Necessity of hospitalization and stress testing in low risk chest pain patients

Neil Beri, Nicholas A. Marston, Lori B. Daniels, Richard M. Nowak, Donald Schreiber, Christian Mueller, Allan Jaffe, Deborah B. Diercks, Nicholas Wettersten, Christopher DeFilippi, W. Frank Peacock, Alexander T. Limkakeng, Inder Anand, James McCord, Judd E. Hollander, Alan H B Wu, Fred S. Apple, John T. Nagurney, Cecilia Berardi, Chad M. CannonPaul Clopton, Sean Xavier Neath, Robert H. Christenson, Christopher Hogan, Gary Vilke, Alan Maisel

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). Objectives: The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI. <. 0.040. μg/l and copeptin. <. 14. pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing. Methods: This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<. 0.040. μg/l) and copeptin. <. 14. pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis. Results: None of the 475 "low risk" patients were diagnosed with MI during the 180. day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p = .002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p. <. .001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p = .040). Conclusions: In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180. days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.

Original languageEnglish (US)
JournalAmerican Journal of Emergency Medicine
DOIs
StateAccepted/In press - May 12 2016

Fingerprint

Chest Pain
Hospitalization
Myocardial Infarction
Troponin I
Confidence Intervals
Electrocardiography
Outpatients
Troponin
Acute Pain
Cardiology
Angiography
copeptins

Keywords

  • Copeptin
  • Discharge
  • Hospitalization
  • Myocardial infarction
  • Stress testing

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Beri, N., Marston, N. A., Daniels, L. B., Nowak, R. M., Schreiber, D., Mueller, C., ... Maisel, A. (Accepted/In press). Necessity of hospitalization and stress testing in low risk chest pain patients. American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2016.10.072

Necessity of hospitalization and stress testing in low risk chest pain patients. / Beri, Neil; Marston, Nicholas A.; Daniels, Lori B.; Nowak, Richard M.; Schreiber, Donald; Mueller, Christian; Jaffe, Allan; Diercks, Deborah B.; Wettersten, Nicholas; DeFilippi, Christopher; Peacock, W. Frank; Limkakeng, Alexander T.; Anand, Inder; McCord, James; Hollander, Judd E.; Wu, Alan H B; Apple, Fred S.; Nagurney, John T.; Berardi, Cecilia; Cannon, Chad M.; Clopton, Paul; Neath, Sean Xavier; Christenson, Robert H.; Hogan, Christopher; Vilke, Gary; Maisel, Alan.

In: American Journal of Emergency Medicine, 12.05.2016.

Research output: Contribution to journalArticle

Beri, N, Marston, NA, Daniels, LB, Nowak, RM, Schreiber, D, Mueller, C, Jaffe, A, Diercks, DB, Wettersten, N, DeFilippi, C, Peacock, WF, Limkakeng, AT, Anand, I, McCord, J, Hollander, JE, Wu, AHB, Apple, FS, Nagurney, JT, Berardi, C, Cannon, CM, Clopton, P, Neath, SX, Christenson, RH, Hogan, C, Vilke, G & Maisel, A 2016, 'Necessity of hospitalization and stress testing in low risk chest pain patients', American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2016.10.072
Beri, Neil ; Marston, Nicholas A. ; Daniels, Lori B. ; Nowak, Richard M. ; Schreiber, Donald ; Mueller, Christian ; Jaffe, Allan ; Diercks, Deborah B. ; Wettersten, Nicholas ; DeFilippi, Christopher ; Peacock, W. Frank ; Limkakeng, Alexander T. ; Anand, Inder ; McCord, James ; Hollander, Judd E. ; Wu, Alan H B ; Apple, Fred S. ; Nagurney, John T. ; Berardi, Cecilia ; Cannon, Chad M. ; Clopton, Paul ; Neath, Sean Xavier ; Christenson, Robert H. ; Hogan, Christopher ; Vilke, Gary ; Maisel, Alan. / Necessity of hospitalization and stress testing in low risk chest pain patients. In: American Journal of Emergency Medicine. 2016.
@article{299455a9d6fe4c84a6990a89bf5fef45,
title = "Necessity of hospitalization and stress testing in low risk chest pain patients",
abstract = "Background: Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). Objectives: The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI. <. 0.040. μg/l and copeptin. <. 14. pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing. Methods: This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<. 0.040. μg/l) and copeptin. <. 14. pmol/l at presentation and after 2 h were considered {"}low risk{"} and selected for further analysis. Results: None of the 475 {"}low risk{"} patients were diagnosed with MI during the 180. day follow-up period (including presentation). The negative predictive value of this strategy was 100{\%} (95{\%} confidence interval(CI):99.2{\%}-100.0{\%}). Furthermore no one died during follow up. 287 (60.4{\%}) patients in the low risk group were hospitalized. In the {"}low risk{"} group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3{\%}[95{\%}CI:3.8{\%}-9.7{\%}] versus 0.5{\%}[95{\%}CI:0.0{\%}-2.9{\%}], p = .002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6{\%}[95{\%}CI:62.9{\%}-74.0{\%}] vs 22.9{\%}[95{\%}CI:17.1{\%}-29.6{\%}], p. <. .001). Those tested had less cardiac rehospitalizations during follow-up (1.7{\%} vs 5.1{\%}, p = .040). Conclusions: In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180. days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.",
keywords = "Copeptin, Discharge, Hospitalization, Myocardial infarction, Stress testing",
author = "Neil Beri and Marston, {Nicholas A.} and Daniels, {Lori B.} and Nowak, {Richard M.} and Donald Schreiber and Christian Mueller and Allan Jaffe and Diercks, {Deborah B.} and Nicholas Wettersten and Christopher DeFilippi and Peacock, {W. Frank} and Limkakeng, {Alexander T.} and Inder Anand and James McCord and Hollander, {Judd E.} and Wu, {Alan H B} and Apple, {Fred S.} and Nagurney, {John T.} and Cecilia Berardi and Cannon, {Chad M.} and Paul Clopton and Neath, {Sean Xavier} and Christenson, {Robert H.} and Christopher Hogan and Gary Vilke and Alan Maisel",
year = "2016",
month = "5",
day = "12",
doi = "10.1016/j.ajem.2016.10.072",
language = "English (US)",
journal = "American Journal of Emergency Medicine",
issn = "0735-6757",
publisher = "W.B. Saunders Ltd",

}

TY - JOUR

T1 - Necessity of hospitalization and stress testing in low risk chest pain patients

AU - Beri, Neil

AU - Marston, Nicholas A.

AU - Daniels, Lori B.

AU - Nowak, Richard M.

AU - Schreiber, Donald

AU - Mueller, Christian

AU - Jaffe, Allan

AU - Diercks, Deborah B.

AU - Wettersten, Nicholas

AU - DeFilippi, Christopher

AU - Peacock, W. Frank

AU - Limkakeng, Alexander T.

AU - Anand, Inder

AU - McCord, James

AU - Hollander, Judd E.

AU - Wu, Alan H B

AU - Apple, Fred S.

AU - Nagurney, John T.

AU - Berardi, Cecilia

AU - Cannon, Chad M.

AU - Clopton, Paul

AU - Neath, Sean Xavier

AU - Christenson, Robert H.

AU - Hogan, Christopher

AU - Vilke, Gary

AU - Maisel, Alan

PY - 2016/5/12

Y1 - 2016/5/12

N2 - Background: Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). Objectives: The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI. <. 0.040. μg/l and copeptin. <. 14. pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing. Methods: This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<. 0.040. μg/l) and copeptin. <. 14. pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis. Results: None of the 475 "low risk" patients were diagnosed with MI during the 180. day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p = .002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p. <. .001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p = .040). Conclusions: In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180. days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.

AB - Background: Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). Objectives: The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI. <. 0.040. μg/l and copeptin. <. 14. pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing. Methods: This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<. 0.040. μg/l) and copeptin. <. 14. pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis. Results: None of the 475 "low risk" patients were diagnosed with MI during the 180. day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p = .002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p. <. .001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p = .040). Conclusions: In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180. days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.

KW - Copeptin

KW - Discharge

KW - Hospitalization

KW - Myocardial infarction

KW - Stress testing

UR - http://www.scopus.com/inward/record.url?scp=85006700507&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85006700507&partnerID=8YFLogxK

U2 - 10.1016/j.ajem.2016.10.072

DO - 10.1016/j.ajem.2016.10.072

M3 - Article

C2 - 27847253

AN - SCOPUS:85006700507

JO - American Journal of Emergency Medicine

JF - American Journal of Emergency Medicine

SN - 0735-6757

ER -