title: Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission.
abstract: OBJECTIVE
  Patients with potentially ischemic chest pain are commonly admitted to the hospital or observed after a negative evaluation in the emergency department (ED) owing to concern about adverse events. Previous studies have looked at 30-day mortality, but no current large studies have examined the most important information regarding ED disposition: the short-term risk for a clinically relevant adverse cardiac event (including inpatient ST-segment elevation myocardial infarction, life-threatening arrhythmia, cardiac or respiratory arrest, or death).
  
  
  OBJECTIVE
  To determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with 2 troponin-negative findings, nonconcerning initial ED vital signs, and nonischemic, interpretable electrocardiographic findings.
  
  
  METHODS
  We conducted a blinded data review of 45,416 encounters obtained from a prospectively collected database enrolling adult patients admitted or observed with the following inclusion criteria: (1) primary presenting symptom of chest pain, chest tightness, chest burning, or chest pressure and (2) negative findings for serial biomarkers. Data were collected and analyzed from July 1, 2008, through June 30, 2013, from the EDs of 3 community teaching institutions with an aggregate census of more than 1 million visits. We analyzed data extracted by hypothesis-blinded abstractors.
  
  
  METHODS
  The primary outcome was a composite of life-threatening arrhythmia, inpatient ST-segment elevation myocardial infarction, cardiac or respiratory arrest, or death during hospitalization.
  
  
  RESULTS
  Of the 45,416 encounters, 11,230 met criteria for inclusion. Mean patient age was 58.0 years. Of the 11 230 encounters, 44.83% of patients arrived by ambulance and 55.00% of patients were women. Relevant history included hypertension in 46.00%, diabetes mellitus in 19.72%, and myocardial infarction in 13.16%. The primary end point occurred in 20 of the 11 230 patients (0.18% [95% CI, 0.11%-0.27%]). After excluding patients with abnormal vital signs, electrocardiographic ischemia, left bundle branch block, or a pacemaker rhythm, we identified a primary end point event in 4 of 7266 patients (0.06% [95% CI, 0.02%-0.14%]). Of these events, 2 were noncardiac and 2 were possibly iatrogenic.
  
  
  CONCLUSIONS
  In adult patients with chest pain admitted with 2 negative findings for serial biomarkers, nonconcerning vital signs, and nonischemic electrocardiographic findings, short-term clinically relevant adverse cardiac events were rare and commonly iatrogenic, suggesting that routine inpatient admission may not be a beneficial strategy for this group.
authors.affiliation: Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus2Department of Emergency Medicine, Mount Carmel St. Ann's, Westerville, Ohio.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Weinstock
authors.affiliation: Division of Emergency Critical Care, Stony Brook Medicine, Stony Brook, New York.
authors.forename: Scott
authors.initials: S
authors.lastname: Weingart
authors.affiliation: Department of Emergency Medicine, Mount Carmel St. Ann's, Westerville, Ohio.
authors.forename: Frank
authors.initials: F
authors.lastname: Orth
authors.affiliation: Division of Cardiology, Mount Carmel St. Ann's, Westerville, Ohio.
authors.forename: Douglas
authors.initials: D
authors.lastname: VanFossen
authors.affiliation: Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus.
authors.forename: Colin
authors.initials: C
authors.lastname: Kaide
authors.affiliation: Mount Carmel Health System, Columbus, Ohio.
authors.forename: Judy
authors.initials: J
authors.lastname: Anderson
authors.affiliation: Department of Emergency Medicine, Icahn School of Medicine, New York, New York.
authors.forename: David H
authors.initials: DH
authors.lastname: Newman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis*; D004452:Echocardiography; D004630:Emergencies / Q000453:epidemiology*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006331:Heart Diseases / Q000097:blood / Q000175:diagnosis / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015146:Midwestern United States / Q000453:epidemiology; D010343:Patient Admission; D012189:Retrospective Studies; D014336:Troponin / Q000097:blood*
chemical_list: D015415:Biomarkers; D014336:Troponin