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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 79-82

Discharge against medical advice in patients with acute coronary syndrome during the COVID-19 outbreak


Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Date of Submission26-Apr-2021
Date of Decision04-Aug-2021
Date of Acceptance17-Aug-2021
Date of Web Publication03-Nov-2021

Correspondence Address:
Dr. Alireza Rashidinejad
Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Vali-Asr Ave, Tehran 1996911101
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_23_21

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  Abstract 


Background: Patients' hesitation to seek medical care has seriously compromised the management of acute coronary syndrome during coronavirus disease 2019 (COVID-19) outbreak. In the present study, we have reported the rate of discharged against medical advice (DAMA) among patients referred to chest pain unit (CPU) of a tertiary cardiovascular center and compared their clinical outcomes with whom admitted or managed conservatively. Methods: Patients with modified HEART risk score ≥4 referred to the CPU were included in the present study. Population requiring CPU admission due to positive serial troponin were divided into admitted and DAMA groups. Patients with negative serial troponin were managed as outpatient (conservative treatment group). 30-day major adverse cardiac events (MACE) and all-cause mortality were compared between the study groups. Results: A modified HEART risk score (≥4) was calculated for 440 of 5490 patients visited our CPU. One hundred and one (22.9%), 80 (18.1%), and 249 (56.5%) patients were categorized as DAMA, admitted, and conservative treatment groups, respectively. Myocardial infarction was significantly higher in the DAMA versus admitted group (2 vs. 0; P ≤ 0.001). MACE and all-cause mortality were significantly higher in the DAMA group than that in the conservative treatment group (5 vs. 2; P = 0.02 and 4 vs. 2; P = 0.055, respectively). Conclusion: In the present study, we have demonstrated a considerable rate of DAMA in patients with high modified HEART risk score referring to CPU during the COVID-19 outbreak. Importantly, the DAMA group experienced a higher incidence rate of 30-day MACE and all-cause mortality compared to patients who were admitted or managed conservatively.

Keywords: Acute coronary syndrome, COVID-19, discharged against medical advice, HEART pathway, modified HEART Risk Score


How to cite this article:
Parhizgar SE, Vahedinezhad M, Yari T, Mohajer B, Maghsoudloo Z, Sadeghipour P, Mozayanimonfared A, Hosseini Z, Maleki M, Firouzi A, Alemzadeh-Ansari MJ, Hosseini Z, Rashidinejad A. Discharge against medical advice in patients with acute coronary syndrome during the COVID-19 outbreak. Res Cardiovasc Med 2021;10:79-82

How to cite this URL:
Parhizgar SE, Vahedinezhad M, Yari T, Mohajer B, Maghsoudloo Z, Sadeghipour P, Mozayanimonfared A, Hosseini Z, Maleki M, Firouzi A, Alemzadeh-Ansari MJ, Hosseini Z, Rashidinejad A. Discharge against medical advice in patients with acute coronary syndrome during the COVID-19 outbreak. Res Cardiovasc Med [serial online] 2021 [cited 2021 Dec 3];10:79-82. Available from: https://www.rcvmonline.com/text.asp?2021/10/3/79/329844




  Introduction Top


Chest pain is the most common cardiovascular complaint in patients referring to the emergency department.[1] Thus, appropriate risk stratification has a vital role in determining the high-risk population and controlling unnecessary burden on the emergency department. One of the validated risk stratification tools for that purpose is the modified HEART risk score, which takes into account patients' history, electrocardiograms, age, cardiovascular risk factors, and troponin levels and, thus, determines patients with a higher risk of short-term major adverse cardiac events (MACE) (i.e., HEART Pathway).[2]

However, the coronavirus disease 2019 (COVID-19) pandemic has influenced the standard care for many emergent conditions including acute coronary syndrome (ACS).[3] Limited access to previously readily available resources in the wake of the recent transferal of resource allocation toward the care of patients with COVID-19, medical staff's fears of contamination via multiple exposures, and patients' hesitation to seek medical care for fear of disease transmission can be specified as significant factors confounding ACS management with potentially catastrophic consequences.[4]

We aimed to evaluate the prognosis of ACS between 3 groups of patients: patients who were discharged against medical advice (DAMA), those who accepted to be hospitalized, and the ones who were treated as outpatient via the conservative approach during the early period of the COVID-19 pandemic.


  Methods Top


The present cross-sectional study was conducted on consecutive patients with chest pain who referred to the emergency department of a large tertiary and teaching cardiovascular center during the early period of the COVID-19 pandemic in Iran. Patients with ST-segment elevation myocardial infarction (STEMI) were excluded. The Modified HEART risk score was routinely calculated and recorded for each patient in the emergency department. Based on the HEART Pathway, serial troponin measurements were requested for patients with a modified HEART risk score of 4 and above, and those with positive troponin tests were admitted to the chest pain unit (CPU) for further evaluation.[2] The study protocol was approved by the Ethics Committee of Rajaie Cardiovascular Medical and Research Center.

Statistical analysis

The continuous and categorical variables were reported as the mean ± the standard deviation and numbers (%), respectively. The Chi-square test or the Fisher's exact test was implemented to compare the categorical variables between the groups. The continuous variables were compared between the groups using the t-test. Two-sided P values were reported. All the statistical analyses were performed using the STATA software (StataCorp, TX, USA).


  Results Top


From February 20 to April 24, 2020, a total of 5490 chest pain visits were recorded by the emergency department [Figure 1]. Patients with STEMI (n = 48), patients with a modified HEART risk score of below 4 (n = 4985), and also 17 patients who had imaging and/or laboratory data compatible with COVID-19 and, consequently, referred to COVID-19 care centers, were excluded from the study and also patients with a minimum modified HEART risk score of 4 (n = 440) were divided into two categories: those with negative serial troponin measurements were candidate for medical follow-up and, thus, discharged from the emergency department with appropriate ACS medical therapy (the conservative treatment group, n = 259) and the ones with positive serial troponin tests who received recommendations from their treating physicians to be admitted to the CPU (n = 181). From the latter group, patients either accepted to be admitted (the admitted group, n = 80) or discharged themselves against medical advice with appropriate full medical ACS therapy (containing aspirin 325 mg PO stat followed by 81 mg PO daily, clopidogrel 300 mg PO stat followed by 75 mg PO daily, atorvastatin 80 mg PO stat then 40 mg PO daily, metoprolol 25 mg PO BD-based on pulse rate, and nitrate PO depending on the presence of angina) (the DAMA group, n = 101) [Figure 1]. The reasons for DAMA are summarized in [Figure 2]. Importantly, 17 patients had imaging and/or laboratory data compatible with COVID-19 and were, consequently, referred to COVID-19 care centers. The three study groups were followed for 30 days after the first visit to the emergency department. The primary and secondary endpoints of the current study were MACE and all-cause mortality, respectively.
Figure 1: Study flowchart

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Figure 2: Reasons for discharge against medical advice during the study period

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The baseline demographic and clinical characteristics of the three study groups are depicted in [Table 1]. The patients allocated to the conservative treatment group had significantly lower modified HEART risk scores than the other two groups. The details of the study population's 30-day clinical outcomes are summarized in [Table 2].
Table 1: Baseline demographic and clinical characteristics of the studied population

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Table 2: Detailed 30-day follow-up clinical outcome in our study groups

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A comparison between the admitted group and the DAMA group showed similar rates of MACE (2 vs. 5; P = 0.32) and all-cause mortality (2 vs. 4; P = 0.45). Notably, the incidence rate of myocardial infarction (MI) during the follow-up period was significantly higher in the DAMA group than in the admitted group (2 vs. 0; P ≤ 0.001). No significant differences were detected between the admitted and conservative treatment groups with regard to MACE (2 vs. 2; P = 0.23) and all-cause mortality (2 vs. 2; P = 0.23). Finally, the rates of MACE and all-cause mortality were significantly higher in the DAMA group than in the conservative treatment group (5 vs. 2; P = 0.02 and 4 vs. 2; P = 0.055, respectively). Of note, the two reported cases of MACE (and all-cause mortality) in the conservative treatment group were caused by ischemic strokes.


  Discussion Top


The results of the present cross-sectional study showed DAMA in more than half of the patients with modified HEART risk scores of 4 and above and positive serial troponin tests. The DAMA group had a significantly higher incidence rate of MI during our 30-day follow-up than the admitted group and significantly higher rates of MACE and all-cause mortality than the conservative treatment group (i.e., modified HEART risk scores ≥4 and negative serial troponin tests). In addition, our findings revealed acceptable rates of 30-day MACE and all-cause mortality in patients risk-stratified as the conservative treatment group, indicating the HEART Pathway as an acceptable approach during the COVID-19 pandemic.

A substantial drop in the incidence rate of ACS has been reported since the early period of the COVID-19 pandemic.[5],[6],[7] Patients' disinclination to seek medical care for fear of disease transmission may be the salient reason. Such reluctance may be deemed the culprit for the increased outhospital deaths and mid- and long-term complications of acute coronary events (e.g., heart failure).[3] We found that hesitation to seek medical care and fear of the pandemic persisted even after our patients referred to the emergency department. Indeed, we recorded DAMA in 55.8% (101 of 181) of our patients with a minimum modified HEART risk score of 4 and positive serial troponin tests, which translated into two cases of MI and three cases of cardiovascular mortality during the 30-day follow-up. This finding underscores the notion that the risk of MACE set against COVID-19 transmission should be fully explained to patients, which implicates the complementary role of the media vis-à-vis public awareness in an era when the medical community is overwhelmed by the pandemic burden.

COVID-19 panic (64%) was the first cause of DAMA in our study [Figure 2]. Importantly, dissatisfaction with treatment in the emergency department contributed to 15% of the DAMA rate in our study. We believe that such dissatisfaction could be ameliorated by well-thought-out treatment protocols. Further, since elective revascularization modalities were postponed during the pandemic, there could have been more room for more invasive approaches toward the treatment of patients with ACS, which might have boosted patient satisfaction with the treatment.[3]

In our previous investigation, we discussed the status of our 48 patients with STEMI admitted during the same period as that in the present study and reported no DAMA.[4] Mafham et al. reported a substantial drop in admission rates in patients with non-STEMI in comparison with those affected by STEMI (42% vs. 23%, respectively), which might have resulted from a generally incessant and severe picture of STEMI by comparison with non-ST elevation ACS.[3] Nevertheless, given its incidence and the risk of future disabling heart failure,[8] non-ST elevation ACS warrants due attention with a view to raising public awareness and reducing the burden on the medical community.

Indubitably, patients with COVID-19 have imposed an unexpected load on emergency departments, which may have complicated the care of noninfected patients who might have higher morbidity and mortality than infected patients. This accentuates the value of risk estimation tools in the stratification of patients.[9] In the present study, we did not seek to validate the modified HEART risk score during the COVID-19 pandemic; still, our results showed that risk stratification based on the HEART Pathway in patients with STEMI might be applicable. According to our findings, patients with a minimum modified HEART risk score of 4 and with negative serial troponin tests (the conservative treatment group) were discharged from the emergency department with acceptable 30-day outcomes. Crucially, our conservative treatment group accounted for more than half of the population with modified HEART risk scores of 4 and above (n = 259 [56.3%]), which may have translated into significantly less burden on the emergency department, especially during this critical period. Risk stratification based on the modified HEART risk score could be applied in the majority of emergency rooms with a minimum of facilities (electrocardiography and cardiac troponin measurement).

The main limitations of the current study are its observational nature and limited sample size. In addition, that we evaluated only hard cardiovascular endpoints during the follow-up period can be considered another weakness of note, given that such other endpoints as the incidence of disabling heart failure and reductions in the left ventricular ejection fraction might have discriminating roles with respect to the mid- and long-term outcomes of each of our study groups.


  Conclusion Top


We herein demonstrated a considerable rate of DAMA in patients with elevated modified HEART risk scores referring to the emergency department during the COVID-19 period. Our DAMA group experienced a higher incidence rate of MACE during the 30-day follow-up. We posit that fear of contamination tends to persist after patients' medical contact, which underscores the importance of patient awareness and also the value of improving therapeutic pathways in non-COVID-19 patients.

Ethical clearance

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bjørnsen LP, Naess-Pleym LE, Dale J, Grenne B, Wiseth R. Description of chest pain patients in a Norwegian emergency department. Scand Cardiovasc J 2019;53:28-34.  Back to cited text no. 1
    
2.
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: Value of the HEART score. Neth Heart J 2008;16:191-6.  Back to cited text no. 2
    
3.
Mafham MM, Spata E, Goldacre R, Gair D, Curnow P, Bray M, et al. COVID-19 pandemic and admission rates for and management of acute coronary syndromes in England. Lancet 2020;396:381-9.  Back to cited text no. 3
    
4.
Firouzi A, Baay M, Mazayanimonfared A, Pouraliakbar H, Sadeghipour P, Noohi F, et al. Effects of the COVID-19 pandemic on the management of patients with ST-elevation myocardial infarction in a tertiary cardiovascular center. Crit Pathw Cardiol 2021;20:53-5.  Back to cited text no. 4
    
5.
Abdi S, Salarifar M, Mortazavi SH, Sadeghipour P, Geraiely B. COVID-19 sends STEMI to quarantine!? Clin Res Cardiol 2020;109:1567-8.  Back to cited text no. 5
    
6.
De Rosa S, Spaccarotella C, Basso C, Calabrò MP, Curcio A, Filardi PP, et al. Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era. Eur Heart J 2020;41:2083-8.  Back to cited text no. 6
    
7.
Ashraf S, Ilyas S, Alraies MC. Acute coronary syndrome in the time of the COVID-19 pandemic. Eur Heart J 2020;41:2089-91.  Back to cited text no. 7
    
8.
George B, Misumida N, Ziada KM. Revascularization Strategies for non-ST-elevation myocardial infarction. Curr Cardiol Rep 2019;21:39.  Back to cited text no. 8
    
9.
Chieffo A, Stefanini GG, Price S, Barbato E, Tarantini G, Karam N, et al. EAPCI position statement on invasive management of acute coronary syndromes during the covid-19 pandemic. Eur Heart J 2020;41:1839-51.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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