Key result
Inpatient evaluation shows no benefit over early ER discharge for 30-day adverse cardiac events.
Why the study?
The best disposition of chest pain patients who rule out for MI but have non-low clinical risk scores in the high-sensitivity troponin era is not well studied.
Does inpatient evaluation reduce the incidence of 30-day adverse cardiac events in emergency room patients with chest pain who rule out for MI compared to early ER discharge?
Case-Control (n=2,060)
Yes
Does inpatient evaluation reduce the incidence of 30-day adverse cardiac events in emergency room patients with chest pain who rule out for MI compared to early ER discharge?
Absolute Event Rate: 0.6% vs 0.4%
p-value: p=0.76
In carefully selected patients who rule out for MI, early ER discharge appears to be a safe alternative to inpatient evaluation without an increase in short-term adverse cardiac events.
BACKGROUND: The best disposition of chest pain patients who rule out for myocardial infarction (MI) but have non-low clinical risk scores in the high-sensitivity troponin era is not well studied. HYPOTHESIS: In carefully selected patients who rule out for MI, and have a high-sensitivity troponin T ≤ 50 ng/L with an absolute increase less than 5 ng/L on repeat measurements, early emergency room (ER) discharge might be equivalent to inpatient evaluation in regards to 30-day incidence of adverse cardiac events (ACEs) regardless of the clinical risk score. METHODS: A total of 12 847 chest pain patients presenting to our health system ERs from January 2017 to September 2019 were retrospectively investigated. A propensity score matching algorithm was used to account for baseline differences between admitted and discharged cohorts. We then estimated and compared the incidence of 30-day and 1-year composite ACEs (MI, urgent revascularization, or cardiovascular death) between both groups. A multivariate Cox regression model was used to evaluate the effect of admission on outcomes. RESULTS: A total of 2060 patients were matched in 1:1 fashion. The primary endpoint of 30-day composite ACEs occurred in 0.6% and 0.4% of the admission and the discharged cohorts, respectively (P = .76). One-year composite ACEs was also similar between both groups (4% vs 3.7%, P = .75). In a multivariate Cox regression model, the effect of inpatient evaluation was neutral (hazard ratio 1.1, confidence interval 0.62-1.9, P = .75). CONCLUSIONS: Inpatient evaluation was not associated with better outcomes in our selected group of patients. Larger-scale randomized trials are needed to confirm our findings.
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Mahmoud et al. (2020) conducted a case-control in Chest pain, ruled out for myocardial infarction (n=2,060). Inpatient evaluation vs. Early emergency room (ER) discharge (outpatient evaluation) was evaluated on 30-day composite adverse cardiac events (urgent revascularization, myocardial infarction, or cardiovascular death) (p=0.76). Inpatient evaluation of selected chest pain patients who ruled out for MI was not associated with a lower incidence of 30-day adverse cardiac events compared to early ER discharge (0.6% vs 0.4%, P=0.76).
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