title: Compliance with outpatient stress testing in low-risk patients presenting to the emergency department with chest pain.
abstract: Recent evidence suggests that stress testing prior to emergency department (ED) release in low-risk chest pain patients identifies those who can be safely discharged home. When immediate stress testing is not feasible, rapid outpatient stress testing has been recommended. The objective of this study was to determine compliance rate and incidence of adverse cardiac events in patients presenting to the ED with low-risk chest pain referred for outpatient stress testing. Retrospective chart and social security death index review were conducted in 448 consecutive chest pain patients who presented to a university hospital and level I trauma center between April 30 and December 31, 2007. Patients were evaluated with an accelerated chest pain protocol defined as a 4-hour ED rule out and referral for outpatient stress testing within 72 hours of ED release. Only patients without known cardiac disease, a thrombolysis in myocardial infarction risk score ≤2, negative serial ECGs and cardiac biomarkers, and benign ED course were eligible for the protocol. Primary outcome measures included compliance with outpatient stress testing and documented 30-day incidence of adverse cardiac events following ED release. The social security death index was queried to determine 12-month incidence of all-cause mortality in enrolled patients. Logistic regression analysis of characteristics associated with outpatient stress test compliance was determined and incidence of adverse cardiac events in those who were and were not compliant with outpatient stress testing was compared. Significance was set at P < 0.05. A total of 188 patients (42%) completed outpatient stress testing, but only 27 (6%) completed testing within 72 hours of ED discharge. Compliance was correlated with insurance and race, but not patient age, gender, or thrombolysis in myocardial infarction risk score. No significant differences in adverse cardiac events were documented in patients who did and did not comply with outpatient stress testing. Compliance with outpatient stress testing is poor in low-risk chest pain patients following ED release. Despite poor compliance, the documented incidence of adverse cardiac events in this low-risk cohort was lower than that reported in patients with negative provocative testing prior to ED release.
authors.affiliation: Department of Emergency Medicine, University of Florida College of Medicine, Gainesville.
authors.forename: Peter
authors.initials: P
authors.lastname: Milano
authors.forename: Donna L
authors.initials: DL
authors.lastname: Carden
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Jackman
authors.forename: Arada
authors.initials: A
authors.lastname: Rongkavilit
authors.forename: Kevin
authors.initials: K
authors.lastname: Groves
authors.forename: Joseph
authors.initials: J
authors.lastname: Tyndall
authors.forename: Joel
authors.initials: J
authors.lastname: Moll
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D002637:Chest Pain / Q000175:diagnosis* / Q000628:therapy; D002985:Clinical Protocols; D015331:Cohort Studies; D003266:Continuity of Patient Care; D016208:Databases, Factual; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D018570:Risk Assessment; D055815:Young Adult