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Chest-pain follow-up linked to better survival, heart health

By Krystnell Storr

NEW YORK (Reuters Health) - After an emergency-room visit for chest pain, people who follow-up with a doctor are less likely than those who don’t do so to have a heart attack or die in the next year, Canadian researchers say.

Based on more than 200,000 patients at low risk for heart attack who were seen in an Ontario ER for chest pain, the study team found that almost 30 percent never went for any kind of follow-up. But those who did tended to fare better.

“Patients often mistake being discharged from the emergency department for having a clean bill of health, but this is not necessarily true” said the study’s senior author, Dr. Dennis Ko, a cardiologist at the University of Toronto’s Sunnybrook Health Sciences Centre.

Doctors use follow-up appointments as an opportunity to pin down the cause of an individual’s chest pain, which can be hard to do, Ko said, especially for patients without heart attack risk factors like diabetes or high blood pressure or pre-existing cardiac conditions.

After running more tests, the primary care doctor can refer the patient to a cardiologist or another specialist. Indeed, patients in the study who saw their primary care doctor and a cardiologist, or just a cardiologist, were the least likely to die or have a heart attack within a year of their ER visit.

"We were surprised that there really was a benefit to getting follow-up in this group because these patients did not have a lot of risk factors for heart disease," Ko told Reuters Health.

Chest Pain is one of the main symptoms of a heart attack, and according to the U.S. Centers for Disease Control and Prevention, more than 5 million Americans visit an emergency room complaining of chest pain each year.

Medical guidelines state that after discharge, even patients with no apparent heart attack should be sent for a follow-up exam to investigate the chest pain.

In a past study, Ko’s team had shown that people at high risk for heart disease did better if they followed-up an ER visit, although many of those patients didn’t seek further treatment either.

To see whether follow-ups make a difference for low-risk patients, Ko and his colleagues analyzed medical records for 216,527 patients who were discharged after having their chest pains assessed at an Ontario emergency department between April 2004 and March 2010.

The patients were all over age 50 and considered at low risk for heart disease because they did not have diabetes or any known heart risk factors. People with other serious illnesses, such as cancer, were excluded from the analysis.

The researchers looked at whether patients saw a primary care doctor or specialist within 30 days of their ER visit and tracked whether they died or had a heart attack in the 12 months after that.

During the first month, 29 percent of patients - almost 70,000 people - did not see any kind of doctor. Sixty percent saw at least their primary care doctor, 8 percent saw both a primary care doctor and a cardiologist and 4 percent of patients saw only a cardiologist.

Compared to patients who got no follow-up, those who saw both a primary care physician and a cardiologist had a 19 percent lower risk of heart attack or death in the next year. For those who saw just a cardiologist, the risk was 13 percent lower, the study team reports in the American Heart Journal.

Seeing just a primary care doctor was not linked to reduced risk compared to not seeing any doctor. Still, the authors emphasize that primary care typically plays an important “gatekeeper” role in referring patients to the right specialists.

Why so many patients never followed up their ER visit with any kind of doctor is unclear from the data the researchers had. But further studies should look at who would most benefit from follow-up attention and how to make sure they get it, the authors write.

“I think one of the most striking findings is that in a system where all medical costs are paid, 29 percent of patients did not follow up with any doctor after having chest pain,” Umesh Khot told Reuters Health.

Khot is a cardiologist at the Cleveland Clinic in Ohio and was not involved in the study. But he said it raises questions about how healthcare providers connect patients to outpatient care and highlights the fact that a lot of challenges remain.

“This tells me that even if you remove the issue of costs, a sizeable number of patients still do not follow-up. We tend to think that costs are the major barrier but this research indicates there are other barriers,” Khot said.

Among them, poverty or coping with other illnesses might make it too difficult to go for follow-up treatment, even if there is no charge, he speculated.

Khot said that patients not following-up on medical care is a problem throughout medicine. In the case of emergency room visits, he said, making sure the ER doctor discusses follow-up with the patient is one step that would help.

Ko thinks that patients should avoid the misconception that once they are released, they no longer have to worry. He said a person can still have a medical problem and simply be deemed safe to go home for treatment on an outpatient basis.

“The key thing to understand is that you should take your health seriously and make sure that when your emergency department doctor tells you to follow-up, it is important to do so,” Ko said.

SOURCE: http://bit.ly/Uow5mE American Heart Journal, online June 11, 2014.

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