Necessity of hospitalization and stress testing in low risk chest pain patients.
Beri N, Marston NA, Daniels LB, Nowak RM, Schreiber D, Mueller C, Jaffe A, Diercks DB, Wettersten N, DeFilippi C, Peacock WF, Limkakeng AT, Anand I, McCord J, Hollander JE, Wu AH, Apple FS, Nagurney JT, Berardi C, Cannon CM, Clopton P, Neath SX, Christenson RH, Hogan C, Vilke G, and Maisel A. Necessity of hospitalization and stress testing in low risk chest pain patients. Am J Emerg Med 2016.
The American journal of emergency medicine
BACKGROUND: Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI).
OBJECTIVES: The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI<0.040μg/l and copeptin<14pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing.
METHODS: This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<0.040μg/l) and copeptin<14pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis.
RESULTS: None of the 475 "low risk" patients were diagnosed with MI during the 180day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p=.002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p
CONCLUSIONS: In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.
Medical Subject Headings
Biomarkers; Chest Pain; Cost-Benefit Analysis; Early Diagnosis; Electrocardiography; Emergency Service, Hospital; Exercise Test; Female; Follow-Up Studies; Glycopeptides; Humans; Male; Middle Aged; Multicenter Studies as Topic; Myocardial Infarction; Patient Admission; Patient Discharge; Patient Readmission; Predictive Value of Tests; Retrospective Studies; Risk Assessment; Troponin I