Clin Rheumatol DOI 10.1007/s10067-015-2948-4
BRIEF REPORT
Chest pain in lupus patients: the emergency department experience Masoom Modi 1 & Mariko L. Ishimori 1 & Vaneet K. Sandhu 1 & Daniel J. Wallace 1 & Michael H. Weisman 1
Received: 11 February 2015 / Revised: 9 April 2015 / Accepted: 17 April 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract Heart disease, a major cause of morbidity and mortality in SLE patients, often manifests as chest pain (CP). Our goal was to understand the prevalence and outcome of CP presentations for SLE patients in the emergency department (ED). Billing records of patients who presented to CedarsSinai Medical Center ED with ICD-9 codes for SLE and secondary ICD-9 codes for CP (786.50–786.59) between March 2009 and October 2013 were reviewed. Two study groups were formed: discharge from ED versus hospital admission. Visits were evaluated for basic cardiac work-up with an electrocardiogram (EKG) and cardiac enzymes; hospital admissions were evaluated for CP etiology and discharge diagnoses. Of 2675 ED visits with ICD-9 codes for SLE, 397 visits had secondary codes for CP (15 %); 173 were discharged and 224 became hospital admissions. While 92 % of admissions had basic cardiac work-up, over 50 % had chest pain attributed to non-cardiac causes. Only 7.2 % had a discharge diagnosis related to cardiovascular disease. Fifteen percent of all SLE coded patients had complaints of CP, a figure higher than the national average for non-SLE CP (10 %). There is a majority of non-cardiac diagnoses given to SLE patients at discharge. CP is likely to be a window of opportunity to address the known cardiac morbidity and mortality in SLE patients perhaps at an early stage of development of this complication. Our study strengthens the need for more investigations to assess the etiology of CP in this population.
* Michael H. Weisman [email protected] 1
Division of Rheumatology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite B131, Los Angeles, CA 90048, USA
Keywords Cardiovascular diseases . Chest pain . Emergency department . Systemic lupus erythematosus
Introduction Systemic lupus erythematosus (SLE), an autoimmune disorder predominantly affecting women, exhibits a wide range of signs and symptoms, many of which trigger an emergency department (ED) visit. Further, it has been established that cardiac disease in SLE patients is a significant cause of morbidity and mortality, with a majority of patients dying from ischemic heart disease [1]. Traditional risk factors (hyperlipidemia, hypertension, and family history) combined with sustained inflammation and prior use of glucocorticoids may contribute to the early onset of cardiovascular disease in these patients [2]. The overall risk of cardiovascular disease (CVD) has been estimated to be ninefold higher in SLE patients compared to the general population, based on a Swedish age-matched population study [3]. In addition, it is well known that chest pain (CP) is ubiquitous and the second most common chief complaint for ED visits preceded only by abdominal pain [4], with women in the general population having a higher number of chest pain ED visits than men in two of three different age groups [5]. Given that CVD is common in women with SLE, coupled with the higher number of chest pain ED visits by women in the general population, it becomes important to understand the prevalence of chest pain in SLE patients. This would provide an opportunity for earlier detection and management of potentially serious cardiac problems as well as expansion of the currently limited diagnostic tools available for lupus cardiac disease.
Clin Rheumatol
Methods This study was approved by the Institutional Review Board at Cedars-Sinai Medical Center (CSMC). The CSMC Emergency Department is a level I trauma center and critical care center, located in west Los Angeles, with an estimated 80, 000 patient visits annually and diverse patient demographics, in terms of gender, ethnicity, and socio-economic status. In this retrospective study, we reviewed emergency department billing records of patients who presented to the CSMC ED coded for SLE between March 2009 and October 2013 (ICD-9-CM: 710.0 and 695.4); this data was then reviewed for secondary codes for chest pain (ICD-9-CM: 786.50 through 786.59) and divided into two groups: discharge from ED versus hospital admission. Subsequently, all of the visits in both groups with concurrent lupus and chest pain ICD-9 codes
Fig. 1 a Selection of study groups based on visits coded for SLE and CP. b Percent of 173 visits (white bars) represented by 127 unique patients (black bars) discharged from the ED broken down by number of visits. c
were evaluated for basic cardiac work-up consisting of an electrocardiogram (EKG) and cardiac enzymes. Admitted SLE visits were evaluated for length of hospitalization and attending reported etiology of chest pain (particularly whether the chest pain was attributable to cardiovascular disease). Selected demographics (age, sex, and ethnicity) for each visit were collected. P values were calculated based on individual visits and determined using a two-tailed t test for continuous data and a chi-squared test for categorical data. A P value of ≤0.05 was used as an indication of significance.
Results Overall, we examined approximately 360,000 ED visits from March 2009 to October 2013; 2675 ED visits had ICD-9
Percent of 224 hospital admissions (white bars) represented by 161 unique patients (black bars) broken down by number of admissions
Clin Rheumatol Table 1
Selected demographics of SLE and CP visits ED discharge
Hospital admission
Percent female Average age (years) African-American Non-Hispanic White Hispanic White
92 % 45 45.0 % 33.0 % 18.0 %
91 % 56 41.5 % 40.0 % 14.2 %
Asian and other
4.0 %
4.3 %
P value
BRIEF REPORT
Chest pain in lupus patients: the emergency department experience Masoom Modi 1 & Mariko L. Ishimori 1 & Vaneet K. Sandhu 1 & Daniel J. Wallace 1 & Michael H. Weisman 1
Received: 11 February 2015 / Revised: 9 April 2015 / Accepted: 17 April 2015 # International League of Associations for Rheumatology (ILAR) 2015
Abstract Heart disease, a major cause of morbidity and mortality in SLE patients, often manifests as chest pain (CP). Our goal was to understand the prevalence and outcome of CP presentations for SLE patients in the emergency department (ED). Billing records of patients who presented to CedarsSinai Medical Center ED with ICD-9 codes for SLE and secondary ICD-9 codes for CP (786.50–786.59) between March 2009 and October 2013 were reviewed. Two study groups were formed: discharge from ED versus hospital admission. Visits were evaluated for basic cardiac work-up with an electrocardiogram (EKG) and cardiac enzymes; hospital admissions were evaluated for CP etiology and discharge diagnoses. Of 2675 ED visits with ICD-9 codes for SLE, 397 visits had secondary codes for CP (15 %); 173 were discharged and 224 became hospital admissions. While 92 % of admissions had basic cardiac work-up, over 50 % had chest pain attributed to non-cardiac causes. Only 7.2 % had a discharge diagnosis related to cardiovascular disease. Fifteen percent of all SLE coded patients had complaints of CP, a figure higher than the national average for non-SLE CP (10 %). There is a majority of non-cardiac diagnoses given to SLE patients at discharge. CP is likely to be a window of opportunity to address the known cardiac morbidity and mortality in SLE patients perhaps at an early stage of development of this complication. Our study strengthens the need for more investigations to assess the etiology of CP in this population.
* Michael H. Weisman [email protected] 1
Division of Rheumatology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite B131, Los Angeles, CA 90048, USA
Keywords Cardiovascular diseases . Chest pain . Emergency department . Systemic lupus erythematosus
Introduction Systemic lupus erythematosus (SLE), an autoimmune disorder predominantly affecting women, exhibits a wide range of signs and symptoms, many of which trigger an emergency department (ED) visit. Further, it has been established that cardiac disease in SLE patients is a significant cause of morbidity and mortality, with a majority of patients dying from ischemic heart disease [1]. Traditional risk factors (hyperlipidemia, hypertension, and family history) combined with sustained inflammation and prior use of glucocorticoids may contribute to the early onset of cardiovascular disease in these patients [2]. The overall risk of cardiovascular disease (CVD) has been estimated to be ninefold higher in SLE patients compared to the general population, based on a Swedish age-matched population study [3]. In addition, it is well known that chest pain (CP) is ubiquitous and the second most common chief complaint for ED visits preceded only by abdominal pain [4], with women in the general population having a higher number of chest pain ED visits than men in two of three different age groups [5]. Given that CVD is common in women with SLE, coupled with the higher number of chest pain ED visits by women in the general population, it becomes important to understand the prevalence of chest pain in SLE patients. This would provide an opportunity for earlier detection and management of potentially serious cardiac problems as well as expansion of the currently limited diagnostic tools available for lupus cardiac disease.
Clin Rheumatol
Methods This study was approved by the Institutional Review Board at Cedars-Sinai Medical Center (CSMC). The CSMC Emergency Department is a level I trauma center and critical care center, located in west Los Angeles, with an estimated 80, 000 patient visits annually and diverse patient demographics, in terms of gender, ethnicity, and socio-economic status. In this retrospective study, we reviewed emergency department billing records of patients who presented to the CSMC ED coded for SLE between March 2009 and October 2013 (ICD-9-CM: 710.0 and 695.4); this data was then reviewed for secondary codes for chest pain (ICD-9-CM: 786.50 through 786.59) and divided into two groups: discharge from ED versus hospital admission. Subsequently, all of the visits in both groups with concurrent lupus and chest pain ICD-9 codes
Fig. 1 a Selection of study groups based on visits coded for SLE and CP. b Percent of 173 visits (white bars) represented by 127 unique patients (black bars) discharged from the ED broken down by number of visits. c
were evaluated for basic cardiac work-up consisting of an electrocardiogram (EKG) and cardiac enzymes. Admitted SLE visits were evaluated for length of hospitalization and attending reported etiology of chest pain (particularly whether the chest pain was attributable to cardiovascular disease). Selected demographics (age, sex, and ethnicity) for each visit were collected. P values were calculated based on individual visits and determined using a two-tailed t test for continuous data and a chi-squared test for categorical data. A P value of ≤0.05 was used as an indication of significance.
Results Overall, we examined approximately 360,000 ED visits from March 2009 to October 2013; 2675 ED visits had ICD-9
Percent of 224 hospital admissions (white bars) represented by 161 unique patients (black bars) broken down by number of admissions
Clin Rheumatol Table 1
Selected demographics of SLE and CP visits ED discharge
Hospital admission
Percent female Average age (years) African-American Non-Hispanic White Hispanic White
92 % 45 45.0 % 33.0 % 18.0 %
91 % 56 41.5 % 40.0 % 14.2 %
Asian and other
4.0 %
4.3 %
P value
