title: A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing.
abstract: OBJECTIVE
  We evaluate the safety and feasibility of a critical care pathway protocol in which patients with acute chest pain who are low risk for coronary artery disease and short-term adverse cardiac outcomes receive outpatient stress testing within 72 hours of an emergency department (ED) visit.
  
  
  METHODS
  We performed an observational study of an ED-based chest pain critical pathway in an urban, community hospital in 979 consecutive patients. Patients enrolled in the protocol were observed in the ED before receiving 72-hour outpatient stress testing. The pathway was primarily analyzed for rates of death or myocardial infarction in the 6 months after ED discharge and outpatient stress testing. Secondary outcome measures included need for coronary intervention at initial stress testing and within 6 months after discharge, subsequent ED visits for chest pain, and subsequent hospitalization.
  
  
  RESULTS
  Of 871 stress-tested patients aged 40 years or older, who had low risk for coronary artery disease and short-term adverse cardiac events, and had 6-month follow-up, 18 (2%) required coronary intervention, 1 (0.1%) had a myocardial infarction within 1 month, 2 (0.2%) had a myocardial infarction within 6 months, 6 (0.7%) had normal stress test results after discharge but required cardiac catheterization within 6 months, and 5 (0.6%) returned to the ED within 6 months for ongoing chest pain. Hospital admission rates decreased significantly from 31.2% to 26.1% after initiation of the protocol (P<.001).
  
  
  CONCLUSIONS
  For patients with chest pain and low risk for short-term cardiac events, outpatient stress testing is feasible, safe, and associated with decreased hospital admission rates. With an evidence-based protocol, physicians efficiently identify patients at low risk for clinically significant coronary artery disease and short-term adverse cardiac outcomes.
authors.affiliation: Department of Emergency Medicine, Kaiser Permanente Medical Center, Walnut Creek, CA 94696, USA. marycmeyer@hotmail.com
authors.forename: Mary C
authors.initials: MC
authors.lastname: Meyer
authors.forename: Robert P
authors.initials: RP
authors.lastname: Mooney
authors.forename: Anna K
authors.initials: AK
authors.lastname: Sekera
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000379:methods*; D002140:California; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D019091:Critical Pathways; D003937:Diagnosis, Differential; D004635:Emergency Medicine / Q000379:methods*; D019317:Evidence-Based Medicine / Q000379:methods; D005080:Exercise Test; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D010043:Outcome and Process Assessment, Health Care; D012017:Referral and Consultation; D018570:Risk Assessment / Q000379:methods