Outpatient versus observation/inpatient management of emergency department patients rapidly ruled-out for acute myocardial infarction: Findings from the HIGH-US study.

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2021-01

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Abstract

Background

The actual Emergency Department (ED) dispositions of patients enrolled in observational studies and meeting criteria for rapid acute myocardial infarction (AMI) rule-out are unknown. Additionally, their presenting clinical profiles, cardiac testing/treatments received, and outcomes have not been reported.

Methods

Patients in the HIGH-US study (29 sites) that ruled-out for AMI using a high-sensitivity cardiac troponin I 0/1-hour algorithm were evaluated. Clinical characteristics of patients having ED discharge were compared to patients placed in observation or hospital admitted (OBS/ADM). Reports of any OBS/ADM cardiac stress test (CST), cardiac catheterization (Cath) and coronary revascularization were reviewed. One year AMI/death and major adverse cardiovascular event rates were determined.

Results

Of the 1,020 ruled-out AMI patients 584 (57.3%) had ED discharge. The remaining 436 (42.7%) were placed in OBS/ADM. Patients with risk factors for AMI, including personal or family history of coronary artery disease, hypertension, previous stroke or abnormal ECG were more often placed in OBS/ADM. 175 (40.1%) had a CST. Of these 32 (18.3%) were abnormal and 143 (81.7%) normal. Cath was done in 11 (34.3%) of those with abnormal and 13 (9.1%) with normal CST. Of those without an initial CST 85 (32.6%) had Cath. Overall, revascularizations were performed in 26 (6.0%) patients. One-year AMI/death rates were low/similar (P = .553) for the groups studied.

Conclusions

Rapidly ruled-out for AMI ED patients having a higher clinician perceived risk for new or worsening coronary artery disease and placed in OBS/ADM underwent many diagnostic tests, were infrequently revascularized and had excellent outcomes. Alternate efficient strategies for these patients are needed.

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Humans, Myocardial Infarction, Hypertension, Disease Progression, Troponin I, Electrocardiography, Exercise Test, Hospitalization, Patient Discharge, Myocardial Revascularization, Risk Factors, Algorithms, Time Factors, Middle Aged, Emergency Service, Hospital, Female, Male, Coronary Artery Disease, Kaplan-Meier Estimate, Cardiac Catheterization, Biomarkers, Observational Studies as Topic

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https://hdl.handle.net/10161/25090

Published Version (Please cite this version)

10.1016/j.ahj.2020.10.067

Publication Info

Nowak, Richard M, Gordon Jacobsen, Alexander Limkakeng, William F Peacock, Robert H Christenson, James McCord, Fred S Apple, Adam J Singer, et al. (2021). Outpatient versus observation/inpatient management of emergency department patients rapidly ruled-out for acute myocardial infarction: Findings from the HIGH-US study. American heart journal, 231. pp. 6–17. 10.1016/j.ahj.2020.10.067 Retrieved from https://hdl.handle.net/10161/25090.

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