Objectives: We sought to characterise the demographics, length of admission, final diagnoses, long-term outcome and costs associated with the population who presented to an Australian emergency department (ED) with symptoms of possible acute coronary syndrome (ACS).
Design, setting and participants: Prospectively collected data on ED patients presenting with suspected ACS between November 2008 and February 2011 was used, including data on presentation and at 30 days after presentation. Information on patient disposition, length of stay and costs incurred was extracted from hospital administration records.
Main outcome measures: Primary outcomes were mean and median cost and length of hospital stay. Secondary outcomes were diagnosis of ACS, other cardiovascular conditions or non-cardiovascular conditions within 30 days of presentation.
Results: An ACS was diagnosed in 103 (11.1%) of the 926 patients recruited. 193 patients (20.8%) were diagnosed with other cardiovascular-related conditions and 622 patients (67.2%) had non-cardiac-related chest pain. ACS events occurred in 0 and 11 (1.9%) of the low-risk and intermediate-risk groups, respectively. Ninety-two (28.0%) of the 329 high-risk patients had an ACS event. Patients with a proven ACS, high-grade atrioventricular block, pulmonary embolism and other respiratory conditions had the longest length of stay. The mean cost was highest in the ACS group ($13 509; 95% CI, $11 794–$15 223) followed by other cardiovascular conditions ($7283; 95% CI, $6152–$8415) and non-cardiovascular conditions ($3331; 95% CI, $2976–$3685).
Conclusions: Most ED patients with symptoms of possible ACS do not have a cardiac cause for their presentation. The current guideline-based process of assessment is lengthy, costly and consumes significant resources. Investigation of strategies to shorten this process or reduce the need for objective cardiac testing in patients at intermediate risk according to the National Heart Foundation and Cardiac Society of Australia and New Zealand guideline is required.
- 1. Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. NCHS Data Brief 2010; 43: 1-8.
- 2. Acute Coronary Syndrome Guidelines Working Group. National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184 (8 Suppl): S1-S32. https://www.mja.com.au/journal/2006/184/8/guidelines-management-acute-coronary-syndromes-2006. <MJA full text>
- 3. Chew DP, Aroney CN, Aylward PE, et al. Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand Guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ 2011; 20: 487-502.
- 4. Queensland Health Finance Branch. Activity based funding model 2010-11. Technical paper 2011.
- 5. Australian Institute of Health and Welfare. Australia's Health 2010. Chapter 8: Expenditure and workforce. Canberra: AIHW, 2010. (Australia's Health Series No. 12. AIHW Cat. No. AUS 122.) http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442452958 (accessed Feb 2015).
- 6. Cullen L, Than M, Brown AF, et al. Comprehensive standardized data definitions for acute coronary syndrome research in emergency departments in Australasia. Emerg Med Australas 2010; 22: 35-55.
- 7. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation 2012; 126: 2020-2035.
- 8. Hess EP, Brison RJ, Perry JJ, et al. Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med 2012; 59: 115-125.e1.
- 9. Body R, Carley S, McDowell G, et al. Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay. J Am Coll Cardiol 2011; 58: 1332-1339.
- 10. Christenson J, Innes G, McKnight D, et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med 2006; 47: 1-10.
- 11. Domanovits H, Schillinger M, Paulis M, et al. Acute chest pain - a stepwise approach, the challenge of the correct clinical diagnosis. Resuscitation 2002; 55: 9-16.
- 12. Chew DP, French J, Briffa TG, et al. Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust 2013; 199: 185-191.
- 13. Cullen L, Greenslade J, Hammett CJ, et al. Comparison of three risk stratification rules for predicting patients with acute coronary syndrome presenting to an Australian emergency department. Heart Lung Circ 2013; 22: 844-851.
- 14. Than M, Cullen L, Reid CM, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet 2011; 377: 1077-1084.
- 15. Than M, Cullen L, Aldous S. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol 2012; 59: 2091-2098.
- 16. Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol 2013; 62: 1242-1249.
- 17. George T, Ashover S, Cullen L, et al. Introduction of an accelerated diagnostic protocol in the assessment of emergency department patients with possible acute coronary syndrome: the Nambour Short Low-Intermediate Chest pain project. Emerg Med Australas 2013; 25: 340-344.
- 18. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac Chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med 2014; 174: 51-58.
- 19. Macdonald SP, Nagree Y, Fatovich DM, et al. Comparison of two clinical scoring systems for emergency department risk stratification of suspected acute coronary syndrome. Emerg Med Australas 2011; 23: 717-725.
- 20. Penumetsa SC, Mallidi J, Friderici JL, et al. Outcomes of patients admitted for observation of chest pain. Arch Intern Med 2012; 172: 873-877.
- 21. Prasad V, Cheung M, Cifu A. Chest pain in the emergency department: the case against our current practice of routine noninvasive testing. Arch Intern Med 2012; 172: 1506-1509.
- 22. Cullen L, Parsonage WA, Greenslade J, et al. Comparison of early biomarker strategies with the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for risk stratification of emergency department patients with chest pain. Emerg Med Australas 2012; 24: 595-603.
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.