Post-ER care for chest pain reduces risk of heart attack, death

Seeing a doctor within a month of an emergency room visit for chest pain significantly reduced the risk of heart attack or death among high risk patients, according to research published the American Heart Association journal Circulation.

Chest pain is the most common reason people go to the emergency room in developed countries and accounts for more than 5 million ER visits each year in the United States.

The study is the first to demonstrate the importance of follow-up care for chest pain patients after leaving the ER, researchers said. High risk patients in this study were those with previously diagnosed heart disease or diabetes.

"Being discharged from the emergency department is reassuring for patients, but it is critical that they follow up with their doctor to reduce their risks of future heart attacks or premature death," said Dennis T. Ko, M.D., M.Sc., senior author and scientist at the Institute for Clinical Evaluative Sciences, Cardiologist at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. "Patients need to advocate for themselves and physicians need to be more diligent about arranging follow-up care."

Researchers analyzed data on 56,767 adults (average age 66, 53 percent men) in Ontario, Canada, who were diagnosed with chest pain in an emergency room between April 2004 and March 2010; had been previously diagnosed with heart disease or diabetes; and didn't require additional hospitalization or die within a month. They tracked data for a median 3.7 years and accounted for differences in key patient characteristics such as age, gender, health status and location.

Among the findings:

• Only 17 percent of high risk chest pain patients seen in the emergency room were evaluated by cardiologists within a month; 58 percent saw a primary care physicians alone, and 25 percent had no physician follow-up within a month.
• Patients who followed up with a cardiologist within 30 days were 21 percent 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 seen by a primary care physician were 7 percent less likely to have a heart attack or die compared to those patients who sought no follow up care.
• 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 cardiologist were 15 percent less likely to have a heart attack or die within the first year, compared to patients who received follow up care from their primary care physician.

Patients who didn't seek follow-up care within a month received the lowest rate of care and had the worst health outcomes -- demonstrating the need to improve follow-up with high risk chest pain patients after they're discharged from the emergency room, Ko said.

The study notes that there are several reasons patients did not receive additional physician follow-up including: patients believing they didn't need additional care and the lack of a coordinated referral system from the emergency department to physicians who can provide follow-up care.

While there is no cost for seeing a physician at follow-up in the Canadian health care system, the barriers for follow up care could include expense in other countries.

"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 follow-up care to begin with," Ko said. "We need systems of care that better identify these patients who are at increased risk because getting that follow-up can significantly reduce their risks of heart attack or premature death."

Because the study focused on high risk patients, the results may not apply to all who have chest pain. Researchers recommend further study that will also investigate economic factors.