ACCELERATED DIAGNOSTIC PROTOCOLS USING STRESS TESTS REDUCE COSTS FOR EMERGENCY ROOM TRIAGE OF LOW-RISK PATIENTS WITH CHEST PAIN: A MULTICENTER PROSPECTIVE TRIAL

G. Nucifora. LP. Badano, M. Baldassi, G. Scaffidi, B.C. Astarita,

G. Pettinati, D. Gregori, N. Sarraf-Zadegan, A. Karavidas, P.M. Fioretti, on behalf of the ASSENCE Investigators

IRCAB Foundation, Udine, / Italy

G Ital Cardiol Vol.7 Suppl.1-5 2006

Background. Management of low-risk patients presenting to emergency department (ED) with chest pain (CP) suggestive of acute coronary syndrome, remains a continuing challenge, resulting often in unnecessary admissions in Coronary Care Units and wasting of resources. Several accelerated diagnostic strategies have been previously validated as feasible, safe, and effective for early stratification of such patients but resource utilization and coste of care have never been compared in a randomized trial.

Objectives. To compare length of in-hospital stay, resource utilization and average costs of care of routine use of early pre-discharge dobutamine stress echocardiography (DSE), exercise treadmill testing (ETT) and conventional ED/hospital observational period in triaging of low-risk patients with CP, negative serial enzymes and non-diagnostic ECG.

Methods. A total of 290 patients with no ischemic ECG changes, normal CK-MB and cardiac troponin at 6 hours from ED presentation, and who were to be admitted, were enrolled in 10 participating centers and randomized to DSE (n=110) or ETT (n=89) or conventional observational period (n=91). All patients were followed for 2 months.

Results. 73 (66%) patients in DSE arm and 56 (63%) in EET arm were immediately discharged after exclusion of inducible ischaemic (p=ns). In-hospital events were more common among patients in the conventional arm: there were 7 AMI (6 in the conventional arm and 1 in the DSE arm, p=0,03), 2 PCI ) both in the conventional arm; p=ns) and 1 CABG (in the DSE arm; p=ns). lschemic origin of chest pain was ruled out in 48 patients (53%) of the conventional arm, 86 (78%) of the DSE arm and 75 (84%) of the ETT arm (p<0.,001). Mean in-hospital length-of-stay for patient was 43.0 ± 71.8 hours in DSE arm, 40,4 ± 38.8 hours in ETT arm and 87,7 ± 63.4 hours in conventional arm (p<0,0001). During two-month follow-up event rate was similar between the three arms; there were 1 cardiovascular death (in the DSE arm), 3 AMI (one in each arm). 10 PCI (5 in DSE arm and ETT arm, respectively) and 3 CABG (one in each arm). Patients in the conventional arm were more frequently re-hospitalized (p=0,034). and more frequently underwent further diagnostic procedures, in particular 2D-echocardiography (p<0,0001), ETT (p<0,0001), myocardial scintigraphy (p=0,004) and coronary angiography (0.037), compared with the other two groups. Mean total cost per patient in the conventional arm was significantly higher than that in the DSE and ETT arms (4087 ± 4519 US$. 2314 4383 US$ and 2465 ± 3525 US$ respectively, p=0,010); there was no difference between DSE and ETT arms in terms of resource utilization and costs.

Conclusions. Accelerated diagnostic protocols with early DSE and ETT in ED patients with CP, normal CK-MB, troponin and ECG at 6 hours are safe and reduce length of in-hospital stay, in-hospital and outpatient resource utilization and costs of care as compared to the conventional ED/hospital observational period strategy.