Abstract 4343575: Expedited outpatient work-up is safe for evaluation of some emergency department patients with chest pain

Abstract

Background: Chest pain is a common presenting symptom in the emergency departments (EDs). Safe and timely outpatient evaluation is reasonable for some patients without acute coronary syndrome. This study aimed to evaluate the safety of an expedited outpatient diagnostic pathway for patients with chest pain at moderate risk of adverse cardiac events. Methods: A multidisciplinary team designed a pathway consisting of a stress ECG within 5 days, and a cardiology visit with an advanced practice provider within 7 days, of ED discharge. Patients presenting with chest pain were eligible if they had non-critical high-sensitivity troponins (< 35 ng/L for men, <17 ng/L for women), were at least moderate risk of adverse cardiac events (HEART score ≥4), were able to complete exercise stress ECG testing, and had insurance coverage for outpatient care. Data on patient compliance with the pathway, stress ECG results, and 30-day ED returns, were collected from 12/1/2023 to 11/30/2024. Results: Over twelve months, 55 patients met pathway criteria and were discharged from ED. Of these, 52 patients (95%) either completed the pathway or elected to follow-up with an established cardiology provider: 38 had outpatient stress ECG, 4 had coronary computed tomography angiogram (CCTA) per ED, and 10 followed up with established providers. There were 3 patients lost to follow-up. Of the 38 stress ECGs, 4 were abnormal (10%) and led to more imaging with three being negative for obstructive coronary artery disease (CAD) and one showing obstructive CAD, leading to invasive coronary angiography and stenting. One patient with a positive stress ECG was sent to ED from diagnostic lab for additional testing, which turned out negative. No patients re-presented to the ED with acute coronary syndrome within 30 days. Conclusion: A novel expedited outpatient pathway for evaluation of patients with chest pain showed a high completion rate, low rates of abnormal stress testing, and no acute coronary syndrome ED visits within 30 days. Pathways allowing for expedited outpatient evaluation of chest pain especially for patients without established cardiology care may reduce ED length of stay and avoid observation stays for stress testing while maintaining high standards of patient care. Future research should focus on evaluating long-term outcomes and assessing opportunities to implement similar pathways for other patient populations to optimize resource utilization while enhancing the patient experience.