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Is routine coagulation testing necessary in patients presenting to the emergency department with chest pain?
1Department of Emergency Medicine, Southampton University Hospitals NHS Trust, Tremona Road, Southampton, Hants SO16 6YD, UK.
Insights
Routine coagulation tests for emergency department patients with chest pain are unnecessary. Testing should be reserved for patients with a history of liver disease or those using warfarin or heparin, reducing unnecessary blood work.
Area of Science:
- Emergency Medicine
- Cardiology
- Clinical Pathology
Background:
- Emergency departments (EDs) often perform protocolized blood tests before full clinical assessment due to the need for rapid patient management.
- Cardiologists at this institution require coagulation profiles for all patients with suspected acute coronary syndrome (ACS).
Purpose of the Study:
- To evaluate the necessity of routine coagulation testing in emergency department patients presenting with chest pain.
- To determine if current coagulation testing practices for suspected ACS align with clinical necessity.
Main Methods:
- A retrospective cohort study of 1000 consecutive patients presenting to the ED with chest pain was conducted.
- International Normalized Ratio (INR) and Activated Partial Thromboplastin Time Ratio (APTR) were retrieved. A 24-hour follow-up was performed if initial tests were not sent from the ED.
- Potential causes for abnormal coagulation results were assessed based on initial patient evaluation.
Main Results:
- Coagulation tests were performed on 640 patients; 79 of 592 processed samples showed abnormal results.
- All abnormal coagulation tests were predictable based on patient history (warfarin/heparin use, liver disease) or were clinically insignificant.
- Abnormal results did not preclude necessary interventions like coronary angiography or therapeutic heparin use.
Conclusions:
- Routine coagulation testing in adults presenting to the ED with chest pain is not necessary.
- Coagulation testing policies should be revised to target patients with increased risk of coagulopathy (e.g., warfarin/heparin use, liver disease).
Background:
Driven by the need for rapid assessment, treatment and appropriate disposition of patients in the emergency department (ED), blood tests are often performed in a protocolised fashion before full clinical assessment. The cardiologists at this institution currently insist upon a coagulation profile in each patient referred with a possible acute coronary syndrome.
Methods:
A retrospective cohort of 1000 consecutive patients presenting to the ED with chest pain was identified. If performed, the international normalised ratio (INR) and the activated partial thromboplastin time ratio (APTR) were retrieved for each patient. If no coagulation sample was sent from the ED, a search was performed to determine whether a sample was sent within the subsequent 24-h period by the admitting hospital team. A cause of a raised INR or APTR that could have been identified easily at initial patient assessment in the ED was sought.
Results:
640 patients were identified who had coagulation tests sent from the ED as part of their assessment. Of the 592 coagulation samples successfully processed 79 were abnormal. All of these abnormal tests could have been predicted on the basis of a history of warfarin or heparin use or a history of liver disease, or were trivial enough to not preclude coronary angiography or the therapeutic use of heparin.
Conclusion:
Routine coagulation testing in adults presenting to ED with chest pain is unnecessary. This practice should be replaced by a coagulation testing policy based on an increased risk of coagulopathy due to warfarin or heparin use or a history of liver disease.
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