Trends in Care and Outcomes Among Emergency Department Patients With Chest Pain Without Myocardial Infarction

Study objective To characterize trends in hospitalization, downstream care, and outcomes among emergency department (ED) patients with chest pain without acute myocardial infarction (AMI) diagnosis. Methods We analyzed claims data from a large national commercial insurer (2007-2021) and identified ED visits with a principal diagnosis of chest pain. We excluded visits with secondary diagnoses of AMI or other significant cardiopulmonary conditions and those preceded by cardiac testing, coronary procedures, AMI admissions, or chest pain ED visits within 6 months. Usage outcomes included index hospitalization (principal), 7-day cardiac testing, and 30-day coronary revascularization. The principal clinical outcome was 180-day postindex AMI hospitalization. Adjusted annual rates were estimated using generalized estimating equations, and trends were assessed using inverse-variance-weighted linear regression. Results We included 773,250 index chest pain ED visits (mean age 54.2 years; 54.3% women). Adjusted hospitalization rates declined from 42.7% to 18.6%, and 7-day noninvasive testing decreased from 26.7% to 9.1%. Revascularization within 30 days declined from 5.8% to 3.6%. Overall, 180-day postindex AMI hospitalization showed no significant temporal trend, ranging from 0.8% to 1.2%. However, a modest increasing trend was observed among patients aged 70 years and older. Conclusion Among ED patients with chest pain without AMI diagnosis, hospitalization, cardiac testing, and revascularization declined substantially from 2007 to 2021. Overall, downstream AMI hospitalization remained stable, although those in older adults experienced modest rises. Although efforts continue to identify additional low-risk patients for safe discharge, future research should quantify the potential benefits of hospitalization and cardiac testing, particularly for older adults and high-risk patients.