Triaging and evaluating patients with chest pain remains a problem. High-risk patients can be identified by various clinical algorithms, but determining low-risk patients who can be discharged safely is more difficult. This difficulty means that many low-risk patients are admitted to hospitals for observation. Cardiac monitoring usually is ordered, based on the perceived value of identifying dysrhythmias, even though the value of monitoring is uncertain in low-risk patients.
Hollander and associates studied the use of telemetry monitoring in patients admitted for chest pain who were at low risk for cardiovascular complications. Low-risk patients with chest pain who had normal cardiac enzyme levels and normal electrocardiography results and whose Goldman risk score was less than 8 percent were admitted to nonintensive care-monitored beds (see accompanying table). Among the 1,029 low-risk patients admitted to telemetry beds (59 percent of all patients admitted for telemetry monitoring), 15 were diagnosed as having had an acute myocardial infarction, and 121 were diagnosed with unstable angina. There were two deaths from noncardiac causes. The rate of cardiovascular deaths that might have been prevented by telemetric monitoring was zero percent. No patients developed sustained ventricular tachycardia or ventricular fibrillation while being monitored.
|Goldman score < 8 percent
|Troponin I level < 0.3 ng per mL
|Creatine kinase-MB level < 5 ng per mL
The authors conclude that low-risk patients with chest pain are at very low risk for serious arrhythmia and do not benefit from telemetry monitoring. These patients could be maintained in a nonmonitored bed during their observation period. Rapid evaluation for potential coronary artery disease is still recommended.
In an editorial in the same journal, Blomkalns and Gibler agree that there is no value in telemetry monitoring in low-risk patients, and they note that eliminating this step will relieve the pressure on scarce monitored hospital beds. They suggest that some or all of these patients could be sent home after a six- to eight-hour period in an appropriately designed observation unit. Further improvements in risk stratification will be useful.