Ode to the hospitalist.

As this nation's leading cause of death, cardiovascular disease is a major issue confronting emergency room physicians, hospitalists, as well as cardiologists. The recent paradigm of ambulatory evaluation with chest pain clinics has received much enthusiasm. Nonetheless, misdiagnosed myocardial infarctions constitute the highest paid malpractice judgment against emergency physicians in this country. (1) As a result, patients are frequently admitted to the hospitalists' service (in those hospitals fortunate enough to have them), for further evaluation and treatment.

Wachter and Goldman (2) first detailed the role of the then novel specialty of "hospitalists" in their seminal 1996 article. Since that time, these physicians have revolutionized the practice of inpatient care; internists and primary care physicians now have the option of focusing on a total outpatient practice. In addition, hospitalists admit a variety of diagnoses such as pneumonia, diabetic ketoacidosis, gastrointestinal bleed, and chest pain, allowing subspecialists to act in a consultative role.

Traditionally, nighttime physician staffing in community hospitals has been limited to emergency department physicians. In rural settings, there may be only one such provider. The institution of the hospitalists' service, however, has greatly unburdened the emergency department staff, allowing them uninterrupted care of their own patients. Hospitalists typically respond to Code Blues and provide urgent patient assessment and treatment while the subspecialist is en route to the hospital. The rapid growth of this discipline clearly underscores their critical role.

In this issue of the Southern Medical Journal, Cakir and Blue (3) retrospectively reviewed 260 chest pain admissions to their hospitalists' service, of which only 24 (9.2%) were ultimately diagnosed with acute coronary syndrome (ACS). This unexpectedly low incidence may partially be explained by the authors' omission of the International Classification of Disease (ICD-9) codes 411.1 (acute coronary syndrome) and 414.01 (coronary artery disease [CAD]) from their inclusion criteria. Equally surprising was the finding that a family history of CAD, diabetes mellitus, hypertension, and tobacco use were not predictors of ACS.

In total, 175 patients (67.3%) underwent stress testing. While published statistics vary, this figure, too, seems low for an inpatient cohort. However, data is unavailable regarding how many of the 34 cardiac catheterizations were performed directly, bypassing an antecedent stress test. The prognostic value of stress testing in CAD, utilizing various diagnostic criteria, with or without imaging studies, is well established. (4-6) In addition, we have previously correlated rest and treadmill electrocardiographic findings with the severity of valvular disease. (7) With the increasing availability of newer imaging modalities such as cardiac computed tomographic angiography, future rates of noninvasive testing are expected to be even higher.

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The authors concluded that stratification of patients into high, intermediate, and low risk based upon the Diamond and Forrester algorithm (8) was predictive of ACS in their series. From the relative distribution of documented CAD among the ACS and non-ACS groups, this conclusion appears valid for the duration of the hospitalization. No patients in the non-ACS group underwent percutaneous coronary intervention or bypass surgery.

The main limitation of this study is reflective of the specialty: lack of longitudinal follow-up data--a shortcoming the authors readily acknowledge. They have no documentation of coronary anatomy in the 226 noncatheterized patients (86.9%) and no functional data in the 85 nonstress patients (32.7%). As no postdischarge outcomes data were collected, the incidence of major adverse cardiovascular event rates is unavailable. The value of any prognostication algorithm or diagnostic test lies in its predictive value over time, not simply during the index hospitalization. While a rough false-positive rate can be determined by the findings of the 34 catheterized patients, the much more crucial false-negative rate is unknown.

It would be premature to recommend a triage protocol based upon these results. Nonetheless, this study is helpful in orienting the clinician in his or her approach to risk stratification of chest pain syndromes. Other templates of evaluation have proven quite useful. For instance, the cost-effectiveness, and more importantly cost-safety, of emergency department-based sestamibi imaging shows great promise. (9)

Finally, as a personal note from one who has greatly benefited from the hospitalists' program at our institution, they are an essential part of our inpatient care team. I certainly rest easier knowing that a competent, well-trained physician is available around the clock for emergency situations. The inpatient counterpart of the primary care physician, hospitalists are also invaluable for coordination of care in patients with multiple medical issues. As generalists, they maintain the "forest," allowing subspecialists to concentrate on their respective, individual "trees." Keep up the great work.

References

1. Kamineni R, Alpert JS. Acute coronary syndromes: evaluation and risk stratification. Prog Cardiovasc Dis 2004;46:379-392.

2. Wachter RM, Goldman L. The emerging role of 'hospitalists' in the American health care system. N Engl J Med 1996;335:514-517.

3. Cakir B, Blue K. How to improve the management of chest pain: hospitalists and use of prediction rules. South Med J 2007;100:242-247.

4. Okin PM, Chen JP, Kligfield P. Effect of baseline segment elevation on test performance of standard and heart rate-adjusted ST segment depression criteria. Am Heart J 1990;119:1280-1286.

5. Albers AR, Krichavsky MZ, Balady GJ. Stress testing in patients with diabetes mellitus: diagnostic and prognostic value. Circulation 2006;113:583-592.

6. Mark DB, Shaw L, Harrell FE, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary disease. N Engl J Med 1991;325:849-853.

7. Chen JP, Okin PM, Roman MJ, et al. Combined rest and exercise electrocardiographic repolarization findings in relation to structural and functional abnormalities in asymptomatic aortic regurgitation. Am Heart J 1996;132:343-347.

8. Diamond GA, Forrester SF. Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 1979;300:1350-1358.

9. Kontos MC, Kurdziel K, McQueen R, et al. Comparison of 2-dimensional echocardiography and myocardial perfusion imaging for diagnosing myocardial infarction in emergency department patients. Am Heart J 2002;143:659-667.

To see one's life as a journey, as an adventure of discovery, as an
opportunity to learn from one's struggles as well as from one's delights
is to me an appealing and insightful perspective.
--David Barstow

Jack P. Chen, MD, FACC, FSCAI, FCCP 

From the Department of Cardiology, Saint Joseph's Hospital of Atlanta, Atlanta, GA.

Reprint requests to Jack P. Chen, MD, FACC, FSCAI, FCCP, St. Joseph's Hospital of Atlanta, 5670 Peachtree Dunwoody Road #880, Atlanta, GA 30342. Email: [e-mail]

Accepted November 9, 2006.