Low-risk chest pain patients clogging wards

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Unnecessary investigations for low-risk chest pain are forcing other, sicker, patients to wait longer for a bed


Hospital wards are clogged with chest pain patients unlikely to have an acute coronary syndrome and who should have been discharged after initial investigation, according to a Brisbane doctor.

Despite the well-intentioned desire to avoid missing a heart attack, unnecessarily investigating these patients was forcing other, sicker, patients to wait longer for a bed, audiences at the Preventing Overdiagnosis Conference in Barcelona heard earlier this month. Associate Professor Ian Scott, director of the Department of Internal Medicine and Medical Assessment and Planning Unit at the Princess Alexandra Hospital, said his research suggested the overwhelming majority of patients with negative initial investigations in the ED were not at risk of further cardiac events six months later.

The research, which has been submitted for publication, analysed the rates of readmission for acute coronary syndrome, death or cardiac-related admission in patients with undifferentiated chest pain admitted to a ward from emergency departments.

After a negative initial investigation, further testing of the patients was not clinically useful, the researchers found.

“If you’ve got atypical chest pain, a Thrombolysis in Myocardial Infarction score of zero or one, normal ECG results and a negative troponin, then that’s it,” Professor Scott said.

“That patient does not have coronary artery disease, doesn’t have acute coronary syndrome, and therefore doesn’t need to be investigated, doesn’t need to be admitted to hospital and can be discharged.”

And yet many such patients were still hospitalised and investigated, he said. “That blocks up the system, because you’re filling up your inpatient wards with lot of people with atypical chest pain that don’t need to be there.”

Fewer than one in five patients with undifferentiated chest pain admitted from emergency departments had acute coronary syndrome as the final discharge diagnosis.

While the safest option for a patient presenting to general practice with chest pain and risk factors was to go to the emergency department, Professor Scott said he hoped the research would free up capacity in hospitals.

As well as the need to take responsibility for the stewardship of limited resources, clinicians were obliged to help patients avoid unnecessary harm, he said.

“It’s not only physical harm from getting drugs and investigations they don’t need, but also psychological harm from being given a diagnosis or a label that in fact is not warranted and causes anxiety,” he said.

“Modern medicine does a lot of good but it also has the potential to do significant harm.

“So we should use it wisely, and we should try to avoid investigations when we know that the probability of the patient having the condition of interest is very low and all we’re likely to do is to find incidental results or a false positive diagnosis that leads to unnecessary treatment.”

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