Most Tests for Life-Threatening Chest Pain Are Probably a Waste

More than eight million emergency department visits each year in the United States are due to nontraumatic chest pain — making it the second most common reason patients present to the emergency room. But a new study published in JAMA Internal Medicine found that these situations are rarely serious.

Many patients present with signs and symptoms consistent with life-threatening conditions but, fortunately, the number of people who actually do have serious problems is relatively small. Researchers from the University of California, San Francisco examined a national database of nonfederal, general, acute care hospital visits.

The cohort consisted of 10,907 patients making up over 42 million hospital visits from January 2005 to December 2011. Just over three-fourths of the patients were ages 18 to 64, a little over a half were female, and nearly two-thirds were Caucasian. Just under 5% of these emergency room visits were due to chest pain as the primary symptom. About 57% of the patients were discharged and about 31% were admitted to the hospital. Mortality only occurred in 51 patients (0.4%).

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Physicians are typically taught to consider six life-threatening conditions when a patient has chest pain, including: acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, esophageal rupture, and perforated peptic ulcer. The team calculated the frequency of each diagnosis for age subgroups.

The most common diagnosis was nonspecific chest pain (51.7%), but serious diagnoses were associated with increased age.

• Ages 18 to 44: Cardiac dysrhythmia in 89 patients (1.8%)
• Ages 45 to 64: Cardiac dysrhythmia in 99 patients (2.6%), acute myocardial infarction in 106 patients (2.8%), and coronary atherosclerosis in 233 patients (5.4%)
• Ages 65 to 79: Acute myocardial infarction in 68 patients (3.5%), cardiac dysrhythmias in 67 patients (3.9%), and coronary atherosclerosis in 150 patients (7%)
• Ages 80 and higher: Acute myocardial infarction in 37 patients (3.7%), nonhypertensive congestive heart failure in 44 patients (5.7%), and coronary atherosclerosis in 79 patients (7.8%)

“Our findings show that healthcare professionals require accurate differential diagnosis lists with information regarding the likelihood of life-threatening conditions to be able to limit wasteful tests and improve patient outcomes,” the authors wrote. They noted that acute myocardial infarction wasn’t exactly rare occurrences, but the other serious conditions are often times ruled out in the general population.

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