Can ED chest pain patients with intermediate HEART scores be managed as outpatients?

Autor: Moustapha A; College of Medicine, University of Saskatchewan, Regina, SK, Canada., Mah AC; College of Medicine, University of Saskatchewan, Regina, SK, Canada., Roberts L; Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada., Leach A; Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada., Kaban G; Department of Emergency Medicine, University of Saskatchewan, Regina, SK, Canada., Zimmermann R; Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Regina, SK, Canada., Shavadia J; Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Saskatoon, SK, Canada., Orvold J; Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Saskatoon, SK, Canada., Mondal P; Clinical Research Support Unit, College of Medicine, Saskatoon, SK, Canada., Martin LJ; Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada. ljm598@mail.usask.ca.
Jazyk: angličtina
Zdroj: CJEM [CJEM] 2022 Nov; Vol. 24 (7), pp. 770-779. Date of Electronic Publication: 2022 Sep 21.
DOI: 10.1007/s43678-022-00355-4
Abstrakt: Purpose: Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics.
Methods: This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score.
Results: There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8).
Conclusion: This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.
(© 2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)
Databáze: MEDLINE
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