Patients dismissed from the hospital with a diagnosis of noncardiac chest pain: cardiac outcomes and health care utilization

Abstract

Objective: To determine the proportion of patients with noncardiac chest pain (NCCP) who see a gastroenterologist, the type and frequency of gastrointestinal (GI) and cardiac tests performed, and the frequency of cardiac death.

Patients and methods: A cohort of Olmsted County, Minnesota, residents presenting to the emergency department (ED) with chest pain between January 1, 1985, and December 31, 1992, was identified through the Rochester Epidemiology Project. We assessed the frequency of ED, cardiology, and gastroenterology visits and corresponding tests after a diagnosis of NCCP (n=320). We also assessed the frequency of cardiac events.

Results: During follow-up, 49% of patients sought care in the ED, 42% had repeated cardiology evaluations, and 15% were seen by a gastroenterologist. Thirty-eight percent underwent esophagogastroduodenoscopy, but very few underwent manometry or a pH probe. Patients with NCCP of unknown origin had 3 times the rate of GI consultations as their counterparts with a GI disorder. Survival free of cardiac death in the subset with NCCP with a GI disorder was 90.2% at 10 years and 84.8% at 20 years, compared with 93.7% at 10 years and 88.1% at 20 years for the subset with NCCP of unknown origin.

Conclusion: The frequency of health care utilization in NCCP patients is high, but relatively few GI consultations and even fewer GI tests are performed. Patients dismissed from the hospital with NCCP continue to experience cardiac events, which may highlight a need for more aggressive cardiovascular risk factor management in this population.

FIGURE 1.

Patient population. ED = emergency department; NCCP = noncardiac chest pain.

FIGURE 2.

Subspecialty consultations and emergency department (ED) visits in patients with noncardiac chest pain (NCCP) (mean visits per 10 person-years). Rate ratios are adjusted for age and sex. CV = cardiovascular; GI = gastrointestinal; U = unknown. ^a Rate ratio comparing NCCP-U vs NCCP-GI for ED visits: 0.9 (P=.8). ^b Rate ratio comparing NCCP-U vs NCCP-GI for CV visits: 1.1 (P=.6). ^c Rate ratio comparing NCCP-U vs NCCP-GI for GI visits: 3.2 (P=.01).

FIGURE 3.

Gastrointestinal (GI) testing in patients with noncardiac chest pain (NCCP) (mean tests per 10 person-years). Rate and hazard ratios are adjusted for age and sex. EGD = esophagogastroduodenoscopy; U = unknown. ^a Rate ratio comparing NCCP-U vs NCCP-GI for EGD: 0.9 (P=.6). ^b Hazard ratio comparing NCCP-U vs NCCP-GI for pH probes: 1.7 (P=.6). ^c Hazard ratio comparing NCCP-U vs NCCP-GI for manometry: 1.2 (P=.8).

FIGURE 4.

A, Overall survival. B, Survival free of cardiac death. C, Survival free of noncardiac death. D, Survival in noncardiac chest pain cohort vs expected survival; P=.19 (log-rank test). ED = emergency department; GI = gastrointestinal.