Sent home from the ER? Follow-up care is crucial after chest pains

Every year, thousands of Canadians end up in hospital emergency rooms, complaining of chest pains. ER doctors usually order several tests to determine if these patients have suffered a heart attack or are about to have one. Much of the time, the tests fail to detect they are in immediate danger, and they are sent home.

However, that doesn't mean they have been given a clean bill of health – although some patients might think so. They should still see their family physician, or a cardiologist, soon afterward to determine the underlying cause of their chest pain, which could be a warning sign of an impending heart attack.

But a new study, published Monday in the journal Circulation, found that a significant proportion of patients – 25 per cent – didn't get follow-up care within a month, which increased their chances of having a potentially fatal heart attack.

Of those patients, 8.6 per cent had a heart attack or died of one within a year. The findings are based on more than 56,000 adults who visited ER departments of Ontario medical centres between 2004 and 2010.

"They may have been falsely reassured," the first time they were admitted to hospital with chest pains, said the senior author of the study, Dr. Dennis Ko, a cardiologist at Sunnybrook Health Sciences Centre in Toronto.

"They may have thought to themselves, 'Well, I didn't have a heart attack. That's good. I don't need to see anybody else,'" speculated Ko, who is also a researcher at Toronto's Institute for Clinical Evaluative Sciences. "Just going to the emergency room is not enough. You need to continue to manage your condition ... so that your long-term outlook can be improved."

Indeed, the study showed that those patients who sought additional medical attention were able to reduce their chances of suffering a heart attack.

About 58 per cent of patients saw a primary-care physician within a month of being at the ER. Their risk of having a heart attack over the next 12 months dropped to 7.7 per cent. And 17 per cent were evaluated by a cardiologist, which helped to push their risk down to 5.5 per cent. (Some of the patients in the lowest-risk group saw both a family doctor and a cardiologist.)

Ko noted that the patients who went to a cardiologist had the most evaluation of their heart function, which tended to result in more medical therapy.

The study helps to shed light on one of major problems of the health-care system – a failure to properly co-ordinate care after a patient has been discharged from hospital.

"I would suspect most emergency-room physicians tell patients to follow up with their family doctor," said Ko. "But there is still a gap in care partly because the emergency physicians can't make an appointment for the patient." And sometimes, he noted, patients don't have a family doctor who they can rely on for continuing care.

All the patients in the study had medical conditions such as diabetes and pre-existing cardiovascular disease. So they certainly could be considered at high risk of a heart attack and should have been closely observed by a physician, he noted.

"We need systems of care that better identify these patients who are at increased risk because getting that follow-up can significantly reduce their risk of heart attack or premature death."