Original Article

How to Improve the Management of Chest Pain: Hospitalists and Use of Prediction Rules

Authors: Beril Cakir, MD, Kay Blue, RN

Abstract

Background: Three percent of patients with acute myocardial infarction are still missed despite the excess number of admissions with chest pain. The purpose of this study was to review the characteristics of patients who were admitted with chest pain, to evaluate the appropriateness of admissions and the outcomes. We also discuss whether use of a prediction rule could have made a difference in the management of these cases.


Methods: We performed retrospective chart review on all patients admitted to the hospitalist service with a diagnosis of chest pain. Each patient was risk stratified using Diamond and Forrester algorithm for probability of coronary artery disease (CAD), retrospectively. Results were analyzed using χ2 test or exact test and Student’s t test.


Results: Of 260 patients admitted with chest pain to the hospitalist service, only 24 (9.2%) received the final diagnosis of acute coronary syndrome (ACS). The patients in the ACS group were older and more likely to be male and to have a history of hyperlipidemia, CAD, peripheral vascular disease, cerebrovascular disease and percutaneous coronary intervention (PCI). Of 34 patients who underwent cardiac catheterization, 20 (58.8%) had occlusive CAD and 14 of them received PCI. Risk stratification of patients, retrospectively, revealed 28.3% of the total patient population was high risk, while 6.6% of them were low risk. The number of ACS cases was highest in the high risk group, while none was detected in the low risk group.


Conclusions: Our study demonstrated that using a prediction rule could have prevented about 6% of the chest pain admissions. Therefore, the use of risk stratification methods should be encouraged to decrease cost and improve efficiency of care.


Key Points


* Missed acute myocardial infarction ranks as the highest single diagnosis in terms of dollars paid in malpractice against ED physicians.


* As hospital medicine makes a name for itself, hospitalists are being asked to take on more and more responsibility for triaging/admitting chest pain patients.


* Use of risk stratification methods/prediction rules should be encouraged to improve cost and care efficiency in the management of chest pain.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Miller CD, Lindsell CJ, Khandelwal S, et al. Is the initial diagnostic impression of noncardiac chest pain adequate to exclude cardiac disease? Ann Emerg Med 2004;44:565–574.
 
2. Blomkalns AL, Gibler WB. Development of the chest pain center: rationale, implementation, efficacy, and cost effectiveness. Prog Cardiovasc Dis 2004;46:393–403.
 
3. Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am 2001;19:87–103.
 
4. Wilkinson K, Severance H. Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am 2001;19:35–66.
 
5. Kamineni R, Alpert JS. Acute coronary syndromes: initial evaluation and risk stratification. Prog Cardiovasc Dis 2004;46:379–392.
 
6. Hollander JE, Blomkalns AL, Brogan GX, et al. Standardized reporting guidelines for studies evaluating risk stratification of emergency department patients with potential acute coronary syndromes. Ann Emerg Med 2004;44:589–598.
 
7. Morise AP. Comparison of the Diamond-Forrseter method and a new score to estimate the pretest probability of coronary disease before exercise testing. Am Heart J 1999;138:740–745.
 
8. Diercks DB, Hollander JE, Sites F, et al. Derivation and validation of a risk stratification model to identify coronary artery disease in women who present to the emergency department with potential coronary artery disease. Acad Emerg Med 2004;11:630–634.
 
9. Selker H, Beshansky JR, Griffith JL, et al. Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia: a multicenter, controlled clinical trial. Ann Intern Med 1998;129:845–855.
 
10. Gibler WB, Cannon CP, Blomkalns AL, et al. Practical implementation of the guidelines for unstable angina/NSTEMI in the emergency department. Ann Emerg Med 2005;46:185–197.
 
11. Pollack CV, Gibler WB. 2000 ACC/AHA guidelines for the management of patients with unstable angina and NSTEMI: Practical summary for emergency physicians. Ann Emerg Med 2001;38:229–240.
 
12. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guidelines for the management of patients with unstable angina and NSTEMI: Executive summary and recommendations. Circulation 2000;102:1193–1209.
 
13. Sequist TD, Bates DW, Cook EF, et al. Prediction of missed MI among symptomatic outpatients without coronary artery disease. Am Heart J 2005;149:74–81.
 
14. Bhatt DL, Roe MT, Peterson ED, et al. Utilization of early invasive management strategies for high risk patients with non-ST segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 2004;292:2096–2104.
 
15. Storrow AB, Gibler WB. Chest pain centers: diagnosis of acute coronary syndromes. Ann Emerg Med 2000;35:449–461.
 
16. Gomberd-Maitland M, Murphy SB, Moliterno DJ, et al. Are we appropriately triaging patients with unstable angina? Am Heart J 2005;149:613–618.