Emergency physicians, trained in detecting and managing acute coronary syndrome and armed with advanced diagnostic tools, are experts in diagnosing myocardial infarction and unstable angina. That increased testing and vigilance, however, has come at a cost.
Rising hospital admission rates and resource utilization aimed at minimizing short-term adverse outcomes are due in part to guidelines recommending expedited testing in all comers following ED evaluation for ACS. (Circulation 2010;122:1756; http://bit.ly/2QihgUf.) This conservative, uniform approach is no longer necessary in our increasingly evidence-based, crowded health care system, however.
Large validation studies of the HEART score for ED patients with chest pain support the extremely low incidence of adverse events in patients with a low-risk HEART score. (Crit Pathw Cardiol 2010;9:164; Crit Pathw Cardiol 2011;10:128.)
The risk of major adverse cardiac events (MACE) in this group is one to two percent at 30-45 days, supporting the safety of outpatient evaluation with primary care or cardiology. Further review of the data from the prospective HEART validation study also showed only one death in the low-risk group of nearly 2,500 patients, and its etiology was noncardiac. (Int J Cardiol 2013;168:2153; http://bit.ly/2QgTnfS.) Even more reassuring, observational analysis of testing patterns in the United States suggests an even lower likelihood of adverse events in low-risk patients. The ratio of true disease has decreased as more patients are screened and evaluated in the ED.
Unfortunately, almost half of emergency physicians reported unease with even this small amount of risk despite these overwhelming data consistently demonstrating extremely low rates of adverse outcomes, according to Than, et al. (Int J Cardiol 2013;166:752.) Astoundingly, the majority of them reported they would only be comfortable with a MACE rate in discharged patients of 0.1-0.01 percent! This investigation dates back to 2013; a survey of more than 500 attendees at the 2018 Essentials of Emergency Medicine conference found nearly identical results, with 47 percent of respondents only comfortable with a missed MACE of one in 1,000 or one in 10,000. (See figure.) Whether fueled by fear of medicolegal consequences, concern over the loss of prestige or respect from colleagues, or a well-intentioned attempt to avoid catastrophic patient outcomes, this unrealistically low-risk tolerance is a significant barrier to translation of current knowledge into clinical practice.
Notably, the extremely conservative results reported by Than, et al., may have been influenced by the assumption of the treating physicians that the discharged patient would not receive follow-up as an outpatient. Unlike the Than survey, we invite you to imagine a different scenario: a patient with chest pain in the ED who is deemed low-to-intermediate risk by the HEART score and who is discharged from the ED, preferably after a shared decision-making discussion and in whom further outpatient evaluation is planned. An exercise test raises concerns about ischemic heart disease during the outpatient evaluation, and a subsequent coronary angiogram confirms a significant stenosis, requiring PCI. We propose that this patient should not be seen as a missed MACE but rather an optimal example of careful outpatient follow-up for whom judicious use of resources avoided an unnecessary hospital admission.
Clearly, the gap between practice and evidence should be narrowed. Physician comfort should continue to increase and medicolegal concerns wane as routine application of the HEART score data permeates clinical practice.
Pushing the Envelope
Despite persistent physician discomfort in discharging low-risk HEART patients, emerging literature pushes the envelope even further and may support an aggressive strategy of discharging patients with a HEART score demonstrating a moderate risk of MACE. Limited investigations have demonstrated an abundantly low rate of clinically relevant adverse cardiac events (CRACE), defined as death, STEMI, or life-threatening arrhythmia during hospitalization, in patients with chest pain. Weinstock, et al., found a CRACE rate of just 0.06 percent in more than 7,000 admitted patients who had a negative ED evaluation regardless of risk stratification. (JAMA Intern Med 2015;175:1207; http://bit.ly/2L2bqAi.)
While buoyed by these reassuring outcome data, the approach of increased outpatient management of moderate-risk patients finds its foundation in a consideration of the utility and benefit of observation or intervention, a question posed at the recent 2018 Adena Chest Pain Summit. Attended in person and online by approximately 500 participants worldwide, a panel of emergency medicine, cardiology, and medicolegal experts explored and investigated outcomes in moderate-risk populations and synthesized these data with existing protocols.
The American Heart Association and the American College of Cardiology guidelines have mandated universal application of functional or anatomical testing following negative chest pain evaluation in the emergency department, an onerous requirement that runs counter to a fairly robust body of current evidence. Investigations of undifferentiated ED populations have confirmed a sensitivity of stress testing of only 45 percent, worse than a coin flip. (Ann Intern Med 1998;128:965.)
Even more striking, with the publication of the COURAGE (New Engl J Med 2007;356:1503; http://bit.ly/2UlgAM2) and ORBITA (Lancet 2018;391:31) trials demonstrating no mortality benefit to percutaneous intervention and coronary stenting in those without ACS, admission or observation for preventing adverse outcomes exposes patients to the risks of hospitalization without documented benefit.
Based on this evidence and coupled with his own unpublished data presented at the Adena summit demonstrating no adverse events among 1,037 patients of all risk categories discharged following a negative ED evaluation without function testing, Ezra Amsterdam, MD, the principal author of the 2010 ACC/AHA recommendations, has reversed his position on uniform stress testing in ED patients with possible ACS within 72 hours of presentation. He announced his support for an individualized decision by the treating physician regarding the need for and timing of additional testing. (Eur Heart J Acute Cardiovasc Care 2018;7:285.)
The unanimous consensus recommendation from the 13 emergency medicine and cardiology faculty at the Adena Chest Pain Summit stated: “After a negative ED evaluation for chest pain, a shifted, yet expedited, outpatient evaluation with primary care or cardiology is an acceptable alternative to admission.”
The shift toward outpatient management of chest pain is monumental, and has the potential to generate anxiety on both sides of the stretcher. It is a model based on data, however, and requires considering not only the risks of hospitalization but also the changing health care landscape and demand for evidence-based, cost-effective care. Such a transition cannot happen in a vacuum, but rather in conjunction with comprehensive outpatient protocols, hospital-wide multidisciplinary protocols, and well-informed shared decision-making processes with patients who have access to timely follow-up. Growing and coordinating these approaches allows for increased knowledge and engagement in decision-making, lower rates of observation unit admission, and lower rates of unnecessary provocative testing. (Circ Cardiovasc Qual Outcomes 2012;5:251; http://bit.ly/2PmQ0hZ.)
Emergency physicians are tasked as watchdogs for life-threatening disease and stewards of increasingly costly health care resources. Identifying low-value processes, instituting validated outpatient management algorithms, and establishing comprehensive pathways and shared decision-making mechanisms for outpatient care are part and parcel with those endeavors. After years of irrational application of low-value testing, compelling data and expert consensus have created the justification and obligation to transition toward routine discharge and outpatient management of low- and moderate-risk patients who have completed a negative ED evaluation for chest pain. With emergency medicine investigators and bedside clinician experience having found so many answers, only one question remains: When will our professional organizations and guidelines catch up?
Adena Chest Pain Summit Mission Statement (#ACPS18)
EXCELLENCE OF CARE
Whereas myocardial infarction is one of the leading causes of death;
Whereas emergency physicians should be cognizant of patient populations such as diabetics, women, and the elderly which may have their acute coronary syndrome (ACS) present atypically;
Whereas the risk of ACS after a negative emergency department (ED) evaluation is significantly lower than upon initial ED presentation;
Whereas the risk for a major adverse cardiac event (MACE) is very low in patients with a low-risk HEART score in the immediate post-ED evaluation period;
Whereas the risk of a clinically relevant adverse cardiac event (CRACE) is extremely low in the immediate post-ED evaluation period;
Whereas there is a risk to a hospital admission including nosocomial infection, deep vein thrombosis, pneumonia, sundowning, falls, false-positive tests, and expense to the patient and health-care system;
We propose: After a negative ED evaluation for chest pain, an expedited outpatient evaluation with primary care or cardiology is an acceptable alternative to admission.
Michael Weinstock, MD Cameron Berg, MD
Barbra Backus, MD Paul Juhn, MD
Erik Hess, MD Mizuho Spangler, DO
Salim Rezaie, MD Rob Orman, MD
Michael Pallaci, DO Doug Van Fossen, MD (cardiology)
Ryan Radecki, MD Bruce Chen, MD (cardiology)
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