Emergency‐department Diagnosis of Acute Myocardial Infarction and Ischemia: A Cost Analysis of Two Diagnostic Protocols

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Abstract
To assess the potential cost savings of the emergency-department (ED) diagnosis of acute myocardial infarction (AMI) and other myocardial ischemia using a nine- hour ED evaluation protocol. This one-year study of chest-pain evaluation unit (CPEU) patient charges was undertaken at two midwestern urban university hospital EDs. Included in the study were 447 patients presenting to the EDs with chest pain consistent with myocardial ischemia, nondiagnostic electrocardiograms (ECGs), and stable vital signs. Following initial ED evaluation, CPEU patients underwent nine hours of continuous ECG ST-segment monitoring with serum CK-MB levels determined at zero, three, six, and nine hours. Nonrandomized concurrent chest pain patients with routine ED evaluation and hospital admission without CPEU workup served as controls. At Center 1, patients with negative CPEU evaluations underwent immediate echocardiography (echo) and graded exercise testing (GXT) followed by ED release (CPEU;REL). At Center 2, CPEU patients were released from the ED for outpatient stress thallium testing (CPEU;REL). At Center 2, CPEU patients with positive workups as indicated by elevated CK-MB levels, ischemia by ST-segment monitoring, or positive echo/GXT/ stress thallium testing were admitted to the hospital for further testing. Control patients were admitted directly to the hospital to evaluate for AMI. Hospital charges for CPEU and control groups were compared. (Total charges in dollars, mean +/- SD, student's t-test): [table: see text] At both centers, hospital charges related to the acute evaluation of chest pain were significantly lower with this ED diagnostic protocol for AMI and myocardial ischemia.

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