Age Differences in Acute Chest Pain Outcomes in the ED

Key Takeaways

• Higher age was associated with higher 30-day death or MI and MACE in this cohort.
• Hospitalization (the primary healthcare utilization outcome) and objective cardiac testing (OCT) were also more common with increasing age after adjustment, using young adults as the reference group.
• In the prespecified older-versus-middle-aged analysis, adjusted odds of death or MI and MACE were similar, while hospitalization and OCT remained higher in older adults, and the authors concluded age should be strongly considered in future chest pain risk-stratification approaches.

Among adults evaluated for acute chest pain, increasing age was associated with higher short-term risk after ED evaluation. After adjustment for comorbidities and initial high-sensitivity troponin, older and middle-aged groups also had higher rates of hospitalization and objective cardiac testing (OCT) than young adults. The findings showed age-related differences in both 30-day outcomes and downstream healthcare use after ED chest pain evaluation.

The study used the Wake Forest Chest Pain Registry, a prospective multisite observational cohort of adults aged 18 years or older evaluated for possible ACS with chest pain and at least one troponin ordered. It included 40,979 patients seen across 25 North Carolina EDs from January 1 through December 31, 2021. Age strata were older at 65 years or older, middle-aged at 46 to 64 years, and young at 18 to 45 years. Older adults made up 25.1% of the cohort, middle-aged adults 39.7%, and young adults 35.2%, with a median age of 52 years, 56.6% female sex, 41.3% non-White race or ethnicity, and sites spanning 2 academic centers and 23 community hospitals. All sites used a HEART Pathway-based accelerated diagnostic protocol with hs-cTn, and the analysis compared short-term safety and healthcare use across age groups.

At 30 days, MACE occurred in 9.2% of older adults, 4.7% of middle-aged adults, and 0.8% of young adults. Hospitalization occurred in 56.3%, 35.4%, and 12.8%, respectively, and objective cardiac testing in 28.0%, 20.8%, and 4.6%. Objective cardiac testing included stress testing, coronary computed tomography angiography, and invasive coronary angiography. Across the overall cohort, death or MI occurred in 3.6% and MACE in 4.5% by 30 days. The absolute burden of both events and downstream care increased stepwise with age.

Adjusted models used young adults as the reference group and accounted for sex, race, ethnicity, obesity, smoking, rurality, coronary disease, diabetes, hypertension, hyperlipidemia, insurance, site, and initial hs-cTn. For 30-day death or MI, adjusted odds were higher in older adults at 1.57 (95% CI 1.17-2.12) and in middle-aged adults at 1.57 (95% CI 1.22-2.02). For MACE, adjusted odds were 1.79 (95% CI 1.36-2.36) in older adults and 1.63 (95% CI 1.29-2.06) in middle-aged adults. Hospitalization showed adjusted odds of 2.51 (95% CI 2.27-2.78) in older adults and 1.93 (95% CI 1.80-2.07) in middle-aged adults, while objective cardiac testing showed 3.03 (95% CI 2.64-3.47) and 2.68 (95% CI 2.43-2.95). Hs-cTn was handled as a binary variable using sex-specific 99th percentile upper reference limits, and age remained associated with worse 30-day outcomes and greater utilization after adjustment.

In the prespecified older-versus-middle-aged comparison, adjusted odds for death or MI were 0.99 (95% CI 0.84-1.15) and for MACE were 1.05 (95% CI 0.91-1.21). Older adults still had higher adjusted odds of hospitalization at 1.36 (95% CI 1.26-1.47) and objective cardiac testing at 1.17 (95% CI 1.08-1.27). Investigators wrote in the full article that age should be strongly considered in future chest pain risk-stratification algorithms and that troponin-only pathways may underestimate risk in older patients. This observational North Carolina cohort used EHR-derived, nonadjudicated outcomes, and death or hospitalization could not be classified as cardiac or noncardiac.