Background/Purpose:  

Chest pain (CP) is a common symptom reported by SLE patients often leading to presentation to Emergency Departments (ED). The origin of CP can be attributed to many causes, which may or may not be cardiac in nature. It is important to understand the prevalence of CP in SLE, with ED visits being a window of opportunity for early detection of SLE heart disease.

Methods:  

Billing records of patients who presented to Cedars-Sinai Medical Center ED with ICD-9 codes for SLE between 3/2009–10/2013 were reviewed; this data was then examined for secondary ICD-9 codes for CP (786.50-786.59). Two study groups were formed, based on discharge from ED vs. hospital admission. Visits were evaluated for basic cardiac work up with EKG and cardiac enzymes, and number of visits by individual patient recorded. Hospital admissions were evaluated for CP etiology and discharge diagnoses. Continuous variables were analyzed by paired t test, and categorical data by chi squared test.

Results:  

Of 2675 ED visits with ICD-9 codes for SLE; 397 had secondary codes for CP (15%).  Of the 397 SLE and CP visits, 173 visits were discharged directly from the ED and 224 visits became hospital admissions.

The ED discharged group was significantly younger (p<0.0005) compared with the hospital admitted group. 

ED discharge group:  The 173 ED visits were accounted for by 127 unique patients. 77% of these visits received a basic cardiac work up.  While most patients had just 1 visit, a small number (7%) were frequent users of the ED, with an estimated one fourth of all visits.  

Hospital Admitted Group:  The 224 admissions were accounted for by 161 unique patients. 92% of admitted patients received a basic cardiac work up.

CP in the hospitalized group: The most commonly listed discharge diagnoses based upon primary physician’s work up and opinion, and the listed diagnoses for CP in the discharge summary are shown in Table 1. Rule out of Acute Coronary Syndrome (28.6%) was the most common diagnosis. Over 50% of CP at discharge was attributed to non-cardiac causes. 

Conclusion:  

Of all SLE coded patients presenting to the CSMC ED over a 4.5 year period, 15% had complaints of CP, which is higher than the national average for CP in non-SLE patients (10%). Frequent ED users (3 or more visits) made up only 7% of the total sample, but accounted for 24% of all the ED visits. Over90% of admitted patients had a basic cardiac work up performed. However, only a small percentage had a discharge diagnosis that was related to cardiovascular disease (7.2%). There is a high percentage of a negative cardiac work up with a majority of non-cardiac diagnoses in SLE patients, strengthening the need for more research into improved biomarkers or more specific imaging techniques to assess the etiology of CP. This study was a first step in revealing the high prevalence of CP in SLE patients presenting to the ED, while examining the limited diagnostic capabilities of a traditional cardiac work up.

Table 1: Chest Pain in the Hospitalized Group

Discharge Diagnosis	Percentage of Admissions
Cardiovascular Disease (CAD, MI, Unstable Angina, Microvascular Disease)	7.2%
Pericarditis (SLE related)	3.1%
Other Cardiac NOS (CHF, Arrhytmia, PVD)	4%
Rule out of Acute Coronary Syndrome	28.6%
Musculoskeletal/ Costochondritis	24.6%
Pulmonary (Pulmonary Embolism, Pneumonia, COPD)	13.8%
Gastro-Intestinal	8.9%
Multi-Factorial	9.8%

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/lupus-chest-pain-in-the-emergency-department-a-common-diagnostic-dilemma/