First Author: Quincy K. Tran, MD, PhD – University of Maryland Medical Center, R. Adams Cowley Shock Trauma Center Co-Author: Noreen Mian, BS – Student, University of Toledo College of Medicine and Life Sciences Co-Author: Samira Mudd, MS – Student, Research Associate Program in Emergency Medicine and Critical Care, University of Maryland School of Medicine Co-Author: Jacob Friedman, BS Co-Author: Julian Starks, BS – Student, University of Maryland School of Medicine Co-Author: Jennifer Walker, MD – Emergency Medicine, Critical Care Medicine, Baylor Scott & White Health Co-Author: Ali Pourmand, MD MPH – Attending physician, George Washington University school of medicine and Health Sciences
Introduction: Patients presenting to an emergency department (ED) with chest pain are often subject to various diagnostic imaging and laboratory tests. The American College of Cardiology recommended the Chest X-rays (CXR) for finding other etiologies. However, the utility of CXR in patients with acute coronary syndrome is controversial, as CXR in this patient population frequently does not change any management. This study examines the relevant diagnoses and procedures between the cohorts with asymptomatic chest pain and CXR. We hypothesized that the prevalence of clinically significant etiologies will be low.
Methods: A retrospective analysis was conducted using the TriNetX Research Network, encompassing 20 years of data and 130 millions of patients. Adult patients presenting the ED with an ICD-10 code for chest pain were included and stratified based on whether a CXR was performed. Patients who presented with trauma, fever, hypoxia, or shortness of breath were excluded. The TriNetX propensity score matching algorithm was used to balance cohorts based on multiple demographic and clinical covariates. The primary outcome was the presence of pneumonia, pleural edema, pneumomediastinum, rib fractures, aortic dissection, pneumothorax, hemothorax, and chest tube procedure. Sample size calculation suggested 20000 patients to detect 1% difference of clinical findings.
Results: We included 2,644,979 patients in the primary outcome analysis with a mean age (±SD) of 49 (±20) years with 52% being female. The primary analysis demonstrated the greatest risk difference was the diagnosis of pneumonia (Risk difference 2.0%, 95% CI 2.0 to 2.0, P< 0.001). Given the large sample size, there was statistically significant risk between cohorts when analyzing other outcomes, but even the greatest risk difference between groups was less than 0.1%.
Conclusions: Chest X-ray of patients presenting with chest pain but without other symptoms is associated with 2% difference in risk of diagnosis of pneumonia, without clinically significant increased risk in any other conditions. Further research is necessary to better determine which patients will need CXR, when presenting with chest pain, but was without risk factors like fever, abnormal vital signs or trauma.
