• Chadwick D Miller, Wenke Hwang, James W Hoekstra, Doug Case, Cedric Lefebvre, Howard Blumstein, Brian Hiestand, Deborah B Diercks, Craig A Hamilton, Erin N Harper, and W Gregory Hundley.
• Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
• Ann Emerg Med. 2010 Sep 1; 56 (3): 209-219.e2.

Study ObjectiveWe determine whether imaging with cardiac magnetic resonance imaging (MRI) in an observation unit would reduce medical costs among patients with emergent non-low-risk chest pain who otherwise would be managed with an inpatient care strategy.MethodsEmergency department patients (n=110) at intermediate or high probability for acute coronary syndrome without electrocardiographic or biomarker evidence of a myocardial infarction provided consent and were randomized to stress cardiac MRI in an observation unit versus standard inpatient care. The primary outcome was direct hospital cost calculated as the sum of hospital and provider costs. Estimated median cost differences (Hodges-Lehmann) and distribution-free 95% confidence intervals (Moses) were used to compare groups.ResultsThere were 110 participants with 53 randomized to cardiac MRI and 57 to inpatient care; 8 of 110 (7%) experienced acute coronary syndrome. In the MRI pathway, 49 of 53 underwent stress cardiac MRI, 11 of 53 were admitted, 1 left against medical advice, 41 were discharged, and 2 had acute coronary syndrome. In the inpatient care pathway, 39 of 57 patients initially received stress testing, 54 of 57 were admitted, 3 left against medical advice, and 6 had acute coronary syndrome. At 30 days, no subjects in either group experienced acute coronary syndrome after discharge. The cardiac MRI group had a reduced median hospitalization cost (Hodges-Lehmann estimate $588; 95% confidence interval $336 to $811); 79% were managed without hospital admission.ConclusionCompared with inpatient care, an observation unit strategy involving stress cardiac MRI reduced incident cost without any cases of missed acute coronary syndrome in patients with emergent chest pain.Copyright (c) 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.

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