Necessity of hospitalization and stress testing in low risk chest pain patients

Neil Beri, Nicholas A. Marston, Lori B. Daniels, Richard M. Nowak, Donald Schreiber, Christian Mueller, Allan Jaffe, Deborah B. Diercks, Nicholas Wettersten, Christopher DeFilippi, W. Frank Peacock, Alexander T. Limkakeng, Inder Anand, James McCord, Judd E. Hollander, Alan H.B. Wu, Fred S. Apple, John T. Nagurney, Cecilia Berardi, Chad M. CannonPaul Clopton, Sean Xavier Neath, Robert H. Christenson, Christopher Hogan, Gary Vilke, Alan Maisel

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1 Scopus citations

Abstract

Background Copeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI). Objectives The goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI < 0.040 μg/l and copeptin < 14 pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing. Methods This study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(< 0.040 μg/l) and copeptin < 14 pmol/l at presentation and after 2 h were considered “low risk” and selected for further analysis. Results None of the 475 “low risk” patients were diagnosed with MI during the 180 day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%–100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the “low risk” group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%–9.7%] versus 0.5%[95%CI:0.0%–2.9%], p = .002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%–74.0%] vs 22.9%[95%CI:17.1%–29.6%], p < .001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p = .040). Conclusions In conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180 days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.

Original languageEnglish (US)
Pages (from-to)274-280
Number of pages7
JournalAmerican Journal of Emergency Medicine
Volume35
Issue number2
DOIs
StatePublished - Feb 1 2017

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Keywords

  • Copeptin
  • Discharge
  • Hospitalization
  • Myocardial infarction
  • Stress testing

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Beri, N., Marston, N. A., Daniels, L. B., Nowak, R. M., Schreiber, D., Mueller, C., Jaffe, A., Diercks, D. B., Wettersten, N., DeFilippi, C., Peacock, W. F., Limkakeng, A. T., Anand, I., McCord, J., Hollander, J. E., Wu, A. H. B., Apple, F. S., Nagurney, J. T., Berardi, C., ... Maisel, A. (2017). Necessity of hospitalization and stress testing in low risk chest pain patients. American Journal of Emergency Medicine, 35(2), 274-280. https://doi.org/10.1016/j.ajem.2016.10.072