Characteristics and Outcomes of Young Adults Who Present to the Emergency Department with Chest Pain

Abstract

Abstract.Background: Most studies of emergency department (ED) chest pain patients exclude patients <30-40 years old. As a result, the clinical course of these patients is poorly described. Objective: To study the clinical characteristics, hospital course, and 30-day outcomes of ED chest pain patients <40 years old. The hypothesis was that patients <40 years old without a cardiac history and with normal electrocardiograms (ECGs) or no cardiac risk factors would be at a <1% risk for acute coronary syndromes (ACSs) and 30-day adverse cardiovascular (CV) events. Methods: This was a prospective cohort study of noncocaine-using ED patients, 24-39 years old, who received an ECG for chest pain between July 9, 1999, and October 23, 2000. Structured data collection at presentation included demographics, chest pain description, history, laboratory, and ECG data. Hospital course was followed daily. Thirty-day follow-up was performed by telephone. The main outcomes were discharge diagnosis and 30-day adverse CV events [acute myocardial infarction (AMI), death, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG)]. Results: A total of 487 patients presented 527 times and comprised the study group. Patients were most often 30-39 years old (71%), female (60%), and African-American (73%). Thirty-two percent were admitted. Five hundred seven of 527 patient visits (96%) had 30-day follow-up. Patients had the following cardiac risk factors: tobacco, 37%; hypertension, 22%; family history, 19%; diabetes mellitus, 6%; cholesterol, 6%; prior angina, 3%; known coronary artery disease, 3%; and prior AMI, 2%. Patients usually had unremarkable ECGs (61% normal, 98% nonischemic). Overall, 11 of 527 patients had adverse CV events (2.1%; 95% CI = 0.9% to 3.3%): 8 AMIs (1.5%), 4 deaths (0.8%), 5 PCIs (0.9%), and no CABG. Twenty-five patients had a final diagnosis of ACS (4.7%; 95% CI = 2.9% to 6.5%). The incidence of ACS in the 210 patients without a cardiac history and without cardiac risk factors was 0.5% (95% CI = 0% to 1.4%). At 30 days, none of these 210 patients had AMI, PCI, CABG, or death (0%, 95% CI = 0% to 1.4%). The incidence of ACS in the 312 patients with normal ECGs and a negative cardiac history was 0.3% (95% CI = 0% to 0.9%). At 30 days, there was no AMI, PCI, or CABG in these 312 patients, and one patient with metastatic cancer died (adverse CV event 0.3%, 95% CI = 0% to 0.9%). Conclusions: Although young patients, as a whole, have a 4.7% risk of ACSs and a 2.1% risk of adverse CV events at 30 days, those without known cardiac disease or any cardiac risk factors had a <1% risk of ACSs and were free from adverse CV events over 30 days. Likewise, young patients without a cardiac history and with a normal ECG had a <1% risk of ACSs and adverse CV events at 30 days. It may be reasonable to expedite outpatient management and limit unnecessary admissions in these cohorts.

Evaluation of a Clinical Decision Rule for Young Adult Patients with Chest Pain

“…This is consistent with the rates of 2.1% and 4.7%, respectively, found in previous descriptions of young adults with 15,20 In our subgroup analyses, the overall rate of ACS was somewhat higher than that described by Walker et al, but the ACS rates were all ,2%.…”

“…[5][6][7][8][9][10][11][12][13] A previous study looked at the clinical characteristics and 30-day outcomes of patients younger than 40 years of age and attempted to define a clinical decision rule for patients at ,1% risk for adverse CV events. 15 We examined this decision rule in a larger cohort of patients approximately twice the size of the above-stated study.…”

“…Walker et al described the characteristics and outcomes of young adult chest pain patients and defined a clinical decision rule for patients younger than 40 years of age. 15 The purpose of this study was to validate the clinical decision rule that young adult chest pain patients without known cardiac disease who had either no cardiac risk factors and/or a normal electrocardiogram (ECG) are at low risk (,1%) for AMI and 30-day adverse CV events.…”

Avoidable Utilization of the Chest Pain Observation Unit

“…Because female patients are more likely to present with atypical symptoms of ACS, we expected that female sex, rather than male sex, would be associated with avoidable CPOU utilization. 19–21 However, our findings are consistent with a large body of literature demonstrating that men are more likely than women to receive testing for ACS. 22–26 Chest pressure, vomiting, and lightheadedness may be associated with increased avoidable CPOU placement because physicians may consider these features concerning for ACS and therefore increasing their likelihood of CPOU utilization.…”

How “Low” Can We Go: Assessing Risk in Chest Pain Patients

“…[1][2][3] Two articles in this issue of Academic Emergency Medicine attempt to further answer the question of which chest pain patients we can send home. The study by Walker et al 4 addresses the issue of whether younger patients without cardiac history, risk factors, and ECG abnormalities are truly at low risk for adverse cardiovascular events. In the 16-month study period, the authors prospectively identified and followed 487 patients between the ages of 24 and 39 years presenting to a university ED with non-cocaine-related chest pain.…”