Abstract 68: A Cardiologist-Directed, Selective Testing Approach to Emergency Department Chest Pain Patients is Safe and Efficient

Background: A protocol driven, non-selective approach to low to intermediate risk patients with chest pain (CP) in the Emergency Department (ED) usually consists of a period of observation followed by a noninvasive test, with cardiology consultation reserved for those with an abnormal work-up. This approach leads to a high rate of testing utilization in a patient population with a relatively low pretest probability of disease. We sought to assess the safety of a cardiologist-directed approach, whereby all CP patients were quickly evaluated with selective use of testing. Methods: We instituted a CP protocol which entailed early evaluation of low to intermediate risk CP patients by a cardiologist. Entry criteria included age <75, no known history of CAD, negative initial biomarkers, and a non-diagnostic ECG. Patient data was prospectively recorded over 27 months. Utilization of further testing was at the discretion of the cardiologist. Efficacy of care was assessed by telephone follow-up if available, or with the patient’s physician. Results: A total of 686 consecutive patients who met entry criteria were enrolled in the protocol. The mean age was 48.4 years, 47% (326/686) were female, 9% (64/686) were diabetic, 22% (151/686) smoked, 34% (236/686) had hypertension and 24% (168/686) had dyslipidemia. According to the Diamond Forrester criteria, the CP was characterized as non-cardiac in 55% (383/686), atypical in 43% (293/686), and typical in 2% (11/686). Altogether 59.2% (406/686) of patients in the protocol underwent testing. Testing modalities included: Coronary CT angiography in 34% (138/406), exercise ECG in 17% (71/406), exercise echocardiography in 17% (70/406), exercise nuclear in 16% (67/406), transthoracic echocardiography in 8% (32/406), cardiac catheterization in 5% (19/406), and other test in 3% (9/406). Patients who underwent testing spent a mean of 22.4 hours in the ED compared to 13.8 hours if no test was ordered (p<0.001). Of the patients that underwent initial testing, 10% (41/406) of those tests were abnormal. Ultimately, 9.8% of patients (67/686) were admitted and 0.6% (4/686) were diagnosed with myocardial infarction. Follow-up data was available for 61.4% (421/686). Only 1 patient (0.2%, 1/421) was found to have an adverse event. Prior to institution of this cardiologist-driven approach, the rate of testing in our ED for a similar population was 91.9% (137/149). Therefore our approach resulted in a 35% reduction in the rate of testing (p<0.001). Additionally, our results compare favorably with prior studies of ED CP units with protocol driven testing rates which usually approach 100% by design. Conclusion: A cardiologist-directed approach to CP patients in the ED was safe and resulted in lower testing utilization rates than standard protocol-driven management. Replacing a one-size-fits-all approach will likely result in more patient-centered, selective use of testing.