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Identifying Low Risk Chest Pain Patients and Outcomes of Continuous Cardiac Monitoring

Johnson, Margaret, D.O., Adikeviciute, Ugne, D.O., Vogt , Amber, D.O., F.A.C.O.E.P. and Nicholas Gross Franciscan St. James Health System, Olympia Fields, IL Midwestern University, Downers Grove, IL. Identifying Low Risk Chest Pain Patients and Outcomes of Continuous Cardiac Monitoring.

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Identifying Low Risk Chest Pain Patients and Outcomes of Continuous Cardiac Monitoring

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  1. Johnson, Margaret, D.O., Adikeviciute, Ugne, D.O., Vogt, Amber, D.O., F.A.C.O.E.P. and Nicholas Gross Franciscan St. James Health System, Olympia Fields, IL Midwestern University, Downers Grove, IL Identifying Low Risk Chest Pain Patients and Outcomes of Continuous Cardiac Monitoring

  2. Introduction • The goal of admitting patients for chest pain is to avoid missing a potential myocardial infarction. • It has been standard practice to admit all chest pain syndromes to a continuous cardiac monitored floor, based on American Heart Association (AHA) guidelines. • This study illustrates that the Goldman Criteria provides the emergency department physician with a well-established, easy risk stratification algorithm to employ when admitting chest pain patients to telemetry versus a general medical floor. • The routine use of telemetry for low risk chest pain admission has limited utility. If patients are low risk, they can be safely admitted to a general medical floor without cardiac monitoring for further ACS work up.

  3. Methods • A retrospective chart review included all patients who were admitted to the telemetry floor at Franciscan St. Margaret Health (Hammond and Dyer) hospitals between September 1st, 2012 and July 31st, 2013 with the diagnosis of chest pain and the ICD9 code of 786.5. • Patients were evaluated using the Goldman criteria (Figure 1). The study identified low risk chest pain patients as those with a Goldman risk score <1%, and an initial negative troponin, who were admitted to non-ICU monitored beds . These low risk patients were then analyzed for in-hospital complications and interventions based on their ICD9 discharge codes. • In order to identify patients at risk of life-threatening dysrhythmias, the 290 charts that met the inclusion criteria, were reviewed for the following ICD9 discharge diagnosis: death (798), arrhythmia/cardiac arrest (427), EKG changes (794.3), ischemic heart disease (410, 411, 412, 413, 414) and heart failure (428). • A detailed chart review was performed if a chart had a positive ICD9 code. • Results were considered abnormal if (1) ECG demonstrated ischemia; (2) nuclear imaging revealed any reversible defect. All other findings during the stress test were considered negative for ischemia including equivocal results. • Results were reviewed for percutaneous coronary interventions and if they were positive or negative. Positive cardiac catheterizations were classified as those that either received (1) balloon angioplasty, (2) percutaneous stent placement; or (3) referred for coronary bypass graft. All other findings were considered negative.

  4. Results • A total of 1124 patient’s charts were reviewed who were admitted to either of the northwest Indiana hospitals between September 1st, 2012 and July 31st, 2013. • A total of 290 meet the inclusion criteria. Of these 190 were women (65.6%) and 100 were men (34.5%). The mean age of all patients was 57.5 years (SD 13.78; range: 22.4-99.6). • Upon reviewing discharge diagnosis there were 49 patients with positive ICD9 codes, one patient who was discharged with 3 ICD9 codes and three patients who had 2 ICD9 codes. Patient’s who had a positive discharge diagnosis had a statistically significantly (p = 0.016) longer hospital stay with a mean of 3.26 days (SD 3.524) vs 1.94 days (SD 1.419). These patients were on average older (p = 0.008) with a mean age of 62 years (SD 15.6) vs 56 years (SD 13.2). • .

  5. Results Continued… • In the 20 patients who were diagnosed with arrhythmias, there were no sustained dysrhythmias or medical interventions while on the telemetry unit. • There were 7 patients who had a history of arrhythmia (5 with atrial fibrillation and 2 with unknown arrhythmias). • Of the 12 stress tests performed, the results were abnormal in 5 (41.6%), and 3 patients with a positive stress went on to have a cardiac catheterizations. • In total, 14 patients had a cardiac catheterization, of these patients, 6 (42.9%) had a positive catheterization with either an angioplasty, stent placement or coronary bypass graft. One (7.1%) patient had an angioplasty, 2 (14.3%) had stents placed and 3 (21.4%) were found to have major coronary artery disease and went on to have coronary bypass grafts. • A total of 3 (6.1%) patients had a second positive troponin. One patient had a medical intervention and was moved to the intensive care unit and started on a nitroglycerin drip.

  6. Discussion • The goal of admitting patients for chest pain is to avoid missing a potential myocardial infarction. • Potentially one reason for the vast array of diagnostic approaches is that there is no consensus on how to rapidly and accurately identify chest pain patients at low risk for cardiac complications. • In this retrospective study, it was found that telemetry data did not alter patient management and there was not a single medical intervention that was based on continuous cardiac monitoring. This study illustrates that the Goldman Criteria provides the emergency department physician with a well-established, easy risk stratification algorithm to employ when admitting chest pain patients to telemetry versus a general medical floor. • The study evaluated a total of 290 patients who were admitted to the hospital that met the Goldman criteria as very low-risk chest pain. There were 49 patients who had corresponding ICD9 discharge codes indicating that they may have benefited from being admitted to a monitored telemetry bed. • Although 14 of these patients had cardiac catheterizations and 2 patients needed stent placements while 3 required a CABG, the decision to proceed to invasive procedures was due to elevated cardiac markers and not from results of telemetry monitoring. One patient with a second positive troponin, was diagnosed with an NSTEMI while on the telemetry unit, and was upgraded to an intensive care unit. There were no patients who had a life-threatening arrhythmia or death during their hospital stay. • The routine use of telemetry for low risk chest pain admission has limited utility. • The study concluded that upon admission to the hospital, patients with chest pain should be risk stratified using the Goldman Criteria and troponin level in order to appropriately identify their level of care. If patients are low risk, they can be safely admitted to a general medical floor without cardiac monitoring for further ACS work up.

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