Association of Chest Pain Protocol-Discordant Discharge With Outcomes Among Emergency Department Patients With Modest
Ayesha Khan1, Muhammad S Saleem1, Keith D Willner2
1Geisinger Northeast Internal Medicine Residency Program, Wilkes-Barre, Pennsylvania.
Insights
Discharging chest pain patients with abnormal accelerated diagnostic protocols (ADPs) using high-sensitivity troponin (hsTn) despite rule-in increases major adverse cardiac events (MACE). A HEART score may help identify high-risk patients for closer monitoring.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- Accelerated diagnostic protocols (ADPs) using high-sensitivity troponin (hsTn) are effective for ruling out cardiac events in chest pain patients.
- Limited data exist on outcomes for patients discharged with modestly elevated hsTn levels after ADP assessment.
Purpose of the Study:
- To evaluate the outcomes of patients discharged following ADP assessment, specifically those with mildly elevated hsTnT levels who were discharged.
- To identify factors associated with adverse cardiac events in this patient group.
Main Methods:
- Retrospective cohort study of 10,342 chest pain patients discharged from emergency departments between January 2017 and September 2019.
- Patients had peak hsTnT levels between the limit of quantitation and 52 ng/L.
- Comparison of 30-day major adverse cardiac events (MACE) between ADP-concordant and ADP-discordant discharges.
Main Results:
- Overall MACE rate was 0.28% (29/10,342).
- ADP discordance was independently associated with a 5-fold increased risk of MACE (OR, 6.42).
- Patients with peak hsTnT between 12-51 ng/L discharged discordantly had a significantly higher MACE rate (2.30% vs 0.48%).
- A HEART score of 4 or greater identified 81.3% of ADP-discordant discharges who experienced MACE.
Conclusions:
- Discharging patients with chest pain despite ADP-discordant hsTnT results is associated with significantly higher MACE rates.
- ADP-concordant rule-outs identify low-risk patients, but discordance warrants caution.
- The HEART score may aid in identifying high-risk patients with discordant ADP results, potentially improving discharge decisions.
Importance:
Accelerated diagnostic protocols (ADPs) for chest pain using high-sensitivity troponin (hsTn) levels have excellent sensitivity and negative predictive value for rapid risk stratification of patients with chest pain. However, little is known about the outcomes of patients who are discharged despite abnormal ADP results, ie, after "ruling-in" with a modest elevation of hsTn.
Objective:
To determine outcomes of patients discharged following ADP, including those who were ruled in with modestly elevated levels of hsTnT but discharged nonetheless.
Design, Setting, And Participants:
This retrospective cohort study included patients with chest pain who presented to the emergency departments (EDs) of a large multisite health system ED between January 2017 to September 2019. Patients were assessed using an ADP, had a peak hsTnT level measured between the limit of quantitation and 52 ng/L, were discharged, and had follow-up in the electronic medical record. Data analysis was conducted from January 2017 to September 2019.
Exposures:
Application of an hsTnT ADP.
Main Outcomes And Measures:
Thirty-day major adverse cardiac events (MACE), including myocardial infarction, urgent coronary revascularization, and all-cause death, comparing patients who were discharged following ADP-concordant vs ADP-discordant results.
Results:
Of 10 342 patients with chest pain (mean [SD] age 51 [17] years; 5902 [57%] women) discharged following ADP, 29 (0.28%) had MACE. Patients with MACE were older (median [IQR] age, 66 [53-75] years vs 50 [38-62] years; P < .001) and more likely to have prior CAD (12 [41.4%] vs 1805 [17.5%]; P = .002) and hyperlipidemia (13 [44.8%] vs 2248 [21.8%]; P = .006). Additionally, patients with MACE were 5-fold more likely to have been discharged despite ADP discordance (16 [55.2%] vs 1145 [11.1%]; P < .001). A multivariable logistic regression analysis revealed only ADP discordance was independently associated with MACE (odds ratio, 6.42 [95% CI, 2.94-14.0]; P < .001). When stratified by peak hsTnT level, there were no differences in MACE between ADP-concordant and -discordant discharges provided the peak hsTnT measured was less than 12 ng/L. In contrast, patients with peak hsTnT level between 12 and 51 ng/L were significantly more likely to have MACE if they were discharged after ADP-discordant vs -concordant hsTnT series (14 of 609 [2.30%] vs 5 of 1047 [0.48%]; P < .002). Notably, a HEART (history, electrocardiogram, age, risk factors, troponin) score of 4 or greater retrospectively identified the most ADP-discordant discharges (13 of 16 [81.3%]) who had MACE.
Conclusions And Relevance:
In this cohort study, an hsTnT ADP identified patients who could be discharged from the ED with low 30-day risk of MACE, provided the discharge was based on ADP-concordant "rule-out." Conversely, the rate of MACE was significantly higher among patients discharged despite ADP discordance. Most patients with ADP-discordant discharges who experienced MACE had a HEART score of 4 or greater, suggesting that application of this score may augment discharge decisions of patients despite ADP-discordant troponin series.
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