by Michael Woodhead  

About one in a hundred patients who present to the ED with chest pain are inappropriately discharged despite having an acute coronary syndrome, a new study suggests.  

Emergency medicine specialists at the John Hunter Hospital in Newcastle, NSW, say they would be swamped if they admitted and investigated all patients presenting with chest pain, but they believe that early use of exercise stress testing after discharge could help pick up at least some of those currently being missed.  

Writing in the Emergency Medicine Australasia (21: 455 - 464) they say their prospective study found that almost 70% of 2627 patients presenting with symptoms suggestive acute coronary syndrome were discharged without a diagnosis. Of these 1819 discharged patients, 18 were subsequently diagnosed with either unstable angina or non-ST elevation MI within 30 days.  

They found that 28% of the discharged patients had signs of acute coronary syndrome such as troponin levels or ECG changes evident at discharge and which could have been picked up with better clinical assessment. Only 14% of discharged patients had follow up exercise stress testing, which might have detected ACS.  

“Opportunities exist to improve the safe discharge of patients presenting with chest pain to ED,” they conclude.  

The study authors say emergency departments have generally adopted Heart Foundation guidelines on the investigation of chest pain, but if they followed them to the letter they would have to admit all patients with diabetes or a history of CHD for observation and provocative testing, and this would more than double the number of patients admitted.  

The answer might lie in better clinical decision making instruments that are in development and the early use of exercise stress testing in discharged patients.