of nonspecific chest pain. Our hypothesis is that this group of patients has a high prevalence of ischaemic heart disease. METHODS: This was a prospective follow-up study of mortality in 786 patients who presented to an emergency department in the UK with an episode of nontraumatic chest pain and were discharged without further inpatient assessment. Observed mortality was compared with expected mortality in age-matched and sex-matched local population. RESULTS: The observed mortality of the study group was consistently higher than expected throughout the study period. The 5-year mortality rates for men and women under the age of 65 years were more than double the expected rates for the local population [relative risk of 2.1 (95% confidence interval: 1.4-2.8) and 2.6 (1.4-3.8), respectively]. This increase was less marked in male and female patients aged 65 years or more [relative risk of 1.2 (0.9-1.5) and 1.5 (1.2-1.8), respectively]. Ischaemic heart disease accounted for almost 50% of male deaths in the study group. This compared with an expected rate of less than 30% of male deaths in the local population. An excess of cardiac deaths was not seen in women. INTERPRETATION: Patients discharged from the emergency department following an episode of acute chest pain have significantly reduced 5-year survival. We conclude that further evaluation of this group to establish the prevalence of risk factors is important to support the strategic implementation of appropriate prevention programmes.     

Observational study of prehospital delays in patients with chest pain

Method: A prospective observational study of prehospital times and events was undertaken on a target population of patients presenting with acute chest pain attributable to an acute coronary syndrome over a three month period.

Results: Patients who decided to call the ambulance service were compared with patients who contacted any other service. Most patients who contact non-ambulance services are seen by general practitioners. The prehospital system time for 121 patients who chose to call the ambulance service first was significantly shorter than for 96 patients who chose to call another service (median 57 min v 107 min; p<0.001). Of the 42 patients thrombolysed in the emergency department, those who chose to call the ambulance service had significantly shorter prehospital system times (number 21 v 21; median 44 v 69 min; p<0.001). Overall time from pain onset to initiation of thrombolysis was significantly longer in the group of patients who called a non-ambulance service first (median 130 min v 248 min; p=0.005).

Conclusions: Patient with acute ischaemic chest pain who call their general practice instead of the ambulance service are likely to have delayed thrombolysis. This is likely to result in increased mortality. The most beneficial current approach is for general practices to divert all patients with possible ischaemic chest pain onset within 12 hours direct to the ambulance service.

     

Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients.

One hundred patients with chest pain and negative coronary arteriography were evaluated for musculoskeletal chest wall findings. Sixty-nine patients had chest wall tenderness. Typical chest pain was evoked by palpation in 16 patients. Tender areas were not found in a control group of patients without chest pain. A diagnosis of fibrositis could be made in five patients, including two in whom chest palpation reproduced typical chest pain. The sternal and xiphoid area, left costosternal junctions, and left anterior chest wall were the areas where tenderness was most common, but no significant differences were found comparing locations of tenderness in those with reproduction of typical pain. There was no significant difference in location, exacerbating factors, or other musculoskeletal symptoms among different groups of patients. Thus, most patients with noncardiac chest pain have chest wall tenderness that is not found in a control group without chest pain. However, reproduction of pain by palpation, a more specific diagnostic finding, is found in a minority of these patients.     

Cost-effectiveness analysis of noninvasive strategies to evaluate patients with chest pain

We evaluated clinical and economic outcomes of diagnostic strategies on the basis of pharmacologic stress echocardiography (PhSE) versus exercise electrocardiography test (EET) in 527 patients with chest pain (274 women; age 59 +/- 10 years) who underwent both EET and PhSE. We investigated 3 strategies, ie, coronary angiography: after positive EET (strategy 1); after positive PhSE (strategy 2); or after a positive PhSE performed after a positive EET (strategy 3). A patient was correctly identified if he or she had negative test results and no events, or had positive test results and abnormal coronaries. The cost per patient correctly identified was calculated as the ratio between the cost of each strategy and the number of patients correctly identified. The accuracy in correctly identifying the patients was 78%, 92%, and 91% with strategies 1, 2, and 3, respectively. The cost of each patient correctly identified was 1572 US dollars, 1097 US dollars, and 1081 US dollars with strategies 1, 2, and 3, respectively. In conclusion, PhSE-based strategies are cost-effective versus EET.     

胸痛中心急救网点的建立及快速转运机制

急性非创伤性胸痛具有起病急骤、病情进展快、诊断困难、可救治时间短等特点.胸痛中心的建立可使ST段抬高急性心肌梗死死亡率下降50%.在整个胸痛救治过程中,胸痛中心急救网点的建立,早期启动和快速安全转运是抢救成功的重要环节,也是胸痛中心建设的难点.本文就胸痛中心急救网点的建立及胸痛患者快速转运机制进行讨论.     

ALARMED: adverse events in low-risk patients with chest pain receiving continuous electrocardiographic monitoring in the emergency department. A pilot study

OBJECTIVES: Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We evaluated the utility of CEM in ED patients with chest pain. METHODS: We enrolled stable patients who presented to a single ED with chest pain suspected to be ischemic in origin and who were placed on CEM. Patients were classified according to risk of poor outcome using 3 published stratification tools. Trained observers prospectively recorded number of monitored hours, alarms, changes in management, and monitor-detected adverse events (AEs). The primary outcome measure was the rate of AEs detected by CEM. Secondary outcome measures were the rate of alarms that resulted in a change in management and number of false alarms. RESULTS: We enrolled 72 patients, 56% of whom were categorized as very low-risk by Goldman risk criteria. During 371 monitored hours, we recorded 1762 alarms or 4.7 alarms per monitored hour. There were 11 AEs (0.68%; 95% CI, 0.35%-1.2%), 3 of which resulted in a change in management (0.2%; 95% CI, 0.04%-0.5%). Seven AEs were bradydysrhythmias with a heart rate of 45 or higher; the eighth patient had no change in symptoms and was given atropine for a heart rate of 32. The other 3 AEs were an untreated supraventricular tachycardia, a brief sinus pause that triggered a rate change in intravenous nitroglycerin by the patient's nurse, and a run of premature ventricular contractions after which heparin was administered. None of the 3 patients with a change in management was categorized as the lowest-risk. CONCLUSIONS: Routine CEM in low-risk ED patients with chest pain results in an excessive number of alarms, most of which require no change in management. In these patients, the benefit of CEM may be limited, and given that 99.4% of alarms were false, current CEM technology needs to be improved.     

Differences in the progress of discharged and undischarged patients in a medium secure unit: a pilot study

This study compared 15 patients ('undischarged' group) who were showing little sign of progress in a medium secure unit (MSU) after 2 years with 15 who had been discharged from the same unit 1-2 years following admission. The two groups were compared across a number of broadly defined behavioural indices during their first 6 months and first 12 months following admission. The measures used were indices of progress to wards of lower security (highest ward status and transfers to wards of higher security) and progress in terms of leave (highest leave status and reductions in leave status). In addition, the two groups were compared on number of recorded incidents attributable to them. Discharged patients were significantly older at the time of their admission than the undischarged patients (median ages 33 and 26 years, respectively). They made more progress in their first year in terms of ward security and leave status and were responsible for fewer recorded incidents. These results were also obtained at 6 months following admission with the exception that the difference for highest ward status was not statistically significant. The findings of this small-scale study suggest that within the first 6 months of admission, it may be possible to distinguish patients who will probably make good progress in a MSU from those whose progress is likely to be very slow. Implications of the study are discussed.     

Practicality, safety and accuracy of computed tomography coronary angiography in the evaluation of low TIMI-risk score chest pain patients: a pilot study

Objectives: The present pilot study aimed to assess the practicality, safety and accuracy of performing CT coronary angiography (CT‐CA) in the evaluation of acute chest pain of patients with low thrombolysis in myocardial infarction (TIMI) risk scores. Methods: The present prospective observational study was undertaken in a university teaching hospital between November 2004 and December 2005. Participants were a convenience sample of patients admitted to hospital for investigation of chest pain with TIMI risk scores <3. Consenting patients underwent CT‐CA within 48 h of presentation. Outcomes of interest were practicality (proportion of diagnostic quality scans obtained and preparation time for CT‐CA), rate of serious adverse events, and accuracy at the patient level using selective coronary angiography as the reference standard. Results: Thirty‐four patients were recruited. Diagnostic quality scans were obtained in 26/34 or 76% of patients (four failed CT‐CA and four non‐diagnostic scans). The median CT preparation time was 1.9 h (range 0.17–4.0). No serious adverse events were found. Fourteen of those 26 patients with diagnostic CT‐CA subsequently had selective coronary angiography, of which nine were positive. The sensitivity and specificity of CT‐CA in identifying patients with significant coronary artery disease were 9/9 (100%; 95% confidence interval 72–100%) and 4/5 (80%; 95% confidence interval 28–100%), respectively. Conclusions: The majority of acute chest pain patients with low TIMI risk scores were successfully scanned with a 16‐slice CT to produce CT‐CA studies with good diagnostic quality and accuracy. No major adverse events were found. The place of CT‐CA in diagnostic workup for chest pain remains to be defined.     

Outcome of low-risk patients discharged home after a normal cardiac troponin I

Patients with symptoms suggestive of, but at low risk for, acute coronary syndrome (ACS), who have a negative electrocardiogram (EKG) and a single normal troponin I at 6–9 h after symptom onset are frequently discharged from our Emergency Department (ED). We sought to determine their rate of adverse cardiac events at 30 days (ACE-30), defined as cardiac death or myocardial infarction (MI), by chart review, telephone interview, or county death records. Of 663 patients, data were available for 588 (89%). Mean age was 48 years; 59% were male. There were 390 patients (66%) who complained of chest pain. Previous coronary artery disease (CAD) was reported in 145 patients (25%). Two patients (0.34%) had ACE-30, both with non-ST elevation MI. There were no cases of cardiac death. None of the patients died in Hennepin County within 30 days. At our institution, low-risk patients with symptoms suggestive of ACS who are discharged home after a normal cTnI drawn 6–9 h after symptom onset have a very low incidence of cardiac events at 30 days.     

北京市急诊胸痛的病因学调查分析

目的探讨北京市急诊科胸痛患者的病因学构成,为确立进一步的治疗方案提供依据,降低治疗费用。方法 本研究属多中心前瞻性描述性研究,参研单位包括17所医院。使用统一表格记录入选患者的一般资料,包括既往病史,发病时间,到达医院急诊时间,胸痛特点,心电图描述及诊断,初步诊断,急诊的诊治情况,辅助检查,确定诊断和去向,就诊30d后的临床转归情况。所有数据经SAS8．2统计软件进行统计学处理。结果2009年7—8月,在17个医疗中心连续有效人选至急诊室就诊的胸痛患者,计划纳入6000例,最终5666例患者确认获得有效记录而入选,平均年龄（58．1±18．4）岁,男性2663例,占47％;女性3003例,占53％。胸痛患者占急诊总量的4．7％（5666／130553）。病因学分析结果：冠心病1509例（27．4％）,急性心力衰竭149例（2．6％）,心包炎4例（0．1％）,肺栓塞11例（0．2％）,主动脉夹层8例（0．1％）,急性脑血管病431例（7．6％）,非心源性胸痛2538例（44．9％）。30d随访结果：院外死亡37例（O．7％）,再次入院275例（4．9％）。结论重视并认真对待胸痛患者,特别是无胸痛患者和以伴随症状就诊的患者,正确地做出诊断,及时进行规范诊疗,降低患者的病死率。     

Respiratory dysfunction in chronic neck pain patients. A pilot study

The aim of this pilot study was to add weight to a hypothesis according to which patients presenting with chronic neck pain could have a predisposition towards respiratory dysfunction. Twelve patients with chronic neck pain and 12 matched controls participated in this study. Spirometric values, maximal static pressures, forward head posture and functional tests were examined in all subjects. According to the results, chronic neck patients presented with a statistically significant decreased maximal voluntary ventilation ( P  = 0.042) and respiratory muscle strength (Pimax and Pemax), ( P  = 0.001 and P  = 0.002, respectively). Furthermore, the current study demonstrated a strong association between an increased forward head posture and decreased respiratory muscle strength in neck pateits. The connection of neck pain and respiratory function could be an important consideration in relation to patient assessment, rehabilitation and consumption of pharmacological agents.