A Clinical Prediction Rule for Early Emergency Room Discharge of Low Risk Patients With Chest Pain

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A Clinical Prediction Rule for Early Emergency
Room Discharge of Low Risk Patients With Chest
Pain

• Cotarlan V, Ho D, Pineda J, Netrebko P, McConnell
  T, Qureshi A, Shirani J
• Geisinger Medical Center, Danville, PA

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Presenter Disclosure Information
Cotarlan V Ho D Pineda J Netrebko P McConnell
T Qureshi A Shirani J Clinical Prediction Rule
to Discharge Low Risk Patients With Chest Pain in
ER
DISCLOSURE INFORMATION The following
relationships exist related to this
presentation No Relations to Disclose
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Background

• Chest Pain
• 5 of all ER visits
• 5 x 106 visits to ER annually
• Annual cost 6 x 109
• 2/3 non-cardiac
• Cost of cardiac evaluation 4 x 109

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Chest pain Decision Unit (CDU)

• Low-intermediate risk pts with CP in ER
• 2 sets of negative (normal) cardiac enzymes
• Non-invasive exclusion of CAD
• Stress test
• CT coronary angiography
• Stress test not available 24h/day
• Usually performed the next day
• Prolonged length of stay
• Patient inconvenience
• Increased cost

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Objective

• To identify clinical predictors that allow safe
  early discharge of CDU patients from ER
• After 2 negative sets of cardiac enzyme
• Planned outpatient non-invasive testing for CAD

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METHODS

• Retrospective study (02/2006-01/2007)
• 459 consecutive CDU pts with chest pain
• 2 negative sets of cardiac enzymes
• Stress test or coronary CT angiography
• Exercise stress echo (ESE) 242
  (53)
• Dobutamine stress echo (DSE) 119
  (26)
• Nuclear myocardial perfusion scan 35
  (7)
• Coronary CT angiography 63
  (14)

Total 459
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PCI 13 PCI and 2 CABG
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UNIVARIATE ANALYSIS
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MULTIVARIATE LOGISTIC REGRESSION
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Multivariate analysis Independent Predictors of
Normal Non-Invasive Test

• Atypical CP
• Normal ECG
• No Diabetes
• No known CAD

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Conclusions

• Pts evaluated in ED for chest pain may be safely
  discharged after 2 sets of negative cardiac
  enzymes and could be referred for outpatient CAD
  evaluation if they are non-diabetic, have no
  previous known CAD, present with atypical chest
  pain and have a normal ECG.
• This strategy may potentially reduce length of
  stay, patients inconvenience, ED clutter and
  cost of evaluation