Compliance With Outpatient Stress Testing in Low-risk Patients Presenting to the Emergency Department With Chest Pain

Abstract

Recent evidence suggests that stress testing prior to emergency department (ED) release in low-risk chest pain patients identifies those who can be safely discharged home. When immediate stress testing is not feasible, rapid outpatient stress testing has been recommended. The objective of this study was to determine compliance rate and incidence of adverse cardiac events in patients presenting to the ED with low-risk chest pain referred for outpatient stress testing. Retrospective chart and social security death index review were conducted in 448 consecutive chest pain patients who presented to a university hospital and level I trauma center between April 30 and December 31, 2007. Patients were evaluated with an accelerated chest pain protocol defined as a 4-hour ED rule out and referral for outpatient stress testing within 72 hours of ED release. Only patients without known cardiac disease, a thrombolysis in myocardial infarction risk score ≤2, negative serial ECGs and cardiac biomarkers, and benign ED course were eligible for the protocol. Primary outcome measures included compliance with outpatient stress testing and documented 30-day incidence of adverse cardiac events following ED release. The social security death index was queried to determine 12-month incidence of all-cause mortality in enrolled patients. Logistic regression analysis of characteristics associated with outpatient stress test compliance was determined and incidence of adverse cardiac events in those who were and were not compliant with outpatient stress testing was compared. Significance was set at P < 0.05. A total of 188 patients (42%) completed outpatient stress testing, but only 27 (6%) completed testing within 72 hours of ED discharge. Compliance was correlated with insurance and race, but not patient age, gender, or thrombolysis in myocardial infarction risk score. No significant differences in adverse cardiac events were documented in patients who did and did not comply with outpatient stress testing. Compliance with outpatient stress testing is poor in low-risk chest pain patients following ED release. Despite poor compliance, the documented incidence of adverse cardiac events in this low-risk cohort was lower than that reported in patients with negative provocative testing prior to ED release.

Performance of an outpatient stress testing protocol for low risk chest pain patients presenting to the emergency department

“…In a smaller study in a similar population, Milano et al had similar findings, with 42% of patients returning for testing, but only 6% within 72 h [4]. Studies of patients with insurance, or in other countries, have had more success [5][6][7].…”

Compliance with stress testing in patients discharged from the emergency department following a diagnosis of low-risk chest pain

“…The primary benefits of using a risk stratification protocol in the ED are to improve our ability to diagnose cardiac disease in patients presenting with chest pain while allowing for the identification of patients who may be safely discharged from the ED 11. Implementation of risk stratification guidelines does result in a reduction in the re-presentation rates of patients with chest pain 13.…”

“…Patient compliance with outpatient stress testing varies from 42% to 63% when patients are instructed to follow-up with their PCP to organise testing 11 15–17. The relatively wide range of compliance rates may be partly attributable to the availability of universal health care in some nations and the lack of it in others 18.…”

“…While this approach has been shown to be safe in low-risk patients, there is evidence that patient compliance with outpatient EST is poor 11 12. There does not appear to be an increase in adverse cardiac events (ACE) in the short term for these patients, but patients with significant disease have increased rates of mortality, long term, if they are not followed-up appropriately 4.…”

Chest pain research in Australasian emergency medicine: Putting our mark on the world stage

“…As many emergency physicians are aware, early provocative testing is difficult or near‐impossible to organize in the majority of hospitals, with under 10% of the intermediate/low‐risk patients receiving early testing even in the USA 4 . The ASPECT finding was important for this group, as it should take some of the angst away when discharging back to normal care a group of patients at very low risk of MACE.…”