“Chest pain—please admit”: is there an alternative?: A rapid cardiological assessment service may prevent unnecessary admissions
TL;DR: Any scheme which safely avoided these unnecessary admissions might save resources, reduce stress for patients, and, crucially, reduce the worrying false negatives—those missed cases of high risk coronary heart disease.
Abstract: Emergency medical admissions are important. They continue to rise year after year; consume substantial NHS resources; disrupt other NHS activities; and generate winter bed crises.1 2 Patients with acute central chest pain account for 20-30% of emergency medical admissions.3 4 Most are admitted because of concern about unstable coronary heart disease. Yet fewer than half will have a final diagnosis of acute myocardial infarction or unstable angina.4 Patients without high risk coronary heart disease thus account for over half those presenting with chest pain and over 10% of all emergency medical admissions. Such patients could be safely managed without admission, and most would prefer it. The current system is therefore both ineffective and inefficient. Any scheme which safely avoided these unnecessary admissions might save resources, reduce stress for patients, and, crucially, reduce the worrying false negatives—those missed cases of high risk coronary heart disease. …
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TL;DR: Care in a chest pain observation unit seems to be more effective and more cost effective than routine care for patients with acute, undifferentiated chest pain.
Abstract: Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing
254 citations
TL;DR: This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention.
Abstract: Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.
The objective of this review is to investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.
110 citations
TL;DR: A group of patients admitted over five weeks with chest pain suspected of being cardiac in origin were studied to see how far causation was pursued and how their mortality compared with that of patients with a proven cardiac cause for their symptoms.
Abstract: In patients with acute chest pain the prime need, usually, is to diagnose and treat myocardial infarction or ischaemia. When a cardiac origin for the pain has been excluded, patients are commonly discharged without either a diagnosis or a plan for follow-up. We studied a group of such patients to see how far causation was pursued and how their mortality compared with that of patients with a proven cardiac cause for their symptoms. The study population was 250 patients admitted over five weeks with chest pain suspected of being cardiac in origin. Initial assessment included an electrocardiogram and measurement of troponin T. If neither of these indicated a cardiac event, the patient was deemed to have 'atypical' chest pain and the cause, where defined, was recorded. Outcomes at one year were determined by questionnaire and by assessment of medical notes. Of the 250 patients, 142 had cardiac pain (mean age 79 years, 58% male) and 108 atypical chest pain (mean age 60 years, 55% male). Of those with atypical pain, 40 were discharged without a diagnosis; in the remaining 68 the pain was thought to be musculoskeletal (25), cardiac (21), gastrointestinal (12) or respiratory (10) in origin. 41 patients were given a follow-up appointment on discharge. At one year, data were available on 103 (96%) patients. The mortality rate was 2.9% (3 patients) compared with 18.3% in those with an original cardiac event. Half of the patients with atypical pain had undergone further investigations and 14% had been readmitted. The yield of investigative procedures was generally low (20%) but at the end of the year only 27 patients remained undiagnosed. Patients with atypical chest pain form a substantial proportion of emergency admissions. The symptoms often persist or recur. The commonest causation is musculoskeletal, but a sizeable minority remain undiagnosed even after follow-up.
77 citations
TL;DR: The chest pain observation unit is a practical alternative to routine care for acute chest pain in the United Kingdom and effectively rules out immediate, serious morbidity, but not longer term morbidity and mortality.
Abstract: Objectives: To establish a chest pain observation unit, monitor its performance in terms of appropriate discharge after assessment, and estimate the cost per patient.
Methods: Prospective, observational, cohort study of patients attending a large, city, teaching hospital accident and emergency department between 1 March 1999 and 29 February 2000 with acute undifferentiated chest pain. Patients were managed on a chest pain observation unit, entailing two to six hours of observation, serial electrocardiograph recording, cardiac enzyme measurement, and, where appropriate, exercise stress test. Patients were discharged home if all tests were negative and admitted to hospital if tests were positive or equivocal. The following outcomes were measured—proportion of participants discharged after assessment; clinical status three days after discharge; cardiac events and procedures during the following six months; and cost of assessment and admission.
Results: Twenty three participants (4.3%) had a final diagnosis of myocardial infarction. All were detected and admitted to hospital. A total of 461 patients (86.3%) were discharged after assessment, 357 (66.9%) avoided hospital admission entirely. At review three days later these patients had no new ECG changes and only one raised troponin T measurement. In the six months after assessment, three cardiac deaths, two myocardial infarctions, and two revascularisation procedures were recorded among those discharged. The mean cost of assessment and hospital admission was £221 per patient, or £323 if subsequent interventional cardiology costs were included.
Conclusions: The chest pain observation unit is a practical alternative to routine care for acute chest pain in the United Kingdom. Negative assessment effectively rules out immediate, serious morbidity, but not longer term morbidity and mortality. Costs seem to be similar to routine care.
71 citations
TL;DR: The most commonly encountered syndromes of focal musculoskeletal disorders in clinical practice are summarized.
70 citations
References
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TL;DR: These guidelines are intended for physicians, nurses, and allied healthcare personnel who care for patients with suspected or established acute myocardial infarction and promote rapid identification and treatment of patients with acute MI.
1,630 citations
TL;DR: The American College of Cardiology and the American Heart Association request that the following format be used when citing this document: Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hiratzka LF, Rapaport E, Riegel B, Russell RO, Smith EE III, Weaver WD.
1,325 citations
TL;DR: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk for cardiovascular events receive appropriate care.
Abstract: Background Nearly half of patients hospitalized with unstable angina eventually receive a non–cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. Methods We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST-segment monitoring, determination of creatine kinase is...
532 citations
01 Jan 1998
270 citations
TL;DR: Analysis of linked data has confirmed that the rise in emergency admissions in Scotland is genuine, and only 2% of the increase can be explained by population aging.
Abstract: Emergency admissions in Britain are continuing to rise.1 The highly publicised bed crisis this winter and a number of national meetings have underlined concern over the lack of explanations and frustration at the lack of control. In Scotland, emergency admissions increased by 45% between 1981 and 1994 (fig 1). This represented an annual increase of about 3%, rising to over 5% in 1993 and 1994,2 and probably in 1995. Even steeper increases have been reported by individual hospitals throughout Britain.1 2 In stark contrast, elective admissions have increased by only 1% a year.3 Emergency hospital admissions account for about 40% of total acute bed use in the NHS.2
Trends in elective and emergency admissions in Scotland
Why is this rise occurring? Potential explanations need to account for its generality and persistence. Hospital admissions have actually been increasing for some four decades.1 3 Some recent inflation in the figures was caused by the use of finished consultant episodes and more complete recording. However, analysis of linked data has confirmed that the rise is genuine.2 Only 2% of the increase can be explained by population aging.1 2 Although all age groups and diagnostic categories are involved in …
146 citations