Emergency departments have a new tool to identify patients with chest pain who can be removed safely from cardiac monitoring, with validation of the Ottawa Chest Pain Cardiac Monitoring Rule, according to a research paper published in CMAJ (Canadian Medical Association Journal).

Ottawa researchers had previously developed the Ottawa Chest Pain Cardiac Monitoring Rule as a simple tool to help physicians determine which patients could be safely removed from cardiac monitors.

The current study tested the decision rule in actual patient settings to determine its safety and usefulness. Researchers enrolled 1125 patients with chest pain who visited the emergency departments of The Ottawa Hospital's two campuses (Civic and General), and 796 (70.8%) were monitored during their stay. Of all the patients who were monitored, only 15 (1.9%) patients suffered an arrhythmia during their stay in the emergency department. The rule would have enabled 284 (35.7%) patients to be safely removed from cardiac monitoring.

"Our study results show that clinically important arrhythmias are uncommon among patients presenting to the emergency department with chest pain," writes Dr. Venkatesh Thiruganasambandamoorthy, scientist and emergency physician at The Ottawa Hospital and assistant professor at the University of Ottawa, Ottawa, Ontario, with coauthors. "A substantial number of patients are unnecessarily being placed on cardiac monitoring, while this resource is needed for patients in the waiting room who are more ill."

The rule was designed to be highly sensitive, meaning it would identify all patients with an arrhythmia. In this validation study, it performed as desired, detecting 100% of patients. None of the patients in the study who could be taken off the monitor as per the rule experienced any arrhythmias.

Researchers created the initial decision tool in 2007, but suggest that despite a time lag, it will be useful for clinicians. It has already been implemented in three Canadian emergency departments, two in Ottawa and one in Calgary.

"Overall the management of chest pain patients has not changed much in the past 10 years with most patients requiring serial blood tests to rule out heart attack and end up staying in the emergency department for few hours. Hence, our study results are important, very relevant and will improve the management of chest pain patients in the emergency," says Dr. Thiruganasambandamoorthy. "The results, if implemented, should have a significant and positive impact on wait times and increase the availability of monitored beds for sicker patients."

"We recommend that patients who present to the emergency department with chest pain be removed from cardiac monitoring if they are free of chest pain at the time of assessment and if the ECG is either normal or shows only nonspecific changes. Following this rule will allow for at least one-third of patients to be safely removed from cardiac monitoring immediately after their initial evaluation, freeing up valuable resources that may be allocated to patients who are more ill," the authors conclude.

The study was funded by the Ontario Innovation Fund. Dr. Venkatesh Thiruganasambandamoorthy is currently supported by the National New Investigator salary award through the Heart and Stroke Foundation of Canada.

Article: Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring, Shahbaz Syed, BSc, MD, Mathieu Gatien, MD, Jeffrey J. Perry, MD, MSc, Hina Chaudry, MBBS, Soo-Min Kim, BScH, Kenneth Kwong, BSc, Muhammad Mukarram, MBBS, Venkatesh Thiruganasambandamoorthy, MBBS, MSc, CMAJ, doi: 10.1503/cmaj.160742, published 30 January 2017.