Background: The evaluation of chest pain patients in the emergency department remains a costly and difficult challenge, even though a large proportion of them do not suffer from an acute coronary syndrome. We adopted a clinical decision model, modified from the ANMCO-SIMEU recommendations, and tested its clinical usefulness by assessing: a) the rate of unnecessary hospital admissions, b) the rate of inappropriate discharges based on coronary events (unstable angina, myocardial infarction, death) at 6 months.
Methods: Our population included 511 consecutive patients with chest pain for a period of 6 months. On the basis of the chest pain score and individual risk factors, 383 patients with normal ECG and negative troponin were classified into four categories according to the probability of acute coronary syndrome, resulting in different lengths of hospital stay and planning of further diagnostic tests. Stress testing was mandatory within 72 h if 22 risk factors and typical angina were observed.
Results: Inappropriate discharges and unnecessary admissions were 1% and 9.5%, respectively. The clinical decision model based on the four categories of probability was correctly applied in 83% of cases. One hundred patients were diagnosed with acute coronary syndrome. After discharge, 6 patients underwent stress testing with subsequent revascularization (mean 34 days later) without experiencing new cardiac events. One patient was readmitted with unstable angina before completing non-invasive diagnostic tests. None of 297 patients with atypical chest pain, discharged without additional testing, had adverse cardiac events.
Conclusions: Our clinical decision model resulted in a low rate of inappropriate discharges with a low risk of adverse events and a standard rate of unnecessary admissions. Although clinical judgment remains of paramount importance, a clinical decision model and the risk stratification of patients with chest pain lead to an improvement of quality of care.