Author + information
- Jeremy Miles, MD∗ ()
- ↵∗Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy South, Bronx, New York 10461
I read with great interest the retrospective analysis performed by Eggers et al. (1) on cardiac troponin elevation in patients hospitalized for chest pain and discharged without a specific diagnosis. This is an important study that examines a common dilemma that arises in clinical practice, especially with the advent of high-sensitivity troponin assays (2).
The study analyzed patients who had acute chest pain and troponin elevation, yet, who did not have a specific diagnosis on discharge. Most patients had a discharge International Classification of Diseases-10th revision (ICD-10) diagnosis of unspecified chest pain (79%) or observation for suspected MI (16%). In the analysis, was there a concern that these respective ICD-10 codes were not updated on discharge and did not reflect events that occurred during the hospitalization? Was there a method to confirm the ICD-10 codes so that patients treated, for example, for sepsis, pulmonary embolism, or myocarditis were excluded? As shown in Figure 1 by Eggers et al. , 81,948 patients were discharged without a specified diagnosis; yet, 4,204 patients underwent percutaneous coronary intervention or coronary artery bypass graft. Although these patients were excluded from the study, does the fact that they had an unspecified discharge diagnosis call into question the validity of the provided ICD-10 codes of the included cohort?
Furthermore, 4,989 patients underwent coronary angiography during their hospitalization (Table 1 by Eggers et al. ). Do the authors know if the other 43,883 patients had other forms of coronary testing, such as myocardial perfusion imaging or coronary computed tomography angiography? It would be plausible that a large percentage of patients admitted to “coronary care units or other specialized facilities because of suspected acute coronary syndrome” with acute chest pain and troponin elevation would undergo some form of evaluation for ischemic heart disease. This information would be vital to know, as the authors recommend a careful workup with echocardiography or coronary imaging. However, if many patients had these tests done, it would be unclear if these recommendations would be warranted based on the study outcomes. Additionally, it is important to identify what percentage of patients were discharged on medications such as high-intensity statins and antiplatelets and correlate this data with the adverse event rates.
Please note: Dr. Miles has reported that he has no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Eggers K.M.,
- Jernberg T.,
- Lindahl B.
- Roos A.,
- Bandstein N.,
- Lundback M.,
- Hammarsten O.,
- Ljung R.,
- Holzmann M.J.