Followup care after an ER visit for chest pain reduces risk of heart attack or death: study

In the first study of its kind to demonstrate the importance of followup care for chest pain patients after leaving the emergency room (ER), researchers at the Institute for Clinical Evaluative Sciences (ICES) found that seeing a doctor within a month of an ER visit for chest pain significantly reduced the risk of heart attack or death among high risk patients.

Chest pain is the most common reason patients go to the ER. However, one in four chest pain patients, who have diabetes or established cardiovascular disease, didn’t seek followup care within a month, as recommended.

“Being discharged from the emergency department is reassuring for patients, but it is critical that they followup with their doctor to reduce their risks of future heart attacks or premature death,” says senior author Dr. Dennis Ko, an ICES scientist and a cardiologist at Sunnybrook Health Sciences Centre.

Patients who follow up with a cardiologist have the highest rates of evidence-based medical therapy, diagnostic testing and revascularization procedures.

The observational study of 56,767 Ontario adults (average age 66; 53 per cent male) with higher baseline risk, defined as having diabetes or established cardiovascular disease, diagnosed with chest pain, discharged and without adverse clinical outcomes within 30 days from 2004 to 2010 found that:

• Only 17 per cent of high risk chest pain patients seen in the ER were evaluated by cardiologists within a month.
• 58 per cent saw a primary care physicians alone.
• 25 per cent had no physician followup within a month.
• The rate of having a heart attack or dying at one year was 5.5 per cent in patients followed by a cardiologist, 7.7 per cent followed by a primary care physician, and 8.6 per cent with no followup.
• Patients who followed up with a cardiologist within 30 days were 21 per cent less likely to have a heart attack or die within one year, compared with patients who failed to seek additional care within that time.
• Patients treated by cardiologists received more testing, procedures and medication within 100 days of their ER discharge and had the best health outcomes.
• Patients seen by their primary care physician were 15 per cent less likely to have a heart attack or die within the first year.

The researchers demonstrated a significant gap in the transition of care for chest pain patients after discharge from the ED. Followup with a cardiologist within 30 days of an ED visit was associated with a decreased risk of all-cause mortality or hospitalization.

The study identifies several reasons patients did not receive additional physician followup including: patients believing they didn’t need additional care and the lack of a coordinated referral system from the ER to physicians who can provide followup care.

“As physicians, we are often so focused on knowing which drug to prescribe or which test to order that we overlook the fact that many patients fail to get followup care to begin with,” Ko says. “We need systems of care that better identify these patients who are at increased risk because getting that followup can significantly reduce their risk of heart attack or premature death."

Authors: Andrew Czarnecki, Alice Chong, Douglas S. Lee, Michael J. Schull, Jack V. Tu, Ching Lau, Michael E. Farkouh, and Dennis T. Ko.

The study “Association between physician follow-up and outcomes of care after chest pain assessment in risk patients” was published today in the American Heart Association Journal Circulation.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

FURTHER INFORMATION, PLEASE CONTACT:

• Deborah Creatura
• Communications, ICES
• [email protected]
• (o) 416-480-4780