Abstract 1795: Immediate Exercise Stress Testing in the Chest Pain Center, a 10 Year Experience
Objective In the US, 600,000 patients that present with chest pain are discharged from the Emergency Department (ED) without a diagnosis of CAD. Also, of the 1.5 million patients admitted for chest pain annually, 70% undergo expensive evaluations to confirm a final diagnosis. At the same time, 2–8% of patients with acute myocardial infarction (AMI) who present to the ED are inadvertently sent home, creating a huge dilemma for ED physicians and hospital administration. There is an accurate, safe, rapid, and cost-effective methodology available that can rule out AMI and severe coronary arterial disease (lesion >50%) in the ED/Chest Pain Unit (CPU).
Method This was a retrospective chart review of 11,678 patients with a diagnosis of atypical chest pain that were admitted to the ED of a tertiary community hospital teaching institution from 1996–2005. 1,450 (12%) patients met the criteria of being stressed in the ED after three sets of negative serial cardiac markers (SCM) taken at 0, 2, and 4 hours of admission (Myoglobin, Troponin I, CK-MB).
Results 684 (47%) patients had a regular exercise treadmill test (ETT) in the ED and 766(53%) patients had either a nuclear or echo stress test (adjunct testing) from the ED or from the CPU after four hours of admission. From the 684 patients that had a regular stress test, 120 were either abnormal or incomplete. From those, 76 patients were lost to follow-up, 24 patients were diagnosed positive by angiography, and 20 patients either had a normal angiography or subsequent normal adjunct testing (17% false positive). From the 766 patients that had adjunct testing, 140 were abnormal or incomplete. Of this group, 75 were lost to follow-up, 49 were positive, and 16 had a normal angiography (11.4% false positive). In total, 10% of patients were lost due to follow up.
Conclusion 82% of patients with atypical chest pain, normal ECG, and normal serial cardiac markers can have a normal stress test and be discharged home safely after just four hours of admission, while 5% of patients would have a diagnosis of severe CAD. Stress testing in the ED and chest pain unit is safe, decreases unnecessary admission and cost, and avoids missed myocardial infarction/coronary arterial disease diagnosis in the ED.