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Can ED chest pain patients with intermediate HEART scores be managed as outpatients?

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Abstract

Purpose

Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics.

Methods

This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score.

Results

There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7–32.3) and history (5.3, 95% CI: 2.4–11.8).

Conclusion

This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.

Résumé

Objectif

Les directives actuelles recommandent l'admission à l'hôpital des patients qui se présentent aux urgences avec une douleur thoracique et qui sont classés comme présentant un risque intermédiaire d'effets indésirables selon le score HEART. Bien que l’hospitalisation de ces patients permette une investigation et un traitement en temps opportun, il s’agit d’un processus exigeant en ressources. Cette étude examine si les patients ayant un score HEART intermédiaire peuvent être pris en charge en toute sécurité en ambulatoire par des cliniques d'accès rapide aux douleurs thoraciques.

Méthodes

Cette étude observationnelle rétrospective a inclus tous les patients souffrant de douleurs thoraciques aux urgences orientés vers des cliniques d'accès rapide de janvier 2018 à avril 2020 à Regina et Saskatoon, en Saskatchewan. Les scores HEART des médecins des urgences ont été utilisés à la place des scores HEART des examinateurs lorsqu'ils étaient disponibles. Le principal résultat était le taux d'événements coronariens indésirables majeurs (MACE), une mesure composite du décès, du syndrome coronarien aigu, de l'accident vasculaire cérébral, de l'angiographie coronaire et de la revascularisation à 6 semaines chez les patients à risque intermédiaire. Les résultats secondaires étaient le type de MACE, le taux de MACE avant un rendez-vous à la clinique d’accès rapide et la composante la plus prédictive du score HEART.

Résultats

Il y a eu 1989 orientations vers les urgences, dont 817 pour des patients à risque intermédiaire. 9,3 % des patients à risque intermédiaire ont subi un MACE à 6 semaines. Un MACE est survenu avant le suivi clinique d'accès rapide chez 1,1 % des patients à risque intermédiaire, la coronarographie étant le MACE le plus fréquent. À l’exclusion de l’angiographie coronarienne, le risque de MACE avant le suivi clinique d’accès rapide était de 0,7 % chez les patients à risque intermédiaire. Les composants du score HEART les plus prédictifs de MACE étaient la troponine (OR 11,0, IC 95 % : 3,7-32,3) et les antécédents (5,3, IC 95 % : 2,4-11,8).

Conclusion

Cette étude démontre que les cliniques d'accès rapide sont probablement une alternative sûre à l'admission pour les patients souffrant de douleurs thoraciques à risque intermédiaire et pourraient réduire les admissions coûteuses de patients hospitalisés pour des douleurs thoraciques. En excluant l'angiographie, les taux de MACE étaient bien inférieurs au seuil de 2 % cité par l'American College of Emergency Physicians.

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Availability of data and materials

The data supporting the findings of the study are available within the article. Raw data will be stored with the principal investigator.

Code availability

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Acknowledgements

We thank the staff at the College of Medicine Clinical Research Support Unit for their statistical support, and the rapid access clinics and Health Records Departments at both sites for their assistance in data retrieval.

Funding

This research project was funded by the College of Medicine Office of the Vice-Dean Research Dean’s Summer Research Project Fund and the Department of Emergency Medicine Chief’s Discretionary Funds.

Author information

Authors and Affiliations

  1. College of Medicine, University of Saskatchewan, Regina, SK, Canada

    Aisha Moustapha & Alicia C. Mah

  2. Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada

    Lauren Roberts, Andrew Leach & Lynsey J. Martin

  3. Department of Emergency Medicine, University of Saskatchewan, Regina, SK, Canada

    Glenda Kaban

  4. Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Regina, SK, Canada

    Rodney Zimmermann

  5. Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Saskatoon, SK, Canada

    Jay Shavadia & Jason Orvold

  6. Clinical Research Support Unit, College of Medicine, Saskatoon, SK, Canada

    Prosanta Mondal

Authors
  1. Aisha Moustapha
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Contributions

LM devised the study and supervised the project. LM, AL and LR submitted the project for ethics and operational approval and provided support during data collection and manuscript writing. AL reviewed ECG scoring and HEART scores given. LR obtained patient records from the rapid access clinics at each site, reviewed data abstraction, and provided statistical support. ACM and AM participated equally in data collection and manuscript writing. LR, AL, and LM provided primary manuscript revisions. PM performed the statistical analysis. GK, JO, JS and RZ provided research support during data collection and manuscript writing and revisions.

Corresponding author

Correspondence to Lynsey J. Martin.

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Conflict of interest

None to declare.

Ethical approval

This project was approved by the University of Saskatchewan Biomedical Research Ethics Board (REB-1794).

Consent to participate

Waiver of consent granted by the University of Saskatchewan Biomedical Research Ethics Board.

Consent for publication

Waiver of consent granted by the University of Saskatchewan Biomedical Research Ethics Board.

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Moustapha, A., Mah, A.C., Roberts, L. et al. Can ED chest pain patients with intermediate HEART scores be managed as outpatients?. Can J Emerg Med 24, 770–779 (2022). https://doi.org/10.1007/s43678-022-00355-4

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  • DOI: https://doi.org/10.1007/s43678-022-00355-4

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