title: Physician discretion is safe and may lower stress test utilization in emergency department chest pain unit patients.
abstract: BACKGROUND
  Chest pain unit (CPU) observation with defined stress utilization protocols is a common management option for low-risk emergency department patients. We sought to evaluate the safety of a joint emergency medicine and cardiology staffed CPU.
  
  
  METHODS
  Prospective observational trial of consecutive patients admitted to an emergency department CPU was conducted. A standard 6-hour observation protocol was followed by cardiology consultation and stress utilization largely at their discretion. Included patients were at low/intermediate risk by the American Heart Association, had nondiagnostic electrocardiograms, and a normal initial troponin. Excluded patients were those with an acute comorbidity, age >75, and a history of coronary artery disease, or had a coexistent problem restricting 24-hour observation. Primary outcome was 30-day major adverse cardiovascular events-defined as death, nonfatal acute myocardial infarction, revascularization, or out-of-hospital cardiac arrest.
  
  
  RESULTS
  A total of 1063 patients were enrolled over 8 months. The mean age of the patients was 52.8 ± 11.8 years, and 51% (95% confidence interval [CI], 48-54) were female. The mean thrombolysis in myocardial infarction and Diamond & Forrester scores were 0.6% (95% CI, 0.51-0.62) and 33% (95% CI, 31-35), respectively. In all, 51% (95% CI, 48-54) received stress testing (52% nuclear stress, 39% stress echocardiogram, 5% exercise, 4% other). In all, 0.9% patients (n = 10, 95% CI, 0.4-1.5) were diagnosed with a non-ST elevation myocardial infarction and 2.2% (n = 23, 95% CI, 1.3-3) with acute coronary syndrome. There was 1 (95% CI, 0%-0.3%) case of a 30-day major adverse cardiovascular events. The 51% stress test utilization rate was less than the range reported in previous CPU studies (P < 0.05).
  
  
  CONCLUSIONS
  Joint emergency medicine and cardiology management of patients within a CPU protocol is safe, efficacious, and may safely reduce stress testing rates.
authors.affiliation: Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI 02903, USA. anapoli@lifespan.org
authors.forename: Anthony M
authors.initials: AM
authors.lastname: Napoli
authors.forename: James A
authors.initials: JA
authors.lastname: Arrighi
authors.forename: Matthew S
authors.initials: MS
authors.lastname: Siket
authors.forename: Frantz J
authors.initials: FJ
authors.lastname: Gibbs
mesh_terms: D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000150:complications / Q000175:diagnosis; D002985:Clinical Protocols / Q000592:standards; D017023:Coronary Angiography / Q000379:methods; D019091:Critical Pathways / Q000592:standards*; D019468:Disease Management; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005080:Exercise Test / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control*; D010043:Outcome and Process Assessment, Health Care / Q000379:methods; D010348:Patient Care Team / Q000458:organization & administration; D011446:Prospective Studies; D012017:Referral and Consultation / Q000458:organization & administration; D020379:Risk Adjustment / Q000379:methods / Q000592:standards