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Congestive heart failure patients with chest pain: incidence and predictors of acute coronary syndrome.

OBJECTIVE
New diagnostic and treatment options for emergency department (ED) patients with congestive heart failure (CHF) may facilitate the ED discharge of some patients. However, some patients require admission to exclude concurrent acute coronary syndrome (ACS) as the precipitant of CHF. The objective of this study was to identify the incidence, clinical characteristics, and hospital course of CHF patients who present to the ED with and without concurrent ACS.


METHODS
This was a prospective cohort study of consecutive patients >23 years of age who presented to the ED with chest pain, received an electrocardiogram (ECG), and either had a known history of CHF or presented with new-onset CHF, between July 1999 and April 2001. The hospital course of each patient was followed daily, and telephone follow-up occurred at 30 days. The main outcomes were the incidence of ACS and comparisons of lengths of hospital stay (LOSs), rates of admission to the intensive care unit (ICU), intubations, and death rates among patients with and without ACS.


RESULTS
Two hundred ninety-eight CHF patients presented 380 times. The incidence of ACS in the 380 patient visits was 32% (95% CI = 27% to 36%). Compared with patients who did not have ACS, patients who had concurrent ACS were more likely to have known coronary artery disease (CAD) (67% vs. 42%; p < 0.0001) and hypercholesterolemia (36% vs. 18%; p = 0.0002). Patients with concurrent ACS were also more likely to be admitted to the hospital (97% vs 82%; p < 0.0001), had a longer LOS (5.2 [3.9-6.5] vs 3.2 [2.6-3.8] days; p = 0.006), had higher rates of ICU admission (44% vs. 13%; p < 0.0001), were more likely to be intubated (8% vs. 1%, p = 0.002), and were more likely to die (15 vs 7 deaths; p < 0.0001).


CONCLUSIONS
The incidence of ACS in ED CHF patients with chest pain was 32%. Patients with CHF complicated by ACS had more prolonged hospital stays, required higher levels of care, and had a higher incidence of death than those patients without ACS. Strategies tailored to early identification and management of these patients would be desirable.