title: Diagnostic utility, safety, and cost-effectiveness of emergency department-initiated early scheduled technetium-99m single photon emission computed tomography imaging followed by expedited outpatient cardiac clinic visits in acute chest pain syndromes.
abstract: Conventional emergency department (EMD) approach to triaging acute chest pain syndromes may lead to unnecessary admissions, resulting to in-hospital bed occupancy and increased healthcare costs. We explore the diagnostic utility of early (less than a week) outpatient scheduled single photon emission computed tomography (SPECT) in intermediate-risk chest pain subjects who presented to EMD with non-diagnostic electrocardiogram and negative serum troponin level. Additionally, we intend to study the safety and cost-effectiveness of such a strategy. We conduct a prospective, non-randomized study of 108 subjects who fit the inclusion criteria. After SPECT studies, all subjects were evaluated in the cardiac clinic within 2 weeks of EMD visits. Final diagnosis of coronary artery disease and subsequent disposition to standard medical therapy or follow-on angiography were decided by incorporating pre-test clinical data and SPECT results. Adverse events defined as myocardial infarction and cardiac death was tracked between EMD visit and eventual therapy (either medical therapy or coronary revascularization). Finally, cost-effectiveness was determined based on estimated cost and days of hospitalization saved between standard strategies of ward admission for further evaluation versus the present early outpatient SPECT-based workflow. Among 108 subjects (mean age 58 years, 59% male) included for analysis, 82 (76%) had normal perfusion status. There was no statistical difference in baseline characteristics and prior ischemic heart disease history between groups. In the 26 abnormal perfusion subjects, seven had follow-on coronary angiography in which three were found to have significant stenotic coronary lesions, but only one had intervention performed. There was an unscheduled coronary angiography in the normal perfusion group that yielded normal coronary anatomy. There was no adverse clinical event in both groups. Compared with standard strategy, early outpatient SPECT initiated by EMD physicians followed by cardiac clinic evaluation resulted in 2.9 days of hospitalization or $781.23 saved per patient per EMD visit. EMD-initiated early SPECT studies followed by cardiac clinic evaluation in intermediate-risk acute chest pain syndromes with non-diagnostic ECG and negative serum troponin levels carries excellent diagnostic and therapeutic utility, in addition to being safe and cost-effective.
authors.affiliation: Cardiac Department, National University Heart Centre, National University Hospital, 5 Lower Kent Ridge Road, Level 3 Main Building, Singapore, Singapore, 119074. Raymond_cc_wong@nuhs.edu.sg
authors.forename: Raymond C
authors.initials: RC
authors.lastname: Wong
authors.forename: Arvind Kumar
authors.initials: AK
authors.lastname: Sinha
authors.forename: Malcolm
authors.initials: M
authors.lastname: Mahadevan
authors.forename: Tiong Cheng
authors.initials: TC
authors.lastname: Yeo
mesh_terms: D000553:Ambulatory Care; D001071:Appointments and Schedules; D002637:Chest Pain / Q000000981:diagnostic imaging; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D012449:Safety; D013667:Technetium; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data
chemical_list: D013667:Technetium