Cost Comparison of Cardiac Magnetic Resonance Imaging (MRI) Use in Emergency Department (ED) Patients With Chest Pain
Cost Comparison of Cardiac Magnetic Resonance Imaging (MRI) Use in Emergency Department (ED) Patients With Chest Pain
The purpose of this study is to investigate the best way to evaluate patients with chest pain
 in the emergency department. It compares receiving treatment in an observation unit with
 admission to the hospital. Patients treated in the observation unit will undergo cardiac
 Magnetic Resonance Imaging (MRI) testing. Patients treated with hospital admission will
 undergo the testing their doctor determines is best for them. All patients will undergo
 follow up to find out if they have had any heart related events.
Almost half of patients presenting to the Emergency Department (ED) with possible cardiac
 chest pain are at intermediate risk for short term death or infarction. Most are admitted to
 the hospital for serial ECG's, cardiac biomarkers, cardiology consultation, and stress
 testing or coronary angiogram. However, the 2007 ACC/AHA guidelines suggest that these
 patients can be managed in an observation unit (OU). Recently, cardiac magnetic resonance
 imaging (CMR) has proven more accurate than traditional testing modalities for the diagnosis
 of acute coronary syndrome (ACS), and has also received endorsement from the American College
 of Cardiology (ACC)/American Heart Association (AHA) guidelines. Immediate application of CMR
 in an OU may improve health care utilization compared to standard hospital admission for
 intermediate risk patients.

 Research hypotheses:

 1. Patients in an OU CMR protocol will have lower cost for the index hospitalization than
 standard care.

 2. An OU CMR protocol for patients with intermediate risk chest pain will significantly
 improve the frequency of correct cardiovascular admission decisions when compared to
 standard care.

 Methods summary:

 110 ED patients at intermediate risk for short-term death or infarction, with nondiagnostic
 Electrocardiograms (ECG) and normal initial cardiac biomarkers, will be randomized to
 standard care or OU CMR protocols. Subjects in the OU CMR protocol will undergo CMR perfusion
 and stress testing, followed by serial biomarkers. Standard care subjects will be admitted
 for usual cardiac testing. ACS (infarction, death, coronary revascularization, unstable
 angina) will be assessed by evaluation of hospital course and phone follow-up at 30 days.
 Cost of hospital care will be compared among groups.
Inclusion Criteria:

 -  Age greater than or equal to 18 years of age at the time of enrollment

 -  Chest discomfort or other symptoms consistent with possible Acute Coronary Syndrome
 (ACS) as indicated by the treating physician after obtaining an Electrocardiogram
 (ECG) and cardiac biomarkers for the patient's evaluation

 -  Patient requires an inpatient evaluation for their chest pain

 -  The treating physician feels the patient could be discharged home if cardiac disease
 was excluded

 -  Thrombolysis in Myocardial Infarction (TIMI) risk score ≥ 2 OR physician clinical
 impression of intermediate or high likelihood that the symptoms represent ACS

 -  Negative pregnancy test (if sexually active, female, and of childbearing age)

 Exclusion Criteria:

 -  Initial troponin I > 1.0 ng/ml

 -  New ST-segment elevation on any electrocardiogram (≥ 1 mV)

 -  New ST-segment depression on any electrocardiogram (≥ 2 mV)

 -  Unable to lie flat

 -  Hypotension (systolic < 90 mm Hg)

 -  Contra-indications to MRI(Pacemaker, defibrillator, cerebral aneurysm clips, metallic
 ocular foreign body, implanted devices, claustrophobia)

 -  Patient refusal of medical record review and telephone follow-up at 30 days

 -  Terminal diagnosis with life expectancy less than 3 months

 -  Pregnancy per patient report or positive pregnancy test (Center for Medicare &
 Medicaid Services (CMS) exclusion criteria)

 -  Renal insufficiency(done prior to enrollment)or end stage renal disease

 -  Chronic liver disease (ex. hepatitis, cirrhosis)

 -  History of liver, heart, or kidney transplant