Nontraumatic chest pain is the second most frequent cause of emergency department (ED) visits among adults, resulting in more than 8 million visits annually in the United States.1 Although the predictive value of many signs, symptoms, and diagnostic tests have been defined for life-threatening diagnoses, to our knowledge, the frequency of these diagnoses has not been determined in a nationally representative sample. The pretest probability of a given condition is critical to drive Bayesian analysis and help determine posttest probability when known predictive values of findings from the history, physical examination, and any laboratory, electrocardiographic, or radiologic testing are applied. Methods We analyzed the National Hospital Ambulatory Medical Care Survey database, a national probability sample of visits to nonfederal, general, acute care hospitals in the United States conducted by the National Center for Health Statistics.2 We included all ED visits from January 1, 2005, to December 31, 2011, for adults 18 years and older with the chief concern of nontraumatic chest pain. Data analysis was conducted from September 22, 2014, to September 30, 2015. We calculated the overall frequency of each diagnosis as a percentage of all included visits and for age-based subgroups. We identified 6 life-threatening conditions that are traditionally taught to be considered in patients who present with chest pain: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, esophageal rupture, and perforated peptic ulcer.3,4 The University of California, San Francisco, Institutional Review Board waived review of this study. Patient data from the National Hospital Ambulatory Medical Care Survey database were deidentified. Results We analyzed 10 907 patient records, representing 42 579 676 patient visits to the ED with a primary symptom of chest pain; these visits represented 4.7% of all sampled ED visits. Table 1 provides descriptive characteristics and weighted percentages of these visits. Most patients were aged 18 to 64 years (8215 [75.6%]), female (5685 [52.7%]), non-Hispanic white (6904 [64.5%]), and treated in an urban area (9519 [84.4%]). Private insurance, Medicare, and Medicaid rates were 45.1% (n = 4914), 13.6% (n = 1443), and 18.8% (n = 2132), respectively. In terms of visit disposition, the rate of discharge was 57.4% (n = 6219) (95% CI, 55.0%-59.8%), hospital admission was 30.6% (n = 3331) (95% CI, 28.4%-32.8%), and death in the ED or hospital was 0.4% (n = 51) (95% CI, 0.2%-0.6%). The most common diagnosis was nonspecific chest pain (5624 [51.7%]; 95% CI, 50.1%-53.4%). When stratified by age group (Table 2), the prevalence of serious diagnoses increased with increasing age. In patients aged 18 to 44 years, cardiac dysrhythmia (89 [1.8%]; 95% CI, 1.4%-2.3%) was the only potentially critical diagnosis more frequent than 1%. In patients aged 45 to 64 years, coronary atherosclerosis (233 [5.4%]; 95% CI, 4.2%-6.6%), acute myocardial infarction (106 [2.8%]; 95% CI, 2.1%-3.4%), and cardiac dysrhythmia (99 [2.6%]; 95% CI, 2.0%-3.1%) were more frequent than 1%. In patients aged 65 to 79 years, coronary atherosclerosis (150 [7.0%]; 95% CI, 5.4%-8.5%), cardiac dysrhythmias (67 [3.9%]; 95% CI, 2.7%-5.1%), and acute myocardial infarction (68 [3.5%]; 95% CI, 2.4%-4.6%) were more frequent than 1%. Finally, in patients 80 years or older, coronary atherosclerosis (79 [7.8%]; 95% CI, 5.8%-9.9%), nonhypertensive congestive heart failure (44 [5.7%]; 95% CI, 3.6%-7.7%), and acute myocardial infarction (37 [3.7%]; 95% CI, 2.2%-5.2%) were more frequent than 1%. When examining the percentage of diagnoses that are typically taught to medical students as life-threatening conditions associated with chest pain, only 650 (5.5%; 95% CI, 4.8%-6.1%) of all ED visits for chest pain led to diagnoses of these conditions. When examining each of these conditions independently, 602 diagnoses (5.1%) were for acute coronary syndrome, and the rest were extremely rare, with the remaining totaling less than 48 (0.4%). Discussion Our findings show that health care professionals require accurate differential diagnosis lists with information regarding the likelihood of life-threatening conditions to be able to limit wasteful tests and improve patient outcomes. The likelihood of these conditions, outside of acute myocardial infarction, is rare, and suggests that significant diagnostic testing to rule out these diagnoses may not be warranted in a general population of undifferentiated patients presenting with chest pain. Most existing process quality measures focus on quality of management for patients with established diagnoses, not the accuracy of diagnosis in patients with undifferentiated symptoms.5 As cost pressures increase, efforts toward improving diagnostic accuracy based on quality measures using valid signs or symptoms may be necessary given the effect on subsequent care. Accurate recognition of prevalence estimates, as an adjunct to the predictive value of signs, symptoms, and diagnostic testing, can help physicians make more informed decisions. Back to top Article Information Corresponding Author: Renee Y. Hsia, MD, MSc, Department of Emergency Medicine, University of California, San Francisco, 1001 Potrero Ave, Room 1E21, San Francisco, CA 94110 (firstname.lastname@example.org). Published Online: June 13, 2016. doi:10.1001/jamainternmed.2016.2498. Author Contributions: Dr Hsia had full access to all the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Hale, Tabas. Critical revision of the manuscript for important intellectual content: All authors. Administrative, technical, or material support: Hsia. Study supervision: Hsia. Conflict of Interest Disclosures: None reported. References 1. Amsterdam EA, Kirk JD, Bluemke DA, et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-1776.PubMedGoogle ScholarCrossref 2. McCaig LF, Burt CW. Understanding and interpreting the National Hospital Ambulatory Medical Care Survey: key questions and answers. Ann Emerg Med. 2012;60(6):716-721.e1.PubMedGoogle ScholarCrossref 3. UpToDate. Differential diagnosis of chest pain in adults. http://www.uptodate.com/contents/differential-diagnosis-of-chest-pain-in-adults. Accessed February 21, 2015. 4. Kontos MC, Diercks DB, Kirk JD. Emergency department and office-based evaluation of patients with chest pain. Mayo Clin Proc. 2010;85(3):284-299.PubMedGoogle ScholarCrossref 5. Kanzaria HK, Mattke S, Detz AA, Brook RH. Quality measures based on presenting signs and symptoms of patients. JAMA. 2015;313(5):520-522.PubMedGoogle ScholarCrossref
JAMA Internal Medicine – American Medical Association
Published: Jul 1, 2016
Keywords: chest pain,differential diagnosis,diagnostic techniques, cardiovascular,emergency service, hospital,prevalence,accuracy
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