Compliance with stress testing in patients discharged from the emergency department following a diagnosis of low-risk chest pain.
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ABSTRACT: Objective
To determine rates of compliance with outpatient stress testing in patients with a diagnosis of low-risk chest pain, reasons for non-compliance and incidence of adverse cardiac events (ACE).Methods
This was a prospective study of 79 patients who were discharged from the emergency department with low-risk chest pain. Patients were followed-up by phone interview.Results
36.7% of patients completed EST within 30?days, 2.5% of patients completed their EST within the recommended 72?h. A lack of time was the most common reason for non-compliance and was seen in 32.0% of patients. 20% of ESTs were cancelled by the primary care physician (PCP). 12% of patients were non-compliant, as they believed the pain to be non-cardiac. There were no documented ACEs in the study.Conclusions
Compliance with EST is poor in patients with low-risk chest pain. Non-compliance is related to a number of factors including work commitments, cancellation of studies by the PCP and patients beliefs about the nature of their chest pain.
SUBMITTER: Robinson K
PROVIDER: S-EPMC4832738 | biostudies-literature | 2014
REPOSITORIES: biostudies-literature
Publications
Compliance with stress testing in patients discharged from the emergency department following a diagnosis of low-risk chest pain.
Robinson Kent K Prabhala Shreyas S
Heart Asia 20140808 1
<h4>Objective</h4>To determine rates of compliance with outpatient stress testing in patients with a diagnosis of low-risk chest pain, reasons for non-compliance and incidence of adverse cardiac events (ACE).<h4>Methods</h4>This was a prospective study of 79 patients who were discharged from the emergency department with low-risk chest pain. Patients were followed-up by phone interview.<h4>Results</h4>36.7% of patients completed EST within 30 days, 2.5% of patients completed their EST within the ...[more]
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Project description:Background More than 4 million cardiac noninvasive diagnostic tests are performed annually in the United States. However, questions remain regarding their effectiveness in improving clinical outcomes. We sought to evaluate whether noninvasive diagnostic tests were associated with lower rates of myocardial infarction or cardiovascular death when compared with no testing. Methods and Results We performed a retrospective, population-based cohort study of adults evaluated for chest pain and discharged home from an emergency department in Ontario, Canada. Propensity score matching was employed to reduce confounding between the testing and nontesting groups. There were 370 863 patients evaluated in our cohort. Rates of the composite outcome were low for both groups after propensity-score matching (0.29% and 0.78% for the nontesting group at 90 days and 1 year, respectively, and 0.34% and 0.68% for the noninvasive diagnostic test group at 90 days and 1 year respectively). Over 1 year, patients undergoing noninvasive diagnostic testing had a small but statistically significant lower hazard of developing the composite outcome of myocardial infarction or cardiovascular mortality (hazard ratio, 0.87; 95% CI, 0.78-0.96 [P<0.01]), which appears to be driven by the high-risk subgroup (hazard ratio, 0.75; 95% CI, 0.61-0.92 [P<0.01]). Conclusions We report a lower observed rate of the composite outcome of cardiovascular death or myocardial infarction associated with noninvasive diagnostic testing following evaluation for chest pain in the emergency department. This lower rate was driven by the high-risk subgroup. These results suggest that risk-based testing should be considered for patients discharged from the emergency department for chest pain.
| S-EPMC6898808 | biostudies-literature
Project description:For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012-February 2013 and April 2013-September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46-60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32-0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64-82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98-3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.
| S-EPMC7565964 | biostudies-literature
Project description:ImportanceNoninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.ObjectiveTo determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.Design, setting, and participantsThis retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.ExposuresNoninvasive testing or coronary angiography within 2 days or 30 days of presentation.Main outcomes and measuresThe primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.ResultsThe patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Conclusions and relevanceCardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.
| S-EPMC5710427 | biostudies-literature
Project description:BackgroundThis scoping review with narrative synthesis aimed to analyze scholarly peer-reviewed articles reporting on improving communication with patients discharged from the emergency department with noncardiac chest pain and qualitatively narrate on and summarize items that can be used in guiding communication with patients discharged from the emergency department with noncardiac chest pain.MethodsThe databases of EMBASE/PubMed, Scopus, COCHRANE, CInAHL/EBESCO, UW libraries, and Google Scholar were searched using relevant MeSH and key terms up to February 06, 2020. The selected articles were analyzed for their contents. Items guiding discharge communication were summarized qualitatively.ResultsTwenty-five articles were eligible for full review. These were published in between 1994 and 2020. Of those, 16 (64.0%) originated from the United States and 4 (16%) used some interventional design. A total of 45 different items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain were identified from the studies included in this review. Items were grouped under 6 categories that were related to initial assessment (8 items), information on diagnosis (7 items), information on discharge (9 items), follow-up suggestions (7 items), symptoms that promote return to the emergency department (7 items), and treatment plan (7 items).ConclusionCommunication with patients discharged from the emergency department with noncardiac chest pain can be improved. Results of this investigation might be helpful in guiding quality improvement projects aimed for further improvement of communication with patients discharged from the emergency department with noncardiac chest pain.
| S-EPMC8426084 | biostudies-literature
Project description:It is important that patients with symptoms of acute coronary syndrome receive appropriate medical care as soon as possible. Little is known about the preadmission actions that patients with chest pain take before arrival at the Emergency Department (ED).This study aimed to describe the actions of patients with chest pain or pressure after onset of symptoms. What is the first action following onset of symptoms? Who is the first lay or professional person to be contacted? Which steps are taken first? How is the patient transported to the hospital?Consecutive patients, arriving at the ED of two large hospitals in Belgium, were asked additional questions during the initial assessment.Overall, 35% of 412 consecutive patients with chest pain admitted to the ED were diagnosed with acute coronary syndrome. A total of 57% contacted a GP between symptom onset and arrival at the ED. Only 32% of the patients were transported to the ED by ambulance, 16% drove themselves and 52% arrived by other means of transport (by family, neighbour, GP, public transport).In Belgium, the GP is still the first professional to be contacted for most patients. Other patients initially rely on their partner, family or friends when symptoms emerge. Too often, patients with chest pain rely on other transport to get to the ED instead of calling the Emergency Medical Services. This study included only patients who ultimately attended the ED.
| S-EPMC5671801 | biostudies-other
Project description:BackgroundChest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders.ObjectiveOur aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes.MethodsPatients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism.ResultsEight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to "stress" or "anxiety"; their mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety.ConclusionsWithout prompting, 8% of patients self-identified "stress" or "anxiety" as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes.
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Project description:Chest pain is the second most common reason patients visit emergency departments (EDs) and often results in very low-risk patients being admitted for prolonged observation and advanced cardiac testing. Shared decision-making, including educating patients regarding their 45-day risk for acute coronary syndrome (ACS) and management options, might safely decrease healthcare utilization.This is a protocol for a multicenter practical patient-level randomized trial to compare an intervention group receiving a decision aid, Chest Pain Choice (CPC), to a control group receiving usual care. Adults presenting to five geographically and ethnically diverse EDs who are being considered for admission for observation and advanced cardiac testing will be eligible for enrollment. We will measure the effect of CPC on (1) patient knowledge regarding their 45-day risk for ACS and the available management options (primary outcome); (2) patient engagement in the decision-making process; (3) the degree of conflict patients experience related to feeling uninformed (decisional conflict); (4) patient and clinician satisfaction with the decision made; (5) the rate of major adverse cardiac events at 30 days; (6) the proportion of patients admitted for advanced cardiac testing; and (7) healthcare utilization. To assess these outcomes, we will administer patient and clinician surveys immediately after each clinical encounter, obtain video recordings of the patient-clinician discussion, administer a patient healthcare utilization diary, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up.This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in low-risk chest pain patients from a variety of geographically and ethnically diverse EDs.NCT01969240.
| S-EPMC4031497 | biostudies-literature
Project description:The management of patients with chest pain is a common and challenging clinical problem. Although most of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent management of a serious problem such as acute coronary syndrome (ACS) and those with more benign entities who do not require admission. Although clinical judgment continues to be paramount in meeting this challenge, new diagnostic modalities have been developed to assist in risk stratification. These include markers of cardiac injury, risk scores, early stress testing, and noninvasive imaging of the heart. The basic clinical tools of history, physical examination, and electrocardiography are currently widely acknowledged to allow early identification of low-risk patients who have less than 5% probability of ACS. These patients are usually initially managed in the emergency department and transitioned to further outpatient evaluation or chest pain units. Multiple imaging strategies have been investigated to accelerate diagnosis and to provide further risk stratification of patients with no initial evidence of ACS. These include rest myocardial perfusion imaging, rest echocardiography, computed tomographic coronary angiography, and cardiac magnetic resonance imaging. All have very high negative predictive values for excluding ACS and have been successful in reducing unnecessary admissions for patients at low to intermediate risk of ACS. As patients with acute chest pain transition from the evaluation in the emergency department to other outpatient settings, it is important that all clinicians involved in the care of these patients understand the tools used for assessment and risk stratification.
| S-EPMC2843115 | biostudies-literature
Project description:BackgroundDue to an aging population and the increasing proportion of patients with various comorbidities, the number of patients with acute ischemic heart disease (AIHD) who present to the emergency department (ED) with atypical chest pain is increasing. The aim of this study was to develop and validate a prediction model for AIHD in patients with atypical chest pain.Methods and resultsA chest pain workup registry, ED administrative database, and clinical data warehouse database were analyzed and integrated by using nonidentifiable key factors to create a comprehensive clinical dataset in a single academic ED from 2014 to 2018. Demographic findings, vital signs, and routine laboratory test results were assessed for their ability to predict AIHD. An extreme gradient boosting (XGB) model was developed and evaluated, and its performance was compared to that of a single-variable model and logistic regression model. The area under the receiver operating characteristic curve (AUROC) was calculated to assess discrimination. A calibration plot and partial dependence plots were also used in the analyses. Overall, 4,978 patients were analyzed. Of the 3,833 patients in the training cohort, 453 (11.8%) had AIHD; of the 1,145 patients in the validation cohort, 166 (14.5%) had AIHD. XGB, troponin (single-variable), and logistic regression models showed similar discrimination power (AUROC [95% confidence interval]: XGB model, 0.75 [0.71-0.79]; troponin model, 0.73 [0.69-0.77]; logistic regression model, 0.73 [0.70-0.79]). Most patients were classified as non-AIHD; calibration was good in patients with a low predicted probability of AIHD in all prediction models. Unlike in the logistic regression model, a nonlinear relationship-like threshold and U-shaped relationship between variables and the probability of AIHD were revealed in the XGB model.ConclusionWe developed and validated an AIHD prediction model for patients with atypical chest pain by using an XGB model.
| S-EPMC7644067 | biostudies-literature
Project description:BACKGROUND:The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. METHODS:A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ?21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data. RESULTS:Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33). CONCLUSIONS:HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.
| S-EPMC6309794 | biostudies-literature