Characterization of patients with repeated emergency department visits for chest pain and negative cardiovascular findings

J. Bromley, Ezra A Amsterdam, S. Yadlapalli, B. Lewis

Research output: Contribution to journalArticle

Abstract

To improve management of low risk patients (pts) presenting to the emergency department (ED) with chest pain, we have employed immediate exercise testing (IET) in this group. Low risk pts are identified by clinical criteria on presentation: normal or near normal electrocardiogram and no electrical or hemodynamic instability. We have performed IET in 570 pts and there have been no adverse effects. IET was negative (NEG) for ischemia (≤ 1.0mm ST down double arrow sign @ ≥ 85% max. predicted heart rate) in 74% (N=422) of these pts. The NEG pts were discharged directly from the ED. At an average follow-up of 13 mos (1-45 mos), morbidity was 0.4%(2 non-Q infarctions) and there was no mortality. A subgroup of the NEG pts (11%, N=46) had repeat visits (RV) to the ED for chest pain (2 or more within 12 mos) with no etiology detected and no mortality or coronary events during the 13 mos follow-up. In the RV subgroup, 80% (N=37) had 2-3 ED visits and 20% (N=9) had >3 visits, Thus, the RV subgroup comprised 11% of the NEG pts but accounted for 25% of total ED visits in the NEG population. The RV subgroup was similar (p>0.05) in age to the other NEG IET pts (47 vs. 49 yrs, respectively) and proportion of males (48% vs. 58%) but had more (p<0.05) coronary risk factors (1.9 vs. 1.4) and a higher rate of self-reported psychosocial symptoms (anxiety, panic, depression; 22% vs. 8%), but none were referred for psychological intervention. In conclusion, a subgroup of pts with NEG IET and no evidence of cardiac or other organic pathology, had recurrent ED visits, accounting for a disproportionate number of the total visits by the NEG IET population. Significantly more of the RV NEG group had psychosocial symptoms. The RV NEG subgroup warrants recognition as a special population, which could provide a basis for improved management of these pts.

Original languageEnglish (US)
JournalJournal of Investigative Medicine
Volume47
Issue number2
StatePublished - Feb 1999

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Chest Pain
Hospital Emergency Service
Testing
Exercise
Hemodynamics
Pathology
Electrocardiography
Population
Panic
Mortality
Risk Management
Infarction
Ischemia
Anxiety
Heart Rate
Depression
Psychology
Morbidity

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)

Cite this

Characterization of patients with repeated emergency department visits for chest pain and negative cardiovascular findings. / Bromley, J.; Amsterdam, Ezra A; Yadlapalli, S.; Lewis, B.

In: Journal of Investigative Medicine, Vol. 47, No. 2, 02.1999.

Research output: Contribution to journalArticle

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abstract = "To improve management of low risk patients (pts) presenting to the emergency department (ED) with chest pain, we have employed immediate exercise testing (IET) in this group. Low risk pts are identified by clinical criteria on presentation: normal or near normal electrocardiogram and no electrical or hemodynamic instability. We have performed IET in 570 pts and there have been no adverse effects. IET was negative (NEG) for ischemia (≤ 1.0mm ST down double arrow sign @ ≥ 85{\%} max. predicted heart rate) in 74{\%} (N=422) of these pts. The NEG pts were discharged directly from the ED. At an average follow-up of 13 mos (1-45 mos), morbidity was 0.4{\%}(2 non-Q infarctions) and there was no mortality. A subgroup of the NEG pts (11{\%}, N=46) had repeat visits (RV) to the ED for chest pain (2 or more within 12 mos) with no etiology detected and no mortality or coronary events during the 13 mos follow-up. In the RV subgroup, 80{\%} (N=37) had 2-3 ED visits and 20{\%} (N=9) had >3 visits, Thus, the RV subgroup comprised 11{\%} of the NEG pts but accounted for 25{\%} of total ED visits in the NEG population. The RV subgroup was similar (p>0.05) in age to the other NEG IET pts (47 vs. 49 yrs, respectively) and proportion of males (48{\%} vs. 58{\%}) but had more (p<0.05) coronary risk factors (1.9 vs. 1.4) and a higher rate of self-reported psychosocial symptoms (anxiety, panic, depression; 22{\%} vs. 8{\%}), but none were referred for psychological intervention. In conclusion, a subgroup of pts with NEG IET and no evidence of cardiac or other organic pathology, had recurrent ED visits, accounting for a disproportionate number of the total visits by the NEG IET population. Significantly more of the RV NEG group had psychosocial symptoms. The RV NEG subgroup warrants recognition as a special population, which could provide a basis for improved management of these pts.",
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