Trends in Hospitalization, Cardiac Testing, and Outcomes for Chest Pain Patients, 2007-2021

Annually, over 7 million patients visit US emergency departments (EDs) for chest pain. But over 90% have no evidence of acute myocardial infarction (AMI) or significant cardiopulmonary condition. Historically, such patients were often hospitalized to reduce missed diagnoses and expedite coronary testing. However, high-sensitivity troponins, clinical risk scores, and shared decision-making have transformed ED chest pain management. This study assessed changes in chest pain hospitalization, subsequent cardiac testing, and AMI admissions in 2007-2021.

We conducted a cross-sectional analysis of claims data from a national commercial and Medicare Advantage insurer spanning January 1, 2007, to September 30, 2021. ED visits for adults aged ≥18 years with a principal diagnosis of chest pain (ICD-9: 786.50, 786.51, 786.59; ICD-10: R07.1, R07.2, R07.89, R07.9) were included. Patients with secondary diagnoses of AMI, angina, pulmonary embolism, or acute aortic syndrome were excluded, as were visits within six months of coronary testing/intervention. Outcomes included hospitalization at index ED visit, coronary testing within 7 days, and AMI admissions within 30 days. We modeled outcomes using generalized estimating equations, accounting for demographics, comorbidities, socioeconomic factors, and state fixed effects, and calculated adjusted annual rates.

Among 773,250 ED visits (mean age 54.7 years; 54.7% female), adjusted hospitalization rates declined from 40.4% to 16.3%, a relative decrease of 59.6% (95% CI 58.7–60.6; p<0.001). Coronary testing within 7 days fell from 23.9% to 8.3%, a 65.3% relative reduction (95% CI 64.0–66.5; p<0.001). Adjusted 30-day AMI rates showed no significant trend (annual change -0.005 percentage points; 95% CI -0.047, 0.037; p=0.802), ranging from 2.7% to 4.0%. Subgroup analyses by age revealed similar patterns.

From 2007 to 2021, ED chest pain management changed considerably, with fewer hospital stays and less coronary testing, while maintaining stable AMI outcomes. These results indicate improved risk assessment with reduced resource utilization. Future research should focus on identifying patients who are most likely to benefit from hospitalization or testing. Limitations include dependence on administrative data, which lacks detailed clinical information.