When an emergency physician considers whether to recommend hospitalization for a patient, the decision is typically based on immediate risk—is the patient likely to experience an adverse event within the next few days, or can he be safely managed as an outpatient?
But the decision to admit patients who present with chest pain suggestive of acute coronary syndrome is usually guided by the 30-day risk of major adverse cardiac events (MACE), including death, nonfatal reinfarction, and revascularization, as assessed by the patient's HEART score (history, ECG, age, risk factors, troponin).
“That's pretty unusual when you think about it,” said Michael Weinstock, MD, the associate emergency medicine residency program director and the director of research and CME at Adena Health System and a professor of emergency medicine at The Ohio State University. “If a patient presents to the ED with a condition like pneumonia or cellulitis, we make our decision to admit them based on their risk of decompensating over the next day or two. But for patients with chest pain, the decision is based on the risk of a bad cardiac outcome over the next four to six weeks. Does an increased risk of MACE at four to six weeks justify immediate hospitalization or emergent intervention?”
Dr. Weinstock, Nathan Finnerty, MD, an emergency physician with Intermountain Medical Center in Salt Lake City, and Mike Pallaci, DO, the program director at Adena Health Systems, said it's time to rethink that formula and treat chest pain the same way other conditions are managed in the ED. They proposed that MACE be replaced in the ED and in clinical studies of ED patients with chest pain by a more relevant measure: the risk of clinically relevant adverse cardiac event (CRACE), defined as a composite of life-threatening arrhythmia, ST-segment elevation MI, cardiac or respiratory arrest, and risk of death. (J Am Heart Assoc. 2019;8:e012542; http://bit.ly/2PsnalE.)
The authors illustrated their point with a hypothetical example familiar to many emergency physicians: A 65-year-old man with a history of hypertension and coronary artery disease who presented with two weeks of intermittent, exertional chest pressure, and dyspnea, and had an ECG showing nonspecific findings and a HEART score of 6.
If this patient had presented to his cardiologist, he would likely be scheduled for cardiac catheterization the following week and undergo revascularization for atherosclerotic disease. But if the same patient presented to the ED with the same symptoms and HEART score, he would probably be hospitalized. He would undergo the same cardiac catheterization in both scenarios, but in the second, he would be hospitalized with those added risks and costs or discharged and referred to his cardiologist, and his case would be classified as a missed MACE.
“Because MACE includes revascularization along with death and MI, even if you manage the patient correctly and he has a good outcome, you might get ‘dinged’ for the fact that he was sent home from the ED and later underwent revascularization,” Dr. Finnerty said. “MACE may have allowed us to risk-stratify more patients into either the low- or high-risk category, but now we have this gray area of moderate to high risk. Are these patients truly at risk for hospitalization and death or just another intervention down the road that may or may not reduce their risk of mortality? That's the population in which you have a tendency to overtest and over-interventionalize.”
Dr. Weinstock stressed that their article is not critical of the HEART score, which he called a groundbreaking score that gives emergency clinicians the confidence to send home low-risk patients. But he said they were concerned that using the HEART score and MACE as a cookbook without thinking about context is a disservice to patients if everyone with a HEART score of 4 or higher is admitted. “What are we really doing by spending all this money and exposing them to unnecessary risks and costs?” he asked.
Acceptable Miss Rate
The American College of Emergency Physicians recently published guidelines confirming an acceptable miss rate of MACE of one to two percent. (Ann Emerg Med. 2018;72:e65; http://bit.ly/2ZyQ6vZ.) “Defining the acceptable miss rate for the first time is a big step, and they also confirmed the utility of the HEART score, which is fantastic,” Dr. Weinstock said. “But they did not really address this moderate-risk HEART score patient that we're talking about in our editorial.”
He said the data have shown that most emergency physicians consider an acceptable miss rate to be below one percent, and the lack of clear guidance for these gray-area patients, fear of poor outcomes, risk aversion, and malpractice concerns may drive unnecessary hospitalizations.
“We're not saying that these moderate-risk patients can just go home and they'll be fine, but rather that an expedited outpatient evaluation is likely comparable in terms of outcomes with less use of resources and risk of hospital-acquired infection,” Dr. Finnerty said.
“This is all part of the evolution of the chest pain workup in the ED,” he said. The HEART score expedited that. I think next we will see the 72-hour recommendation for stress testing go by the wayside. Let's look at more relevant outcomes, given that these other interventions and testing are being shown in recent literature not to be as useful as we once thought.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.
No More Stress Testing
Read “Once and for All, Stop Ordering Stress Tests,” by Dan Runde, MD, on p. 19.