New Guideline for Managing Chest Pain in the ED Could Cut Overutilization Costs

Up to one-third of patients with chest pain could be safely taken off emergency department heart monitors under a clinical decision rule validated in a study in the Canadian Medical Association Journal.

“Based on our results, we recommend that patients who present to the emergency department with chest pain be removed from cardiac monitoring if they are free of chest pain at the time of assessment and if the electrocardiogram is either normal or shows only nonspecific changes,” wrote researchers from the University of Ottawa and The Ottawa Hospital. 

“Following this rule will allow for at least one-third of patients to be safely removed from cardiac monitoring immediately after their initial evaluation, freeing up valuable resources that may be allocated to patients who are more ill.”

Most patients who seek emergency care for chest pain are placed on a cardiac monitor for about 8 hours to detect a potentially life-threatening arrhythmia, or irregular heartbeat, according to the study. Yet the condition is rare, with previous studies demonstrating less than 2% of patients with chest pain experience an arrhythmia during an emergency department visit.

The Ottawa Chest Pain Cardiac Monitoring Rule was developed to identify patients who can be safely removed from heart monitors. If patients have no current chest pain and no significant abnormalities on an electrocardiogram, the rule states they can be removed from a heart monitor.

To verify the rule, researchers looked at data for 796 patients with chest pain who received heart monitoring during their stay in Ottawa Hospital’s two emergency departments over 18 months. The rule predicted with 100% accuracy the 15 patients who needed to remain on a heart monitor because of irregular heartbeat, according to the study. In addition, the rule indicated 36% of patients could have safely been removed from heart monitors.

“This rule now has the potential to take a large number of low-risk chest pain patients off of heart monitors,” said study lead author Venkatesh Thiruganasambandamoorthy, MBBS, an emergency physician at The Ottawa Hospital and an assistant professor at the University of Ottawa. —Jolynn Tumolo