Utility of Observation Units for Young Emergency Department Chest Pain Patients

Abstract

2Background: Determining which patients presenting to the emergency department (ED) require

Low-risk Chest Pain Patients Younger Than 40 Years Do Not Benefit From Admission and Stress Testing

“…recent studies have had variable results with positive stress test rates ranging from 3% to 6%. 11,12 However, all the positive stress tests in these studies were considered false-positives except for one. 11 Stress utilization in our cohort was of no yield and also was not associated with false-positives as it has been in other studies.…”

“…6-10 Subsequent studies have also suggested a low utility of routine stress testing in such observation patients, given the low true positive rate. 5,11,12 We hypothesized that observation and selective stress testing in patients age <40 with no history of coronary artery disease (caD), a nonischemic electrocardiogram (ecg), and a normal first troponin i were of very low utility [<1% acute coronary syndrome (acS) or Mace].…”

False-Positive Rates of Provocative Cardiac Testing in Chest Pain Patients Admitted to an Emergency Department Observation Unit

“…2 Several recent studies suggest particularly little benefit, and potential harm, when routine cardiac testing is performed in low-risk eD populations under the age of 40 due to a high likelihood of false-positive or indeterminate test results. [8][9][10] Prasad et al, based on their interpretation of multiple nationalscale studies attempting to link diagnostic testing with cardiac outcomes, noted that although caD is increasingly diagnosed, the rates of aMi are failing to decline. [12][13][14][15][16] this may relate in part to the fact that a clearly defined, consensus strategy to risk stratify and guide the disposition of chest pain patients remains elusive, and the current practice of routine cardiac stress testing or advanced cardiac imaging may indeed have an unfavorable risk-benefit ratio for low-risk chest pain patients.…”

“…[5][6][7][17][18][19][20] instead, it highlights an area for further research aimed at clarifying and improving risk-stratification guidelines for chest pain patients in eDOUs and refining the way in which patients are selected to proceed to undergo provocative testing. [8][9][10]12 Our focus on patients with a positive provocative test and negative catheterization answered the initial question of whether or not an efficiency issue exists in the selection of patients who receive provocative testing in this setting. the next step -determining how to improve patient selection -will require further research into test results of all kinds: positive and negative, true and false.…”

“…thus, these combined eDOU study results support the call of others for further refinement of testing procedures and guidelines. [8][9][10][11][12][14][15][16] the acc and aHa additionally acknowledge that optimal strategies to evaluate chest pain in young adult, female and hypertensive individuals have yet to be elucidated. 4,22 identifying factors that lead to patients receiving unnecessary diagnostic testing has the potential to spur the development of better diagnostic and treatment pathways and to reduce healthcare costs.…”