A clinical trial of a chest-pain observation unit for patients with unstable angina

Michael E. Farkouh, Peter A. Smars, Guy S. Reeder, Alan R. Zinsmeister, Roger W. Evans, Thomas D. Meloy, Stephen L. Kopecky, Marvin Allen, Thomas G. Allison, Raymond J Gibbons, Sherine E. Gabriel

Research output: Contribution to journalArticle

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Abstract

Background: Nearly half of patients hospitalized with unstable angina eventually receive a non-cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. Methods: We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST- segment monitoring, determination of creatine kinase isoenzyme levels, six hours of observation, and a study of cardiac function). The CPU was managed by the emergency department staff. Patients whose test results were negative were discharged, and the others were hospitalized. Primary outcomes (nonfatal myocardial infarction, death, acute congestive heart failure, stroke, or out- of-hospital cardiac arrest) and use of resources were compared between the two groups. Results: The 212 patients in the hospital-admission group had 15 primary events (13 myocardial infarctions and 2 cases of congestive heart failure), and the 212 patients in the CPU group had 7 events (5 myocardial infarctions, 1 death from cardiovascular causes, and 1 case of congestive heart failure). There was no significant difference in the rate of cardiac events between the two groups (odds ratio for the CPU group as compared with the hospital-admission group, 0.50; 95 percent confidence interval, 0.20 to 1.24). No primary events occurred among the 97 patients who were assigned to the CPU and discharged. Resource use during the first six months was greater among patients assigned to hospital admission than among those assigned to the CPU (P=0.003 by the rank-sum test). Conclusions: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk of cardiovascular events receive appropriate care.

Original languageEnglish (US)
Pages (from-to)1882-1888
Number of pages7
JournalNew England Journal of Medicine
Volume339
Issue number26
DOIs
StatePublished - Dec 24 1998

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Unstable Angina
Chest Pain
Observation
Clinical Trials
Hospital Emergency Service
Myocardial Infarction
Heart Failure
Costs and Cost Analysis
Out-of-Hospital Cardiac Arrest
Safety
Patient Admission
Creatine Kinase
Nonparametric Statistics
Cardiology
Isoenzymes
Aspirin
Heparin
Cause of Death
Stroke
Odds Ratio

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Farkouh, M. E., Smars, P. A., Reeder, G. S., Zinsmeister, A. R., Evans, R. W., Meloy, T. D., ... Gabriel, S. E. (1998). A clinical trial of a chest-pain observation unit for patients with unstable angina. New England Journal of Medicine, 339(26), 1882-1888. https://doi.org/10.1056/NEJM199812243392603

A clinical trial of a chest-pain observation unit for patients with unstable angina. / Farkouh, Michael E.; Smars, Peter A.; Reeder, Guy S.; Zinsmeister, Alan R.; Evans, Roger W.; Meloy, Thomas D.; Kopecky, Stephen L.; Allen, Marvin; Allison, Thomas G.; Gibbons, Raymond J; Gabriel, Sherine E.

In: New England Journal of Medicine, Vol. 339, No. 26, 24.12.1998, p. 1882-1888.

Research output: Contribution to journalArticle

Farkouh, ME, Smars, PA, Reeder, GS, Zinsmeister, AR, Evans, RW, Meloy, TD, Kopecky, SL, Allen, M, Allison, TG, Gibbons, RJ & Gabriel, SE 1998, 'A clinical trial of a chest-pain observation unit for patients with unstable angina', New England Journal of Medicine, vol. 339, no. 26, pp. 1882-1888. https://doi.org/10.1056/NEJM199812243392603
Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. New England Journal of Medicine. 1998 Dec 24;339(26):1882-1888. https://doi.org/10.1056/NEJM199812243392603
Farkouh, Michael E. ; Smars, Peter A. ; Reeder, Guy S. ; Zinsmeister, Alan R. ; Evans, Roger W. ; Meloy, Thomas D. ; Kopecky, Stephen L. ; Allen, Marvin ; Allison, Thomas G. ; Gibbons, Raymond J ; Gabriel, Sherine E. / A clinical trial of a chest-pain observation unit for patients with unstable angina. In: New England Journal of Medicine. 1998 ; Vol. 339, No. 26. pp. 1882-1888.
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abstract = "Background: Nearly half of patients hospitalized with unstable angina eventually receive a non-cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. Methods: We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST- segment monitoring, determination of creatine kinase isoenzyme levels, six hours of observation, and a study of cardiac function). The CPU was managed by the emergency department staff. Patients whose test results were negative were discharged, and the others were hospitalized. Primary outcomes (nonfatal myocardial infarction, death, acute congestive heart failure, stroke, or out- of-hospital cardiac arrest) and use of resources were compared between the two groups. Results: The 212 patients in the hospital-admission group had 15 primary events (13 myocardial infarctions and 2 cases of congestive heart failure), and the 212 patients in the CPU group had 7 events (5 myocardial infarctions, 1 death from cardiovascular causes, and 1 case of congestive heart failure). There was no significant difference in the rate of cardiac events between the two groups (odds ratio for the CPU group as compared with the hospital-admission group, 0.50; 95 percent confidence interval, 0.20 to 1.24). No primary events occurred among the 97 patients who were assigned to the CPU and discharged. Resource use during the first six months was greater among patients assigned to hospital admission than among those assigned to the CPU (P=0.003 by the rank-sum test). Conclusions: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk of cardiovascular events receive appropriate care.",
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AU - Smars, Peter A.

AU - Reeder, Guy S.

AU - Zinsmeister, Alan R.

AU - Evans, Roger W.

AU - Meloy, Thomas D.

AU - Kopecky, Stephen L.

AU - Allen, Marvin

AU - Allison, Thomas G.

AU - Gibbons, Raymond J

AU - Gabriel, Sherine E.

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N2 - Background: Nearly half of patients hospitalized with unstable angina eventually receive a non-cardiac-related diagnosis, yet 5 percent of patients with myocardial infarction are inappropriately discharged from the emergency department. We evaluated the safety, efficacy, and cost of admission to a chest-pain observation unit (CPU) located in the emergency department for such patients. Methods: We performed a community-based, prospective, randomized trial of the safety, efficacy, and cost of admission to a CPU as compared with those of regular hospital admission for patients with unstable angina who were considered to be at intermediate risk for cardiovascular events in the short term. A total of 424 eligible patients were randomly assigned to routine hospital admission (a monitored bed under the care of the cardiology service) or admission to the CPU (where patients were cared for according to a strict protocol including aspirin, heparin, continuous ST- segment monitoring, determination of creatine kinase isoenzyme levels, six hours of observation, and a study of cardiac function). The CPU was managed by the emergency department staff. Patients whose test results were negative were discharged, and the others were hospitalized. Primary outcomes (nonfatal myocardial infarction, death, acute congestive heart failure, stroke, or out- of-hospital cardiac arrest) and use of resources were compared between the two groups. Results: The 212 patients in the hospital-admission group had 15 primary events (13 myocardial infarctions and 2 cases of congestive heart failure), and the 212 patients in the CPU group had 7 events (5 myocardial infarctions, 1 death from cardiovascular causes, and 1 case of congestive heart failure). There was no significant difference in the rate of cardiac events between the two groups (odds ratio for the CPU group as compared with the hospital-admission group, 0.50; 95 percent confidence interval, 0.20 to 1.24). No primary events occurred among the 97 patients who were assigned to the CPU and discharged. Resource use during the first six months was greater among patients assigned to hospital admission than among those assigned to the CPU (P=0.003 by the rank-sum test). Conclusions: A CPU located in the emergency department can be a safe, effective, and cost-saving means of ensuring that patients with unstable angina who are considered to be at intermediate risk of cardiovascular events receive appropriate care.

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