Intensive Approach Improves Heart Attack Outcomes

Hospitals with higher admission rates for chest pain have lower rates of acute myocardial infarction (AMI) and death.

Researchers recently examined the relationship between emergency department (ED) admission rates for Medicare beneficiaries presenting with chest pain and clinical outcomes, particularly 30-day rates of AMI and mortality.

Their sample included 158,295 Medicare patients whose primary diagnosis at the conclusion of their ED visit was chest pain. Outcomes were assessed based on the decision to hospitalize or discharge home.

The researchers found substantial variation in chest pain-related admission rates across US hospitals, ranging from 38% to 81% in the lowest and highest quintiles, respectively.

Comparing the highest quintile with the lowest, there were 3.6 fewer AMIs and 2.8 fewer deaths per 1000 patients. In light of this, the authors concluded that hospitals with higher admissions rates in this population have lower rates of AMI and mortality.

“The major finding from the study was that a more intensive approach was associated with better outcomes for patients with chest pain,” study co-author Jesse M. Pines, MD, MBA, MSCE, exclusively told Pharmacy Times.

Although chest pain is a broad complaint that may initially seem low-risk based on symptoms, Dr. Pines described several strategies that can help ED clinicians identify patients at high risk for AMI.

“Electrocardiogram, blood tests (troponin), a concerning history for myocardial ischemia, and [other known] risk factors,” are just a few of these strategies, he explained. However, he added, “the tests we have are not 100% perfect.”

And even though higher admissions are associated with better AMI outcomes, Dr. Pines said “there may be more efficient ways to risk stratify than hospital admission, which can be very costly.”

Beyond cost, Richard Josephson, MD, of the American College of Cardiology Prevention of Cardiovascular Disease Council, told Pharmacy Times that “overzealously treating” patients with chest pain because of their potential risk for AMI might not be worth it.

“If you admit patients into hospitals and treat them for [AMI] when they, in fact, do not need those medications, you are creating the potential for doing more harm than good,” he explained.

Despite the study findings, Dr. Josephson ventured that the number of lives saved and heart attacks avoided isn’t substantial enough to warrant a wide-scale systemic change in how these patients are triaged.

“Not all patients are the same, and because there are well-documented adverse effects associated with several AMI treatment regimens such as aspirin and Brilinta, the risk-benefit just isn’t in favor of over-admitting,” he concluded. “Overprescribing isn’t worth it.”