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Hospitalization may not benefit troponin-negative adults with chest pain
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The risk for short-term clinically relevant adverse cardiac events was rare in adult patients hospitalized for chest pain who had two negative findings for serial biomarkers, nonconcerning vital signs and nonischemic electrocardiographic findings, researchers reported in JAMA Internal Medicine.
The masked data review included reports of 11,230 encounters collected from a prospective database of adults (mean age, 58 years; 55% women) admitted or observed at three community teaching institutions in the Midwest from July 2008 to June 2013. Each adult presented with chest pain, tightness, burning or pressure and tested negative for serial biomarkers via two troponin serum assays. Forty-six percent of adults had a history of hypertension, 19.7% had a history of diabetes and 13.16% had a history of MI.
The primary endpoint of the study was a composite of life-threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest and in-hospital mortality. The primary endpoint was observed in 20 adults (0.18%). After exclusion of those who were unlikely to be discharged from the ED, including those with abnormal vital signs, electrocardiographic ischemia, left bundle branch block or a pacemaker rhythm, the primary endpoint was observed in four of 7,266 adults (0.06%); of those, two events were noncardiac and two were potentially iatrogenic, according to the results.
The researchers identified 62 patients (0.55%) with definite/possible MI; after exclusion of those who were unlikely to be discharged from the ED, they identified 28 patients with definite/possible MI. None of these patients experienced a clinically relevant adverse event, and 26 underwent cardiac catheterization at least 1 day after hospitalization.
Although the incidence of the primary endpoint was rare, the small number of events does not allow for meaningful analysis of potential risk factors, according to the researchers. A “considerably larger database” is needed to identify patients who would benefit most from inpatient admission, they wrote.
“Our study does not demonstrate that patients derive no utility from further management or diagnostic workup after the ED evaluation,” the researchers concluded. “However, our findings suggest that further evaluation may be best performed in the outpatient rather than the inpatient setting, and that this information should be integrated into shared decision-making discussions regarding potential admission.” – by Adam Taliercio
Disclosure: Weinstock reports receiving book royalties. One researcher reports speaking and advising for AstraZeneca. Another researcher reports serving as chief clinical adviser and is on the clinical advisory board for Callibra Inc.
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