A Clinical Trial of a Chest-Pain Observation Unit for Patients with Unstable Angina
Michael E. Farkouh, M.D., Peter A. Smars, M.D., Guy S. Reeder, M.D., Alan R. Zinsmeister, Ph.D., Roger W. Evans, Ph.D., Thomas D. Meloy, M.D., Stephen L. Kopecky, M.D., Marvin Allen, M.D., Thomas G. Allison, Ph.D., Raymond J. Gibbons, M.D., Sherine E. Gabriel, M.D., for The Chest Pain Evaluation in the Emergency Room (CHEER) Investigators
Background Nearly half of patients hospitalized with unstableangina eventually receive a non–cardiac-related diagnosis,yet 5 percent of patients with myocardial infarction are inappropriatelydischarged from the emergency department. We evaluated the safety,efficacy, and cost of admission to a chest-pain observationunit (CPU) located in the emergency department for such patients.
Methods We performed a community-based, prospective, randomizedtrial of the safety, efficacy, and cost of admission to a CPUas compared with those of regular hospital admission for patientswith unstable angina who were considered to be at intermediaterisk for cardiovascular events in the short term. A total of424 eligible patients were randomly assigned to routine hospitaladmission (a monitored bed under the care of the cardiologyservice) or admission to the CPU (where patients were caredfor according to a strict protocol including aspirin, heparin,continuous ST-segment monitoring, determination of creatinekinase isoenzyme levels, six hours of observation, and a studyof cardiac function). The CPU was managed by the emergency departmentstaff. Patients whose test results were negative were discharged,and the others were hospitalized. Primary outcomes (nonfatalmyocardial infarction, death, acute congestive heart failure,stroke, or out-of-hospital cardiac arrest) and use of resourceswere compared between the two groups.
Results The 212 patients in the hospital-admission group had15 primary events (13 myocardial infarctions and 2 cases ofcongestive heart failure), and the 212 patients in the CPU grouphad 7 events (5 myocardial infarctions, 1 death from cardiovascularcauses, and 1 case of congestive heart failure). There was nosignificant difference in the rate of cardiac events betweenthe two groups (odds ratio for the CPU group as compared withthe hospital-admission group, 0.50; 95 percent confidence interval,0.20 to 1.24). No primary events occurred among the 97 patientswho were assigned to the CPU and discharged. Resource use duringthe first six months was greater among patients assigned tohospital admission than among those assigned to the CPU (P=0.003by the rank-sum test).
Conclusions A CPU located in the emergency department can bea safe, effective, and cost-saving means of ensuring that patientswith unstable angina who are considered to be at intermediaterisk of cardiovascular events receive appropriate care.
Source Information
From the Cardiovascular Institute, Mount Sinai Medical Center, New York (M.E.F.); the Division of Emergency Medical Services and Internal Medicine (P.A.S., T.D.M.), the Division of Cardiovascular Diseases and Internal Medicine (G.S.R., S.L.K., T.G.A., R.J.G.), the Section of Biostatistics (A.R.Z.), and the Section of Health Services Evaluation (R.W.E., S.E.G.), Mayo Clinic and Mayo Foundation, Rochester, Minn.; and the Division of Cardiology, Central Utah Medical Clinic, Provo (M.A.).
Address reprint requests to Dr. Smars at the Division of Emergency Medical Services and Internal Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905.
Chest-Pain Observation Units
McFalls E. O., Getchell W. S., Larsen G., Smars P. A., Farkouh M. E., Reeder G. S.
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N Engl J Med 1999;
340:1596-1597, May 20, 1999.
Correspondence
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