A comparative 30-day outcome analysis of inpatient evaluation vs outpatient testing in patients presenting with chest pain in the high-sensitivity troponin era. A propensity score matched case-control retrospective study.
Aged
Biomarkers
/ blood
Chest Pain
/ blood
Emergency Service, Hospital
/ statistics & numerical data
Female
Follow-Up Studies
Humans
Incidence
Inpatients
Male
Middle Aged
Myocardial Infarction
/ blood
Outpatients
Propensity Score
Retrospective Studies
Risk Assessment
/ methods
Troponin
/ blood
United States
/ epidemiology
HEART score performance.
chest pain disposition
high-sensitivity troponin
Journal
Clinical cardiology
ISSN: 1932-8737
Titre abrégé: Clin Cardiol
Pays: United States
ID NLM: 7903272
Informations de publication
Date de publication:
Nov 2020
Nov 2020
Historique:
received:
01
05
2020
revised:
14
07
2020
accepted:
17
07
2020
pubmed:
5
8
2020
medline:
11
8
2021
entrez:
5
8
2020
Statut:
ppublish
Résumé
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. 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. 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. 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). Inpatient evaluation was not associated with better outcomes in our selected group of patients. Larger-scale randomized trials are needed to confirm our findings.
Sections du résumé
BACKGROUND
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
OBJECTIVE
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
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
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
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.
Identifiants
pubmed: 32748994
doi: 10.1002/clc.23435
pmc: PMC7661656
doi:
Substances chimiques
Biomarkers
0
Troponin
0
Types de publication
Comparative Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1248-1254Subventions
Organisme : Geisinger Health System Foundation
ID : 20-058
Informations de copyright
© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.
Références
Acad Emerg Med. 2015 Aug;22(8):955-64
pubmed: 26205260
Circulation. 2018 Nov 13;138(20):e618-e651
pubmed: 30571511
J Patient Saf. 2013 Sep;9(3):122-8
pubmed: 23860193
JAMA Cardiol. 2018 Feb 1;3(2):104-111
pubmed: 29238804
Neth Heart J. 2008 Jun;16(6):191-6
pubmed: 18665203
Ann Intern Med. 2003 Feb 4;138(3):161-7
pubmed: 12558354
Clin Chem. 2011 Sep;57(9):1318-26
pubmed: 21771945
Clin Cardiol. 2020 Nov;43(11):1248-1254
pubmed: 32748994
J Am Coll Cardiol. 2018 Feb 13;71(6):606-616
pubmed: 29420956
Health Serv Res. 2014 Oct;49(5):1701-20
pubmed: 24779867
Int J Cardiol. 2013 Oct 3;168(3):2153-8
pubmed: 23465250
Eur Heart J. 2016 Jan 14;37(3):267-315
pubmed: 26320110
Eur Heart J Acute Cardiovasc Care. 2018 Mar;7(2):111-119
pubmed: 28534694
CMAJ. 2010 Jul 13;182(10):1039-44
pubmed: 20530163
Circulation. 2018 Nov 27;138(22):2456-2468
pubmed: 30571347
JAMA Intern Med. 2015 Jul;175(7):1207-12
pubmed: 25985100
JAMA Cardiol. 2016 Jul 1;1(4):405-12
pubmed: 27438316
Circulation. 2014 Dec 23;130(25):e344-426
pubmed: 25249585
BMC Emerg Med. 2006 May 04;6:6
pubmed: 16674827
N Engl J Med. 1979 Jun 14;300(24):1350-8
pubmed: 440357
J Am Coll Cardiol. 2019 Feb 26;73(7):873-875
pubmed: 30784680
Int J Cardiol. 2017 Oct 15;245:43-48
pubmed: 28874298
J Clin Epidemiol. 2013 Aug;66(8 Suppl):S84-S90.e1
pubmed: 23849158