1
|
Lin Z, Lim SH, Yap QV, Kow CS, Chan YH, Chua SJT, Venkataraman A. Symptoms and coronary risk factors predictive of adverse cardiac events in chest pain patients in an Asian emergency department: the need for a local prediction score. Singapore Med J 2024; 65:397-404. [PMID: 38973188 DOI: 10.4103/singaporemedj.smj-2023-260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/04/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION Clinical assessment is pivotal in diagnosing acute coronary syndrome. Our study aimed to identify clinical characteristics predictive of major adverse cardiac events (MACE) in an Asian population and to derive a risk score for MACE. METHODS Patients presenting to the emergency department (ED) with chest pain and non-diagnostic 12-lead electrocardiograms were recruited. Clinical history was recorded in a predesigned template. Random glucose and direct low-density lipoprotein measurements were taken, in addition to serial troponin. We derived the age, coronary risk factors (CRF), sex and symptoms (ACSS) risk score based on multivariate analysis results, considering age, CRF, sex and symptoms and classifying patients into very low, low, moderate and high risk for MACE. Comparison was made with the ED Assessment of Chest Pain Score (EDACS) and the history, electrocardiogram, age, risk factors, troponin (HEART) score. We also modified the HEART score with the CRF that we had identified. The outcomes were 30-day and 1-year MACE. RESULTS There were a total of 1689 patients, with 172 (10.2%) and 200 (11.8%) having 30-day and 1-year MACE, respectively. Symptoms predictive of MACE included central chest pain, radiation to the jaw/neck, associated diaphoresis, and symptoms aggravated by exertion and relieved by glyceryl trinitrate. The ACSS score had an area under the curve of 0.769 (95% confidence interval [CI]: 0.735-0.803) and 0.760 (95% CI: 0.727-0.793) for 30-day and 1-year MACE, respectively, outperforming EDACS. Those in the very-low-risk and low-risk groups had <1% risk of 30-day MACE. CONCLUSION The ACSS risk score shows potential for use in the local ED or primary care setting, potentially reducing unnecessary cardiac investigations and admission.
Collapse
Affiliation(s)
- Ziwei Lin
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Swee Han Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Qai Ven Yap
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cheryl Shumin Kow
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | |
Collapse
|
2
|
Jian M, Sun X, Li S, Wang H, Zhang H, Li X, He Y, Wang Z. Quantitative Detection of Multiple Cardiovascular Biomarkers by an Antibody Microarray-Based Metal-Enhanced Fluorescence Assay. Anal Chem 2024; 96:7353-7359. [PMID: 38690857 DOI: 10.1021/acs.analchem.4c00266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Accurate detection of multiple cardiovascular biomarkers is crucial for the timely screening of acute coronary syndrome (ACS) and differential diagnosis from acute aortic syndrome (AAS). Herein, an antibody microarray-based metal-enhanced fluorescence assay (AMMEFA) has been developed to quantitatively detect 7 cardiovascular biomarkers through the formation of a sandwich immunoassay on the poly(glycidyl methacrylate-co-2-hydroxyethyl methacrylate)-decorated GNR-modified slide (GNR@P(GMA-HEMA) slide). The AMMEFA exhibits high specificity and sensitivity, the linear ranges span 5 orders of magnitude, and the limits of detection (LODs) of cardiac troponin I (cTnI), heart-type fatty acid binding protein (H-FABP), C-reactive protein (CRP), copeptin, myoglobin, D-Dimer, and N-terminal pro-brain natriuretic peptide (NT-proBNP) reach 0.07, 0.2, 65.7, 0.6, 0.2, 8.3, and 0.3 pg mL-1, respectively. To demonstrate its practicability, the AMMEFA has been applied to quantitatively analyze 7 cardiovascular biomarkers in 140 clinical plasma samples. In addition, the expression levels of cardiovascular biomarkers were analyzed by the least absolute shrinkage and selector operator (LASSO) regression, and the area under receiver operator characteristic curves (AUCs) of healthy donors (HDs), ACS patients, and AAS patients are 0.99, 0.98, and 0.97, respectively.
Collapse
Affiliation(s)
- Minghong Jian
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Xudong Sun
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Shasha Li
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Haodong Wang
- Department of Cardiovascular, The China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Hua Zhang
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
| | - Xiaotong Li
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
| | - Yuquan He
- Department of Cardiovascular, The China-Japan Union Hospital of Jilin University, Changchun 130033, China
| | - Zhenxin Wang
- State Key Laboratory of Electroanalytical Chemistry, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, P. R. China
- School of Applied Chemistry and Engineering, University of Science and Technology of China, Hefei, 230026, P. R. China
- National Analytical Research Center of Electrochemistry and Spectroscopy, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun 130022, P. R. China
| |
Collapse
|
3
|
Yildirim M, Salbach C, Reich C, Milles BR, Biener M, Frey N, Giannitsis E, Mueller-Hennessen M. Comparison of the clinical chemistry score to other biomarker algorithms for rapid rule-out of acute myocardial infarction and risk stratification in patients with suspected acute coronary syndrome. Int J Cardiol 2024; 400:131815. [PMID: 38278492 DOI: 10.1016/j.ijcard.2024.131815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/07/2024] [Accepted: 01/22/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND The clinical chemistry score (CCS) comprising high-sensitivity cardiac troponins (hs-cTn), glucose and estimated glomerular filtration rate has been previously validated with superior accuracy for detection and risk stratification of acute myocardial infarction (AMI) compared to hs-cTn alone. METHODS The CCS was compared to other biomarker-based algorithms for rapid rule-out and prognostication of AMI including the hs-cTnT limit-of-blank (LOB, <3 ng/L) or limit-of-detection (LOD, <5 ng/L) and a dual marker strategy (DMS) (copeptin <10 pmol/L and hs-cTnT ≤14 ng/L) in 1506 emergency department (ED) patients with symptoms suggestive of acute coronary syndrome. Negative predictive values (NPV) and sensitivities for AMI rule-out, and 12-month combined endpoint rates encompassing mortality, myocardial re-infarction, as well as stroke were assessed. RESULTS NPVs of 100% (95% CI: 98.3-100%) were observed for CCS = 0, hs-cTnT LoB and hs-cTnT LoD with rule-out efficacies of 11.1%, 7.6% and 18.3% as well as specificities of 13.0% (95% CI: 9.9-16.6%), 8.8% (95% CI: 7.3-10.5%) and 21.4% (95% CI: 19.2-23.8%), respectively. A CCS ≤ 1 achieved a rule-out in 32.2% of all patients with a NPV of 99.6% (95% CI: 98.4-99.9%) and specificity of 37.4% (95% CI: 34.2-40.5%) compared to a rule-out efficacy of 51.2%, NPV of 99.0 (95% CI: 98.0-99.5) and specificity of 59.7% (95% CI: 57.0-62.4%) for the DMS. Rates of the combined end-point of death/AMI within 30 days ranged between 0.0% and 0.7% for all fast-rule-out protocols. CONCLUSIONS The CCS ensures reliable AMI rule-out with low short and long-term outcome rates for a specific ED patient subset. However, compared to a single or dual biomarker strategy, the CCS displays reduced efficacy and specificity, limiting its clinical utility.
Collapse
Affiliation(s)
- Mustafa Yildirim
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany
| | - Christian Salbach
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany
| | - Christoph Reich
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany
| | - Barbara Ruth Milles
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany
| | - Norbert Frey
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital of Heidelberg, Germany
| | | |
Collapse
|
4
|
Sriselvakumar S, Knipe H. Unsuspected finding of right coronary artery occlusion on nongated CT chest. Radiol Case Rep 2024; 19:1026-1030. [PMID: 38226047 PMCID: PMC10788369 DOI: 10.1016/j.radcr.2023.11.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/17/2024] Open
Abstract
Myocardial infarction (MI) is the main cause of morbidity and mortality globally. This occurs due to occlusion of the coronary artery resulting in ischemia of the cardiac muscles. Typical symptoms include chest pain and discomfort. However, there are atypical symptoms including, but not limited to epigastric pain, nausea, and syncope. Such atypical symptoms upon presentation to the emergency department make it rather easy to overlook a potential MI. We present a case of a 70-year-old woman who had a delayed presentation to the emergency department with epigastric pain, nausea, and syncope. A nongated CT scan of the chest was utilized to rule out an aortic dissection. Interestingly, an unsuspected finding of a right coronary artery occlusion was detected instead. The patient underwent coronary artery stenting and was discharged a week later with a beta-blocker, dual antiplatelet therapy, a diuretic, and an anti-reflux medication. Overall, this case report emphasizes the importance of recognizing other atypical presentations in relation to MI. Additionally, this highlights the importance of the clinician's role in assessing the heart and coronary arteries when evaluating CT scans.
Collapse
Affiliation(s)
| | - Henry Knipe
- Radiology Department Calvary Hospital, Lenah Valley, Tasmania, Australia
| |
Collapse
|
5
|
Van Assche L, Peeters B, Vorlat A, Monsieurs K, Heidbuchel H, Claeys MJ. Safety and effectiveness of the short (0-1h) high sensitive troponin protocol in real-life practice. Acta Cardiol 2023; 78:937-944. [PMID: 37264905 DOI: 10.1080/00015385.2023.2218028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 05/19/2023] [Indexed: 06/03/2023]
Abstract
AIM Recent guidelines recommend the use of a short 0-1h high sensitive cardiac troponin (hs-cTn) algorithm in patients presenting with chest pain at the emergency department (ED). This retrospective observational study evaluates the safety and effectiveness of the new 0-1h hs-cTn I protocol in comparison with the standard 0-3h cTn I protocol for the diagnosis of acute myocardial infarction (AMI). METHODS A total of two times 100 consecutive chest pain patients presenting at the ED in November/December 2018 (standard 0-3h cTn I group) and in November/December 2020 (short 0-1h hs-cTn I group) were enrolled. Decision making was based upon validated assay-specific cut-off values. RESULTS The new 0-1h hs-cTn I protocol had a sensitivity of 100% (95% CI 83.2-100) and a negative predictive value of 100% to rule out AMI. The accuracy of rule-in was slightly lower with a specificity of 92.5% (95% CI 84.4-97.2). The overall protocol accuracy was 94% (95% CI 87.4-97.8) in the short 0-1h hs-cTn I group compared to 88% (95% CI 80.0-93.6) in the standard 0-3h cTn I group (p-value 0.14). The 0-1h hs-cTn I protocol was associated with a numerically higher rate of early hospital discharge compared to the conventional 0-3h cTn I protocol (47% versus 59%; p-value 0.09) and with a shorter median length of stay for those patients (mean 316 min versus 289 min; p-value 0.09). CONCLUSION The abbreviated protocol based on the 0-1h hs-cTn I assays is effective and safe for the exclusion of AMI at the ED.
Collapse
Affiliation(s)
| | - Bart Peeters
- Department of Clinical Biology, Antwerp University Hospital, Antwerp, Belgium
| | - Anne Vorlat
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Koen Monsieurs
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| |
Collapse
|
6
|
Tateishi K, Saito Y, Yasufuku Y, Nakagomi A, Kitahara H, Kobayashi Y, Tahara Y, Yonemoto N, Ikeda T, Sato N, Okura H. Prehospital predicting factors using a decision tree model for patients with witnessed out-of-hospital cardiac arrest and an initial shockable rhythm. Sci Rep 2023; 13:16180. [PMID: 37758799 PMCID: PMC10533815 DOI: 10.1038/s41598-023-43106-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
The effect of prehospital factors on favorable neurological outcomes remains unclear in patients with witnessed out-of-hospital cardiac arrest (OHCA) and a shockable rhythm. We developed a decision tree model for these patients by using prehospital factors. Using a nationwide OHCA registry database between 2005 and 2020, we retrospectively analyzed a cohort of 1,930,273 patients, of whom 86,495 with witnessed OHCA and an initial shockable rhythm were included. The primary endpoint was defined as favorable neurological survival (cerebral performance category score of 1 or 2 at 1 month). A decision tree model was developed from randomly selected 77,845 patients (development cohort) and validated in 8650 patients (validation cohort). In the development cohort, the presence of prehospital return of spontaneous circulation was the best predictor of favorable neurological survival, followed by the absence of adrenaline administration and age. The patients were categorized into 9 groups with probabilities of favorable neurological survival ranging from 5.7 to 70.8% (areas under the receiver operating characteristic curve of 0.851 and 0.844 in the development and validation cohorts, respectively). Our model is potentially helpful in stratifying the probability of favorable neurological survival in patients with witnessed OHCA and an initial shockable rhythm.
Collapse
Affiliation(s)
- Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan.
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Yuichi Yasufuku
- Department of Biostatistics and Data Science, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Atsushi Nakagomi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, Chiba, 260-8677, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Naohiro Yonemoto
- Department of Public Health, Juntendo University School of Medicine Tokyo, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Naoki Sato
- Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
| | - Hiroyuki Okura
- Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| |
Collapse
|
7
|
Shenouda R, Bytyçi I, El Sharkawy E, Hisham N, Sobhy M, Henein MY. Strain Rate Changes during Stress Echocardiography Are the Most Accurate Predictors of Significant Coronary Artery Disease in Patients with Previously Treated Acute Coronary Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13101796. [PMID: 37238281 DOI: 10.3390/diagnostics13101796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/06/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND AND AIMS Dobutamine stress echocardiography (DSE) is a well-established non-invasive investigation for the detection of ischemic myocardial dysfunction. The aim of this study was to evaluate the accuracy of myocardial deformation parameters measured by speckle tracking echocardiography (STE) in predicting culprit coronary artery lesions in patients with prior revascularization and acute coronary syndrome (ACS). METHODS We prospectively studied 33 patients with ischemic heart disease, a history of at least one episode of ACS and prior revascularization. All patients underwent a complete stress Doppler echocardiographic examination, including the myocardial deformation parameters of peak systolic strain (PSS), peak systolic strain rate (SR) and wall motion score index (WMSI). The regional PSS and SR were analyzed for different culprit lesions. RESULTS The mean age of patients was 59 ± 11 years and 72.7% were males. At peak dobutamine stress, the change in regional PSS and SR in territories supplied by the LAD showed smaller increases compared to those in patients without culprit LAD lesions (p < 0.05 for all). Likewise, the regional parameters of myocardial deformation were reduced in patients with culprit LCx lesions compared to those with non-culprit LCx lesions and in patients with culprit RCA legions compared to those with non-culprit RCA lesions (p < 0.05 for all). In the multivariate analysis, the △ regional PSS (1.134 (CI = 1.059-3.315, p = 0.02)) and the △ regional SR (1.566 (CI = 1.191-9.013, p = 0.001)) for LAD territories predicted the presence of LAD lesions. Similarly, in a multivariable analysis, the △ regional PSS and the △SR predicted LCx culprit lesions and RCA culprit lesions (p < 0.05 for all). In an ROC analysis, the PSS and SR had higher accuracies compared to the regional WMSI in predicting culprit lesions. A △ regional SR of -0.24 for the LAD territories was 88% sensitive and 76% specific (AUC = 0.75; p < 0.001), a △ regional PSS of -1.20 was 78% sensitive and 71% specific (AUC = 0.76, p < 0.001) and a △ WMSI of -0.35 was 67% sensitive and 68% specific (AUC = 0.68, p = 0.02) in predicting LAD culprit lesions. Similarly, the △ SR for LCx and RCA territories had higher accuracies in predicting LCx and RCA culprit lesions. CONCLUSIONS The myocardial deformation parameters, particularly the change in regional strain rate, are the most powerful predictors of culprit lesions. These findings strengthen the role of myocardial deformation in increasing the accuracy of DSE analyses in patients with prior cardiac events and revascularization.
Collapse
Affiliation(s)
- Rafik Shenouda
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden
- International Cardiac Centre, Alexandria 21526, Egypt
| | - Ibadete Bytyçi
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden
- Clinic of Cardiology, University Clinical Centre of Kosovo, 10000 Prishtina, Kosovo
| | - Eman El Sharkawy
- International Cardiac Centre, Alexandria 21526, Egypt
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria 21500, Egypt
| | - Noha Hisham
- International Cardiac Centre, Alexandria 21526, Egypt
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria 21500, Egypt
| | - Mohamed Sobhy
- International Cardiac Centre, Alexandria 21526, Egypt
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria 21500, Egypt
| | - Michael Y Henein
- Institute of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden
- Molecular and Clinic Research Institute, St. George University, London SW17 0QT, UK
| |
Collapse
|
8
|
Hughes AEO, Forbriger A, May AM, Scott MG, Char D, Farnsworth CW. Implementation of High-Sensitivity Troponin with a Rapid Diagnostic Algorithm Reduces Emergency Department Length of Stay for Discharged Patients. Clin Biochem 2023; 116:87-93. [PMID: 37054770 DOI: 10.1016/j.clinbiochem.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION High sensitivity troponin (hs-cTn) and diagnostic algorithms are used to rapidly triage patients with symptoms of acute myocardial infarction in emergency departments (ED). However, few studies have evaluated the impact of simultaneously implementing hs-cTn and a rapid rule-out algorithm on length of stay (LOS). METHODS We assessed the impact of transitioning from contemporary cTnI to hs-cTnI in 59,232 ED encounters over three years. hs-cTnI was implemented with an orderable series that included baseline, two-, four-, and six-hour specimens collected at provider discretion and operationalized with an algorithm to calculate the change in hs-cTnI from baseline and provide interpretations of "insignificant", "significant," or "equivocal." Patient demographics, results, chief complaint, disposition, and ED LOS were captured from the electronic medical record. RESULTS cTnI was ordered for 31,875 encounters prior to hs-cTnI implementation and 27,357 after. The proportion of cTnI results above the 99th percentile upper reference limit decreased from 35.0% to 27.0% for men and increased from 27.8% to 34.8% for women. Among discharged patients, the median LOS decreased by 0.6 h (0.5-0.7). LOS among discharged patients with a chief complaint of chest pain decreased by 1.0 h (0.8-1.1) and further decreased by 1.2 h (1.0-1.3) if the initial hs-cTnI was below the limit of quantitation. The rate of acute coronary syndrome upon re-presentation within 30 days did not change post-implementation (0.10% versus 0.07%). CONCLUSION Implementation of an hs-cTnI assay with a rapid rule-out algorithm decreased ED LOS among discharged patients, particularly among those with a chief complaint of chest pain.
Collapse
Affiliation(s)
- Andrew E O Hughes
- Department of Pathology & Immunology. Washington University School of Medicine. St. Louis, MO
| | - Arthur Forbriger
- Department of Emergency Medicine. Washington University School of Medicine. St. Louis, MO
| | - Adam M May
- Department of Medicine. Washington University School of Medicine. St. Louis, MO
| | - Mitchell G Scott
- Department of Pathology & Immunology. Washington University School of Medicine. St. Louis, MO
| | - Douglas Char
- Department of Emergency Medicine. Washington University School of Medicine. St. Louis, MO
| | | |
Collapse
|
9
|
Ashburn NP, Snavely AC, O’Neill JC, Allen BR, Christenson RH, Madsen T, Massoomi MR, McCord JK, Mumma BE, Nowak R, Stopyra JP, in’t Veld MH, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023; 8:347-356. [PMID: 36857071 PMCID: PMC9979014 DOI: 10.1001/jamacardio.2023.0031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/29/2022] [Indexed: 03/02/2023]
Abstract
Importance The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures Cardiac death or MI at 30 days determined by expert adjudicators. Results During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
Collapse
Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James C. O’Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael R. Massoomi
- Department of Cardiology, University of Florida College of Medicine, Gainesville
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Maite Huis in’t Veld
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
10
|
Khan IA, Karim HMR, Panda CK, Ahmed G, Nayak S. Atypical Presentations of Myocardial Infarction: A Systematic Review of Case Reports. Cureus 2023; 15:e35492. [PMID: 36999116 PMCID: PMC10048062 DOI: 10.7759/cureus.35492] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 02/27/2023] Open
Abstract
There is a rising incidence of coronary artery diseases and myocardial infarction (MI). Mortality associated with acute MI (AMI) is directly linked to the time to receive treatment and missed diagnoses. Although health professionals are aware of typical AMI presentation, atypical MI is difficult to diagnose, which on the other hand, is likely to have an impact on morbidity and mortality. Therefore, it is prudent to know such atypical presentations, especially for emergency and primary care physicians. We aimed to systematically evaluate the clinical presentations of atypical MI and analyze them to characterize the common clinical presentations of atypical MI. We researched the PubMed database, did citation tracking, and performed Google Scholar advanced search to find the cases reported on the atypical presentation of MI published from January 2000 to September 2022. Articles of all languages were included; Google Translate was used to translate articles published in languages other than English. A total of 496 (56 PubMed articles, 340 citations from included PubMed articles, and 100 articles from Google Scholar advanced search) were screened; 52 case reports were evaluated, and their data were analyzed. Atypical presentations of myocardial infarction are vast; patients may have chest pain without typical characteristics of angina pain or may not have chest pain. No typical characterization could be done. Most patients were in their fifth decade or above of their life and commonly presented with pain and discomfort in the abdomen, head, and neck regions. Prodromal symptoms were consistent findings, and many patients had two to three comorbidities out of four common comorbidities, i.e., diabetes, hypertension, dyslipidemia, and substance abuse. A patient who is 50 years old or more, having comorbidities such as diabetes, hypertension, dyslipidemia, history of tobacco or marijuana usage, presenting with prodromal symptoms like shortness of breath, dizziness, fatigue, syncope, gastrointestinal discomfort or head/neck pain should be suspected for atypical MI.
Collapse
|
11
|
Ding WY, Romero-Aniorte AI, Tello-Montoliu A, Gil-Pérez P, López-García C, Veliz-Martínez A, Quintana-Giner M, Lip GYH, Rivera-Caravaca JM, Marín F. Simplified Geleijnse score for identifying chest pain features associated with coronary ischemia. Heart Lung 2023; 59:61-66. [PMID: 36739642 DOI: 10.1016/j.hrtlng.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Geleijnse score, which was proposed to assess for coronary ischemia, has practical limitations. OBJECTIVES Our aim was to design and evaluate a simplified version of the Geleijnse score. METHODS We enrolled patients with suspected coronary heart disease but negative troponin T or absence of enzymatic curve, and a non-diagnostic 12-lead ECG. The initial study was performed in a retrospective derivation cohort and the results were subsequently validated in a prospective cohort. RESULTS From 109 patients included in the derivation cohort, 33 (30.3%) received a diagnosis of coronary heart disease. Chest pain with both arms radiation (OR 3.54), severe intensity (OR 2.41), improvement by nitroglycerin (OR 1.61), associated dyspnea (OR 1.97) and prior exertional angina history (OR 2.91) were independently associated with an ischemic origin on multivariate logistic regression analysis. ROC curves comparison demonstrated both the original and simplified scores presented modest predictive ability with significant difference when analyzed using dichotomous cut-offs (0.647 [simplified] vs. 0.544 [original], p = 0.042) but not as a continuous variable (0.670 [simplified] vs. 0.621 [original], p = 0.396). In 305 patients from the validation cohort, the simplified score presented extensively increased predictive accuracy than the Geleijnse, in the continuous (c-indexes = 0.735 vs. 0.685, p = 0.040) and the dichotomic (c-indexes = 0.682 vs. 0.514, p<0.001) forms. CONCLUSIONS A simplified version of the Geleijnse score, including some routine clinical manifestations associated with coronary heart disease, presented significantly better predictive ability compared to the original score.
Collapse
Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Ana Isabel Romero-Aniorte
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Antonio Tello-Montoliu
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Pablo Gil-Pérez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Andrea Veliz-Martínez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Miriam Quintana-Giner
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; Faculty of Nursing, University of Murcia, Murcia, Spain.
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| |
Collapse
|
12
|
Brooks SC, Sivilotti MLA, Hétu MF, Norman PA, Day AG, O'Callaghan N, Latiu V, Newbigging J, Hill B, Johri AM. Focused carotid ultrasound to predict major adverse cardiac events among emergency department patients with chest pain. CAN J EMERG MED 2023; 25:81-89. [PMID: 36315347 DOI: 10.1007/s43678-022-00395-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/04/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Point-of-care focused vascular ultrasound (FOVUS), an assessment of carotid artery plaque, predicts coronary artery disease in outpatients referred for coronary angiography. Our primary objective was to determine the diagnostic accuracy of sonographer-performed FOVUS to predict major adverse cardiac events (MACE) within 30 days among patients with suspected cardiac ischemia in the emergency department (ED). METHODS We conducted a prospective cohort study of patients with chest pain presenting to a tertiary care ED who had an electrocardiogram and cardiac troponin testing. The primary outcome was a composite of death, acute myocardial infarction, or re-vascularization at 30 days. A sonographer performed FOVUS scans in consenting eligible subjects. Emergency physicians, blinded to the sonographer FOVUS result, performed a second FOVUS on some subjects. RESULTS We recruited 326 subjects (age 62.1 ± 13.5 years; 166 (52%) men), 319 of whom completed an FOVUS scan by the sonographer. Of these, 198 (62%) had a positive FOVUS scan and 41 (13%) had a 30-day MACE. The sensitivity was 83% (95% CI 71-94%), specificity 41% (95% CI 36-47%), positive-likelihood ratio 1.41 (95% CI 1.19-1.68), and negative-likelihood ratio 0.41 (95% CI 0.23-0.75). Among 71 subjects also scanned by an emergency physician, the Kappa was 0.50 (95% CI 0.31-0.70), suggesting moderate agreement between sonographer and emergency physician on the determination of significant carotid plaque. CONCLUSIONS The presence of carotid plaque on sonographer-performed FOVUS is associated with 30-day MACE in ED patients presenting with chest pain. The prognostic performance of FOVUS is not sufficient to support its use as a stand-alone risk stratification tool in the ED. Future work should investigate FOVUS in conjunction with validated clinical decision rules for chest pain and the impact of enhanced training and quality improvement in the conduct of FOVUS by emergency physicians. REGISTRATION This study was registered at clinicaltrials.gov (NCT02947360).
Collapse
Affiliation(s)
- Steven C Brooks
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. .,Department of Public Health Sciences, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada. .,Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada.
| | - Marco L A Sivilotti
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada.,Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Marie-France Hétu
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada
| | - Patrick A Norman
- Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Andrew G Day
- Kingston General Hospital Research Institute, Kingston Health Sciences Center, Kingston, ON, Canada
| | - Nicole O'Callaghan
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada
| | - Vlad Latiu
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada
| | - Joseph Newbigging
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, ON, Kingston, Canada
| | - Braeden Hill
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada
| | - Amer M Johri
- Department of Medicine, Division of Cardiology, Cardiovascular Imaging Network at Queen's University, Kingston, ON, Canada.,Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada
| |
Collapse
|
13
|
Muacevic A, Adler JR, Topcu H, Cetinkal G, İkizceli İ, Yigit Y. Improving Risk Stratification of Patients With Chest Pain in the Emergency Department. Cureus 2023; 15:e33202. [PMID: 36726766 PMCID: PMC9887456 DOI: 10.7759/cureus.33202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE The HEARTS3 score is used to predict acute coronary syndrome by evaluating the findings of chest pain patients at the end of the second hour. Additionally, the American College of Cardiology (ACC)/American Heart Association (AHA) 2014 non-ST elevation acute coronary syndrome (NSTE-ACS) management guideline suggests assessing cardiac troponin levels at the third and sixth hours as a class 1A recommendation. This study aimed to explore the value of the HEARTS3 score for the evaluation of patients with chest pain and its utility for determining whether a patient is eligible for early discharge from the emergency department. MATERIAL AND METHODS This study was prospectively conducted between March 1, 2016 to May 31, 2016 at the ED of the Research and Training Hospital in İstanbul. A total of 136 patients were evaluated, and HEARTS3 scores were calculated at the second, third, and sixth hours. Receiver operating characteristic (ROC) curves were used to calculate the specificity, sensitivity, negative predictive value (NPV) and positive predictive value (PPV) of these scores. The primary outcome was the occurrence of major adverse cardiac events (MACEs) within 30 days. RESULTS In total, 29 patients with MACEs and 107 patients without MACEs were identified within 30 days. Based on the ROC curve, the cutoff value for early discharge was 6. The area under curve (AUC) values were 0.943, 0.963 and 0.976 at the second, third, and sixth hours, respectively. The sensitivity of the second-hour HEARTS3 score was 96.6%, and the NPV was 98.6%. Both the sensitivity and NPV reached 100% at the sixth hour. CONCLUSION The HEARTS3 score was considered a feasible method for the prediction of MACEs. We concluded that a patient with a HEARTS3 score less than 6 may be discharged without serial troponin and ECG examination.
Collapse
|
14
|
Ashburn NP, Snavely AC, Paradee BE, O'Neill JC, Stopyra JP, Mahler SA. Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain. J Am Geriatr Soc 2022; 70:2246-2257. [PMID: 35383887 PMCID: PMC9378522 DOI: 10.1111/jgs.17777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The HEART Pathway is a validated protocol for risk stratifying emergency department (ED) patients with possible acute coronary syndrome (ACS). Its performance in different age groups is unknown. The objective of this study is to evaluate its safety and effectiveness among older adults. METHODS A pre-planned subgroup analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time series accrued adult ED patients with possible ACS who were without ST-elevation across three US sites from 11/2013-01/2016. After implementation, providers prospectively used the HEART Pathway to stratify patients as low-risk or non-low-risk. Patients were classified as older adults (≥65 years), middle-aged (46-64 years), and young (21-45 years). Primary safety and effectiveness outcomes were 30-day death or MI and hospitalization at 30 days, determined from health records, insurance claims, and death index data. Fisher's exact test compared low-risk proportions between groups. Sensitivity for 30-day death or MI and adjusted odds ratios (aORs) for hospitalization and objective cardiac testing were calculated. RESULTS The HEART Pathway implementation study accrued 8474 patients, of which 26.9% (2281/8474) were older adults, 45.5% (3862/8474) middle-aged, and 27.5% (2331/8474) were young. The HEART Pathway identified 7.4% (97/1303) of older adults, 32.0% (683/2131) of middle-aged, and 51.4% (681/1326) of young patients as low-risk (p < 0.001). The HEART Pathway was 98.8% (95% CI 97.1-100) sensitive for 30-day death or MI among older adults. Following implementation, the rate of 30-day hospitalization was similar among older adults (aOR 1.25, 95% CI 1.00-1.55) and cardiac testing increased (aOR 1.25, 95% CI 1.04-1.51). CONCLUSION The HEART Pathway identified fewer older adults as low-risk and did not decrease hospitalizations in this age group.
Collapse
Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA,Section on Cardiovascular Medicine, Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Anna C. Snavely
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA,Department of Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brennan E. Paradee
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - James C. O'Neill
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Jason P. Stopyra
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Simon A. Mahler
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA,Department of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA,Department of Implementation ScienceWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| |
Collapse
|
15
|
The derivation and validation of the Manchester Acute Coronary Syndrome Electrocardiograph model for the identification of non-ST-elevation myocardial ischaemia in the Emergency Department. Am J Emerg Med 2022; 57:27-33. [DOI: 10.1016/j.ajem.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/22/2022] Open
|
16
|
McGinnis HD, Ashburn NP, Paradee BE, O'Neill JC, Snavely AC, Stopyra JP, Mahler SA. Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter? Acad Emerg Med 2022; 29:688-697. [PMID: 35166427 PMCID: PMC9232933 DOI: 10.1111/acem.14462] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/04/2022] [Accepted: 02/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted. The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD). METHODS A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments. Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated. RESULTS Among 4,550 patients with HEART Pathway assessments, 24.8% (1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12). CONCLUSION MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.
Collapse
Affiliation(s)
- Henderson D. McGinnis
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Nicklaus P. Ashburn
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Brennan E. Paradee
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - James C. O'Neill
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Anna C. Snavely
- Department of Biostatistics and Data ScienceDepartment of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Jason P. Stopyra
- Department of Emergency MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Simon A. Mahler
- Department of Emergency MedicineDepartment of Implementation ScienceDepartment of Epidemiology and PreventionWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| |
Collapse
|
17
|
Goto Y, Funada A, Maeda T, Goto Y. Termination-of-resuscitation rule in the emergency department for patients with refractory out-of-hospital cardiac arrest: a nationwide, population-based observational study. Crit Care 2022; 26:137. [PMID: 35578295 PMCID: PMC9109290 DOI: 10.1186/s13054-022-03999-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background In Japan, emergency medical service (EMS) providers are prohibited from field termination-of-resuscitation (TOR) in out-of-hospital cardiac arrest (OHCA) patients. In 2013, we developed a TOR rule for emergency department physicians (Goto’s TOR rule) immediately after hospital arrival. However, this rule is subject to flaws, and there is a need for revision owing to its relatively low specificity for predicting mortality compared with other TOR rules in the emergency department. Therefore, this study aimed to develop and validate a modified Goto’s TOR rule by considering prehospital EMS cardiopulmonary resuscitation (CPR) duration. Methods We analysed the records of 465,657 adult patients with OHCA from the All-Japan Utstein registry from 2016 to 2019 and divided them into two groups: development (n = 231,363) and validation (n = 234,294). The primary outcome measures were specificity, false-positive rate (FPR), and positive predictive value (PPV) of the revised TOR rule in the emergency department for predicting 1-month mortality. Results Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a modified Goto’s TOR rule could be defined if patients with OHCA met the following four criteria: (1) initial asystole, (2) unwitnessed arrest by any laypersons, (3) EMS-CPR duration > 20 min, and (4) no prehospital return of spontaneous circulation (ROSC). The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.2% (95% confidence interval [CI], 99.0–99.4%), 0.8% (0.6–1.0%), and 99.8% (99.8–99.9%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 27.5% (95% CI 27.3–27.7%) and 0.904 (0.902–0.905), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI 98.9–99.2%), 0.9% (0.8–1.1%), 99.8% (99.8–99.8%), 27.8% (27.6–28.0%), and 0.889 (0.887–0.891), respectively. Conclusion The modified Goto’s TOR rule (which includes the following four criteria: initial asystole, unwitnessed arrest, EMS-CPR duration > 20 min, and no prehospital ROSC) with a > 99% predictor of 1-month mortality is a reliable tool for physicians treating refractory OHCAs immediately after hospital arrival. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03999-x.
Collapse
Affiliation(s)
- Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa, 920-8640, Japan.
| | - Akira Funada
- Department of Cardiology, Osaka Saiseikai Senri Hospital, Tukumodai 1-1-6, Suita, 565-0862, Japan
| | - Tetsuo Maeda
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa, 920-8640, Japan
| | - Yumiko Goto
- Department of Cardiology, Yawata Medical Center, Yawata I 12-7, Komatsu, 923-8551, Japan
| |
Collapse
|
18
|
Miró Ò, Troester V, García-Martínez A, Martínez-Nadal G, Coll-Vinent B, Lopez-Ayala P, Gil V, Aguiló S, Galicia M, Jiménez S, Moll C, Sánchez C, Cardozo C, López-Sobrino T, Strebel I, Boeddinghaus J, Nestelberger T, Bragulat E, Sánchez M, Müller C, López-Barbeito B. Factors associated with late presentation to the emergency department in patients complaining of chest pain. PATIENT EDUCATION AND COUNSELING 2022; 105:695-706. [PMID: 34246513 DOI: 10.1016/j.pec.2021.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP). METHODS All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS). RESULTS The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS. CONCLUSION Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS. PRACTICE IMPLICATIONS Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.
Collapse
Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy.
| | - Valentina Troester
- The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy; Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, Basel Switzerland
| | - Ana García-Martínez
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Gemma Martínez-Nadal
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy
| | - Blanca Coll-Vinent
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Pedro Lopez-Ayala
- The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy; Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, Basel Switzerland
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Miguel Galicia
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Sònia Jiménez
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Conxi Moll
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carolina Sánchez
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Carlos Cardozo
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Emergency Department, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Teresa López-Sobrino
- Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Ivo Strebel
- The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy; Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, Basel Switzerland
| | - Jasper Boeddinghaus
- The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy; Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, Basel Switzerland
| | - Thomas Nestelberger
- The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy; Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, Basel Switzerland
| | - Ernest Bragulat
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Miquel Sánchez
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Christian Müller
- The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy; Cardiovascular Research Institute Basel (CRIB) and Cardiology Department, University Hospital Basel, Basel Switzerland
| | - Beatriz López-Barbeito
- Emergency Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; The GREAT (Global Research on Acute Conditions Team) Network, Rome, Italy
| |
Collapse
|
19
|
O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing. CAN J EMERG MED 2022; 24:68-74. [PMID: 34273102 DOI: 10.1007/s43678-021-00159-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/05/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). METHODS This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. RESULTS Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. CONCLUSIONS A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.
Collapse
Affiliation(s)
- Connor M O'Rielly
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - James E Andruchow
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada
| | - Andrew D McRae
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada.
| |
Collapse
|
20
|
Chen RF, Cheng KC, Lin YY, Chang IC, Tsai CH. Predicting Unscheduled Emergency Department Return Visits Among Older Adults: Population-Based Retrospective Study. JMIR Med Inform 2021; 9:e22491. [PMID: 34319244 PMCID: PMC8367131 DOI: 10.2196/22491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/11/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Unscheduled emergency department return visits (EDRVs) are key indicators for monitoring the quality of emergency medical care. A high return rate implies that the medical services provided by the emergency department (ED) failed to achieve the expected results of accurate diagnosis and effective treatment. Older adults are more susceptible to diseases and comorbidities than younger adults, and they exhibit unique and complex clinical characteristics that increase the difficulty of clinical diagnosis and treatment. Older adults also use more emergency medical resources than people in other age groups. Many studies have reviewed the causes of EDRVs among general ED patients; however, few have focused on older adults, although this is the age group with the highest rate of EDRVs. Objective This aim of this study is to establish a model for predicting unscheduled EDRVs within a 72-hour period among patients aged 65 years and older. In addition, we aim to investigate the effects of the influencing factors on their unscheduled EDRVs. Methods We used stratified and randomized data from Taiwan’s National Health Insurance Research Database and applied data mining techniques to construct a prediction model consisting of patient, disease, hospital, and physician characteristics. Records of ED visits by patients aged 65 years and older from 1996 to 2010 in the National Health Insurance Research Database were selected, and the final sample size was 49,252 records. Results The decision tree of the prediction model achieved an acceptable overall accuracy of 76.80%. Economic status, chronic illness, and length of stay in the ED were the top three variables influencing unscheduled EDRVs. Those who stayed in the ED overnight or longer on their first visit were less likely to return. This study confirms the results of prior studies, which found that economically underprivileged older adults with chronic illness and comorbidities were more likely to return to the ED. Conclusions Medical institutions can use our prediction model as a reference to improve medical management and clinical services by understanding the reasons for 72-hour unscheduled EDRVs in older adult patients. A possible solution is to create mechanisms that incorporate our prediction model and develop a support system with customized medical education for older patients and their family members before discharge. Meanwhile, a reasonably longer length of stay in the ED may help evaluate treatments and guide prognosis for older adult patients, and it may further reduce the rate of their unscheduled EDRVs.
Collapse
Affiliation(s)
- Rai-Fu Chen
- Department of Information Management, Chia-Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuei-Chen Cheng
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Yu-Yin Lin
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - I-Chiu Chang
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Cheng-Han Tsai
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan.,Department of Emergency, Chiayi Branch, Taichung Veterans General Hospital, Chiayi City, Taiwan
| |
Collapse
|
21
|
Lee SGW, Shin SD, Lee HJ, Suh GJ, Park DJ. Development of a prediction model for clinically important outcomes of acute diverticulitis. Am J Emerg Med 2021; 50:27-35. [PMID: 34271232 DOI: 10.1016/j.ajem.2021.06.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Acute diverticulitis (AD) is a common disease with various outcomes. When AD is diagnosed in the emergency department (ED), the ED clinician must determine the patient's treatment strategy whether the patient can be discharged, needs to be admitted to the general ward, ICU, or needs surgical consultation. This study aimed to identify potential risk factors for clinically important outcomes (CIOs) and to develop a prediction model for CIOs in AD to aid clinical decision making in the ED. METHODS Retrospective data from between 2013 and 2017 in an ED in an urban setting were reviewed for adult AD. Potential risk factors were age, sex, past medical history, symptoms, physical exams, laboratory results, and imaging results. A CIO was defined as a case with one of the following outcomes: hospital death, ICU admission, surgery or invasive intervention, and admission for 7 or more days. The prediction model for CIOs was developed using potential risk factors. Model discrimination and calibration were assessed using the area under the curve (AUC) and 95% confidence intervals (CIs) and the Hosmer-Lemeshow (HL) test, respectively. Model validation was conducted using 500 random bootstrap samples. RESULTS Of the final 337 AD patients, 63 patients had CIOs. Six potential factors (age, abdominal pain (≥ 3 days), anorexia, rebound tenderness, white blood cell count (> 15,000/μl), C-reactive protein (> 10 mg/dL), and CT findings of a complication) were used for the final model. The AUC (95% CI) for CIOs was 0.875 (0.826-0.923), and χ2 was 2.969 (p-value = 0.936) with the HL test. Validation using bootstrap samples resulted in an optimism-corrected AUC of 0.858 (0.856-0.861). CONCLUSION A prediction model for clinically important outcomes of AD visiting a single ED showed good discrimination and calibration power with an acceptable range.
Collapse
Affiliation(s)
- Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea.
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| | - Hui Jai Lee
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, Republic of Korea.
| | - Gil Joon Suh
- Department of Emergency Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| | - Do Joong Park
- Department of Surgery, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
| |
Collapse
|
22
|
Fernández-Cisnal A, Valero E, García-Blas S, Pernias V, Pozo A, Carratalá A, González J, Noceda J, Miñana G, Núñez J, Sanchis J. Clinical History and Detectable Troponin Concentrations below the 99th Percentile for Risk Stratification of Patients with Chest Pain and First Normal Troponin. J Clin Med 2021; 10:jcm10081784. [PMID: 33923925 PMCID: PMC8073372 DOI: 10.3390/jcm10081784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 11/16/2022] Open
Abstract
Decision-making is challenging in patients with chest pain and normal high-sensitivity cardiac troponin T (hs-cTnT; <99th percentile; <14 ng/L) at hospital arrival. Most of these patients might be discharged early. We investigated clinical data and hs-cTnT concentrations for risk stratification. This is a retrospective study including 4476 consecutive patients presenting to the emergency department with chest pain and first normal hs-cTnT. The primary endpoint was one-year death or acute myocardial infarction, and the secondary endpoint added urgent revascularization. The number of primary and secondary endpoints was 173 (3.9%) and 252 (5.6%). Mean hs-cTnT concentrations were 6.9 ± 2.5 ng/L. Undetectable (<5 ng/L) hs-cTnT (n = 1847, 41%) had optimal negative predictive value (99.1%) but suboptimal sensitivity (90.2%) and discrimination accuracy (AUC = 0.664) for the primary endpoint. Multivariable analysis was used to identify the predictive clinical variables. The clinical model showed good discrimination accuracy (AUC = 0.810). The addition of undetectable hs-cTnT (≥ or <5 ng/L; HR, hazard ratio = 3.80; 95% CI, confidence interval 2.27–6.35; p = 0.00001) outperformed the clinical model alone (AUC = 0.836, p = 0.002 compared to the clinical model). Measurable hs-cTnT concentrations (between detection limit and 99th percentile; per 0.1 ng/L, HR = 1.13; CI 1.06–1.20; p = 0.0001) provided further predictive information (AUC = 0.844; p = 0.05 compared to the clinical plus undetectable hs-cTnT model). The results were reproducible for the secondary endpoint and 30-day events. Clinical assessment, undetectable hs-cTnT and measurable hs-cTnT concentrations must be considered for decision-making after a single negative hs-cTnT result in patients presenting to the emergency department with acute chest pain.
Collapse
Affiliation(s)
- Agustín Fernández-Cisnal
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Ernesto Valero
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Vicente Pernias
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Adela Pozo
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Arturo Carratalá
- Clinical Biochemistry Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Jessika González
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - José Noceda
- Emergency Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), 46010 València, Spain;
| | - Gema Miñana
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, Instituto de Investigación Sanitaria (INCLIVA), University of València, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), 46010 València, Spain; (A.F.-C.); (E.V.); (S.G.-B.); (V.P.); (A.P.); (J.G.); (G.M.); (J.N.)
- Correspondence:
| |
Collapse
|
23
|
Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Ballard DW, Reed ME. Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain. J Am Heart Assoc 2021; 10:e020082. [PMID: 33787290 PMCID: PMC8174350 DOI: 10.1161/jaha.120.020082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as “rule‐out” binary classification strategies, while others use graded‐risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin‐only strategies (fourth‐generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA‐ACS). The primary outcome was 60‐day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all‐cause mortality. There were 13 192 patient encounters included with a 60‐day major adverse cardiac event incidence of 3.7%. RISTRA‐ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03–0.10 and 0.07, 95% CI, 0.04–0.11, respectively) and the greatest net benefit across a range of low‐risk thresholds. RISTRA‐ACS demonstrated the highest discrimination for 60‐day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91–0.94, P<0.0001). Conclusions RISTRA‐ACS and HEART pathway were the optimal rule‐out approaches, while RISTRA‐ACS was the best‐performing graded‐risk approach. RISTRA‐ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
Collapse
Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | |
Collapse
|
24
|
Bouzid Z, Faramand Z, Gregg RE, Frisch SO, Martin-Gill C, Saba S, Callaway C, Sejdić E, Al-Zaiti S. In Search of an Optimal Subset of ECG Features to Augment the Diagnosis of Acute Coronary Syndrome at the Emergency Department. J Am Heart Assoc 2021; 10:e017871. [PMID: 33459029 PMCID: PMC7955430 DOI: 10.1161/jaha.120.017871] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background Classical ST-T waveform changes on standard 12-lead ECG have limited sensitivity in detecting acute coronary syndrome (ACS) in the emergency department. Numerous novel ECG features have been previously proposed to augment clinicians' decision during patient evaluation, yet their clinical utility remains unclear. Methods and Results This was an observational study of consecutive patients evaluated for suspected ACS (Cohort 1 n=745, age 59±17, 42% female, 15% ACS; Cohort 2 n=499, age 59±16, 49% female, 18% ACS). Out of 554 temporal-spatial ECG waveform features, we used domain knowledge to select a subset of 65 physiology-driven features that are mechanistically linked to myocardial ischemia and compared their performance to a subset of 229 data-driven features selected by multiple machine learning algorithms. We then used random forest to select a final subset of 73 most important ECG features that had both data- and physiology-driven basis to ACS prediction and compared their performance to clinical experts. On testing set, a regularized logistic regression classifier based on the 73 hybrid features yielded a stable model that outperformed clinical experts in predicting ACS, with 10% to 29% of cases reclassified correctly. Metrics of nondipolar electrical dispersion (ie, circumferential ischemia), ventricular activation time (ie, transmural conduction delays), QRS and T axes and angles (ie, global remodeling), and principal component analysis ratio of ECG waveforms (ie, regional heterogeneity) played an important role in the improved reclassification performance. Conclusions We identified a subset of novel ECG features predictive of ACS with a fully interpretable model highly adaptable to clinical decision support applications. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT04237688.
Collapse
Affiliation(s)
- Zeineb Bouzid
- Department of Electrical & Computer Engineering Swanson School of EngineeringUniversity of Pittsburgh PA
| | - Ziad Faramand
- Department of Acute & Tertiary Care Nursing University of Pittsburgh PA.,University of Pittsburgh Medical Center Pittsburgh PA
| | - Richard E Gregg
- Advanced Algorithm Research Center Philips Healthcare Andover MA
| | - Stephanie O Frisch
- Department of Biomedical Informatics at School of Medicine University of Pittsburgh PA.,Department of Acute & Tertiary Care Nursing University of Pittsburgh PA
| | - Christian Martin-Gill
- Department of Emergency Medicine University of Pittsburgh PA.,University of Pittsburgh Medical Center Pittsburgh PA
| | - Samir Saba
- Division of Cardiology University of Pittsburgh PA.,University of Pittsburgh Medical Center Pittsburgh PA
| | - Clifton Callaway
- Department of Emergency Medicine University of Pittsburgh PA.,University of Pittsburgh Medical Center Pittsburgh PA
| | - Ervin Sejdić
- Department of Electrical & Computer Engineering Swanson School of EngineeringUniversity of Pittsburgh PA.,Department of Bioengineering Swanson School of EngineeringUniversity of Pittsburgh PA.,Department of Biomedical Informatics at School of Medicine University of Pittsburgh PA.,Intelligent Systems Program at School of Computing and Information University of Pittsburgh PA
| | - Salah Al-Zaiti
- Department of Acute & Tertiary Care Nursing University of Pittsburgh PA.,Department of Emergency Medicine University of Pittsburgh PA.,Division of Cardiology University of Pittsburgh PA
| |
Collapse
|
25
|
Kim KH, Park JH, Ro YS, Hong KJ, Song KJ, Shin SD. Emergency department routine data and the diagnosis of acute ischemic heart disease in patients with atypical chest pain. PLoS One 2020; 15:e0241920. [PMID: 33152007 PMCID: PMC7644067 DOI: 10.1371/journal.pone.0241920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/22/2020] [Indexed: 11/21/2022] Open
Abstract
Background Due to an aging population and the increasing proportion of patients with various comorbidities, the number of patients with acute ischemic heart disease (AIHD) who present to the emergency department (ED) with atypical chest pain is increasing. The aim of this study was to develop and validate a prediction model for AIHD in patients with atypical chest pain. Methods and results A chest pain workup registry, ED administrative database, and clinical data warehouse database were analyzed and integrated by using nonidentifiable key factors to create a comprehensive clinical dataset in a single academic ED from 2014 to 2018. Demographic findings, vital signs, and routine laboratory test results were assessed for their ability to predict AIHD. An extreme gradient boosting (XGB) model was developed and evaluated, and its performance was compared to that of a single-variable model and logistic regression model. The area under the receiver operating characteristic curve (AUROC) was calculated to assess discrimination. A calibration plot and partial dependence plots were also used in the analyses. Overall, 4,978 patients were analyzed. Of the 3,833 patients in the training cohort, 453 (11.8%) had AIHD; of the 1,145 patients in the validation cohort, 166 (14.5%) had AIHD. XGB, troponin (single-variable), and logistic regression models showed similar discrimination power (AUROC [95% confidence interval]: XGB model, 0.75 [0.71–0.79]; troponin model, 0.73 [0.69–0.77]; logistic regression model, 0.73 [0.70–0.79]). Most patients were classified as non-AIHD; calibration was good in patients with a low predicted probability of AIHD in all prediction models. Unlike in the logistic regression model, a nonlinear relationship-like threshold and U-shaped relationship between variables and the probability of AIHD were revealed in the XGB model. Conclusion We developed and validated an AIHD prediction model for patients with atypical chest pain by using an XGB model.
Collapse
Affiliation(s)
- Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
- * E-mail:
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Ki Jeong Hong
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| |
Collapse
|
26
|
Influence of previous coronary artery bypass grafting in the difficulty of acute coronary syndrome diagnosis. Eur J Emerg Med 2020; 28:125-135. [DOI: 10.1097/mej.0000000000000755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
Stopyra JP, Snavely AC, Lenoir KM, Wells BJ, Herrington DM, Hiestand BC, Miller CD, Mahler SA. HEART Pathway Implementation Safely Reduces Hospitalizations at One Year in Patients With Acute Chest Pain. Ann Emerg Med 2020; 76:555-565. [PMID: 32736933 DOI: 10.1016/j.annemergmed.2020.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 05/27/2020] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE We determine whether implementation of the HEART (History, ECG, Age, Risk Factors, Troponin) Pathway is safe and effective in emergency department (ED) patients with possible acute coronary syndrome through 1 year of follow-up. METHODS A preplanned analysis of 1-year follow-up data from a prospective pre-post study of 8,474 adult ED patients with possible acute coronary syndrome from 3 US sites was conducted. Patients included were aged 21 years or older, evaluated for possible acute coronary syndrome, and without ST-segment elevation myocardial infarction. Accrual occurred for 12 months before and after HEART Pathway implementation, from November 2013 to January 2016. The HEART Pathway was integrated into the electronic health record at each site as an interactive clinical decision support tool. After integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or nonlow risk (appropriate for further inhospital evaluation). Safety (all-cause death and myocardial infarction) and effectiveness (hospitalization) at 1 year were determined from health records, insurance claims, and death index data. RESULTS Preimplementation and postimplementation cohorts included 3,713 and 4,761 patients, respectively. The HEART Pathway identified 30.7% of patients as low risk; 97.5% of them were free of death and myocardial infarction within 1 year. Hospitalization at 1 year was reduced by 7.0% in the postimplementation versus preimplementation cohort (62.1% versus 69.1%; adjusted odds ratio 0.70; 95% confidence interval 0.63 to 0.78). Rates of death or myocardial infarction at 1 year were similar (11.6% versus 12.4%; adjusted odds ratio 1.00; 95% confidence interval 0.87 to 1.16). CONCLUSION HEART Pathway implementation was associated with decreased hospitalizations and low adverse event rates among low-risk patients at 1-year follow-up.
Collapse
Affiliation(s)
- Jason P Stopyra
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Anna C Snavely
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kristin M Lenoir
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian J Wells
- Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Herrington
- Internal Medicine, Division of Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Chadwick D Miller
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Simon A Mahler
- Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC; Implementation Science and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
28
|
Aydin H, Ozpinar Y, Karaoglu U, Issever M, Aygun H, Karaca O, Bulut M. Comparison of the HEART and HEARTS3 scores to predict major adverse cardiac events in chest pain patients at the emergency department. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920944070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: The aim of this study was to determine the risk assessment of acute coronary syndrome and prediction of major adverse cardiac events by HEART (History, ECG, Age, Risk factors, Troponin) and HEARTS3 (HEART + 3S = Sex, Serial 2-h ECG, and Serial 2-h delta Troponin) scoring systems in patients admitted to the emergency department with chest pain. Methods: This is a single-center prospective cohort study. This study was conducted in patients admitted to the emergency department with chest pain, without ST-elevation myocardial infarction, who were 18 years or older, and agreed to participate in the study. The primary endpoint is the occurrence of major adverse cardiovascular events within 30 days. The receiver operating characteristic curve was used to assess the power of HEART and HEARTS3 scores to predict major adverse cardiovascular events. Results: The mean age of 239 patients was 47.91 ± 13.93 years and 72.4% (173) were male. Major adverse cardiovascular events developed in 20.1% (48) of the patients. The mean HEART and HEARTS3 scores of the patients with major adverse cardiovascular events (5.67 ± 1.46 and 9.38 ± 3.91, respectively) were both statistically and significantly higher than the scores of the patients without major adverse cardiovascular events (2.33 ± 1.44 and 2.22 ± 1.39; p = 0.001). The area under the curve values of HEART and HEARTS3 scores were found to be 0.943 (95% confidence interval: 0.905–0.968) and 0.990 (0.968–0.999), respectively. Conclusion: In our study, the power of HEARTS3 score to predict major adverse cardiovascular events was better in the risk assessment of acute coronary syndrome in patients admitted to the emergency department with chest pain compared to the HEART score. We think that patients with a low HEARTS3 score can be safely discharged from emergency department without further cardiac examination.
Collapse
Affiliation(s)
- Hasan Aydin
- Department of Emergency Medicine, Medipol Mega University Hospital, Istanbul, Turkey
| | - Yasin Ozpinar
- Department of Emergency Medicine, Medipol Mega University Hospital, Istanbul, Turkey
| | - Ulas Karaoglu
- Department of Emergency Medicine, Medipol Mega University Hospital, Istanbul, Turkey
| | - Muhittin Issever
- Department of Emergency Medicine, Medipol Mega University Hospital, Istanbul, Turkey
| | - Huseyin Aygun
- Department of Emergency Medicine, Health Sciences University Bursa Higher Specialization Training and Research Hospital, Bursa, Turkey
| | - Oguz Karaca
- Department of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | - Mehtap Bulut
- Department of Emergency Medicine, Health Sciences University Bursa Higher Specialization Training and Research Hospital, Bursa, Turkey
| |
Collapse
|
29
|
Bautz B, Schneider JI. High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update). Emerg Med Clin North Am 2020; 38:453-498. [PMID: 32336336 DOI: 10.1016/j.emc.2020.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.
Collapse
Affiliation(s)
- Benjamin Bautz
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Jeffrey I Schneider
- Department of Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, USA.
| |
Collapse
|
30
|
DeVon HA, Mirzaei S, Zègre‐Hemsey J. Typical and Atypical Symptoms of Acute Coronary Syndrome: Time to Retire the Terms? J Am Heart Assoc 2020; 9:e015539. [PMID: 32208828 PMCID: PMC7428604 DOI: 10.1161/jaha.119.015539] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/18/2020] [Indexed: 01/12/2023]
Abstract
Studies indicate that symptoms labeled as "atypical" are more common in women evaluated for myocardial infarction (MI) and may contribute to the lower likelihood of a diagnosis and delayed treatment and result in poorer outcomes compared with men with MI. Atypical pain is frequently defined as epigastric or back pain or pain that is described as burning, stabbing, or characteristic of indigestion. Typical symptoms usually include chest, arm, or jaw pain described as dull, heavy, tight, or crushing. In a recent article published in the Journal of the American Heart Association (JAHA), Ferry and colleagues addressed presenting symptoms in men and women diagnosed with MI and reported that typical symptoms in women were more predictive of a diagnosis of MI than for men. A critical question is, are there really typical or atypical symptoms, and if so, who is the reference group? We propose that researchers and clinicians either discontinue using the terms typical and atypical or provide the reference group to which the terms apply (eg, men versus women). We believe it is past time to standardize the symptom assessment for MI so that proper and rapid diagnostic testing can be undertaken; however, we cannot standardize the symptom experience. When we do this, we are at risk of having study results, such as those of Ferry and colleagues, that vary from prior evidence and could lead to what the authors hope to avoid: disadvantaging women in receiving expeditious diagnostic testing and treatment for acute coronary syndrome.
Collapse
|
31
|
Chiang CH, Chiang CH, Lee GH, Gi WT, Wu YK, Huang SS, Yeo YH, Giannitsis E, Lee CC. Safety and efficacy of the European Society of Cardiology 0/1-hour algorithm for diagnosis of myocardial infarction: systematic review and meta-analysis. Heart 2020; 106:985-991. [PMID: 32245882 DOI: 10.1136/heartjnl-2019-316343] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/21/2020] [Accepted: 02/25/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The European Society of Cardiology (ESC) 0/1 hour algorithm has been primarily validated in Europe, America and Australasia with less knowledge of its performance outside of these settings. We aim to evaluate the performance of the ESC 0/1 hour algorithm across different contexts. METHODS We searched PubMed, Embase, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for relevant studies published between 1 January 2008 and 31 May 2019. The primary outcome was index myocardial infarction and the secondary outcome was major adverse cardiac event or mortality. A bivariate random-effects meta-analysis was used to derive the pooled estimate of each outcome. RESULTS A total of 11 014 patients from 10 cohorts were analysed for the primary outcome. The algorithm based on high-sensitivity cardiac troponin (hs-cTn)T (Roche), hs-cTnI (Abbott) and hs-cTnI (Siemens) had pooled sensitivity of 98.4% (95% CI=95.1% to 99.5%), 98.1% (95% CI=94.6% to 99.3%) and 98.7% (95% CI=97.3% to 99.3%), respectively. The algorithm based on hs-cTnT (Roche) and hs-cTnI (Siemens) had pooled specificity of 91.2% (95% CI=86.0% to 94.6%) and 95.9% (95% CI=94.1% to 97.2%), respectively. Among patients in the rule-out category, the pooled mortality rate at 30 days and at 1 year was 0.1% (95% CI=0.0% to 0.4%) and 0.8% (95% CI=0.5% to 1.2%), respectively. Among patients in the observation zone, the pooled mortality rate was 0.7% (95% CI=0.3% to 1.2%) at 30 days but increased to 8.1% (95% CI=6.1% to 10.4%) at 1 year, comparable to the mortality rate in the rule-in group. CONCLUSION The ESC 0/1 hour algorithm has high diagnostic accuracy but may not be sufficiently safe if the 1% miss-rate for myocardial infarction is desired. PROSPERO REGISTRATION NUMBER CRD42019142280.
Collapse
Affiliation(s)
- Cho-Han Chiang
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cho-Hung Chiang
- Department of Medicine, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan
| | - Gin Hoong Lee
- Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Weng-Tein Gi
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Yuan-Kun Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sih-Shiang Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee Hui Yeo
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology and Pneumology, University of Heidelberg, Heidelberg, Germany
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan .,Centre for Intelligent Healthcare, National Taiwan University Hospital, Taipei, Taiwan.,Health Data Science Research Group, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
32
|
Body R, Morris N, Collinson P. Single test rule-out of acute myocardial infarction using the limit of detection of a new high-sensitivity troponin I assay. Clin Biochem 2020; 78:4-9. [PMID: 32135083 DOI: 10.1016/j.clinbiochem.2020.02.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 02/27/2020] [Accepted: 02/29/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine the diagnostic accuracy of a high-sensitivity cardiac troponin I (hs-cTnI) assay in patients presenting to the Emergency Department (ED) with suspected acute coronary syndromes. Specifically, we evaluated the use of a single blood test at the time of arrival in the ED, using low hs-cTnI cut-offs. METHODS In a prospective diagnostic test accuracy study at 14 centers, we included patients presenting to the ED with suspected ACS within 12 h of symptom onset. We drew blood for hs-cTnI (Siemens ADVIA Centaur, overall 99th percentile 47 ng/L, limit of quantification [LoQ] 2.50 ng/L) on arrival. Patients underwent serial cardiac troponin testing over 3-6 h. The primary outcome was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the incidence of major adverse cardiac events (MACE: death, AMI or revascularization) after 30 days. Test characteristics for hs-cTnI were calculated using previously reported cut-offs set at the LoQ and 5 ng/L. RESULTS We included 999 patients, including 131 (13.1%) with an adjudicated diagnosis of AMI. Compared to the LoQ (100.0% sensitivity [95% CI 95.9-100.0%]), 99.7% negative predictive value [NPV; 95% CI 97.6-100.0%]), a 5 ng/L cut-off had slightly lower sensitivity (99.2%; 95% CI 95.8-100.0%) and similar NPV (99.8%; 95% CI 98.6-100.0%) but would rule out more patients (28.6% at the LoQ vs 50.4% at 5 ng/L). MACE occurred in 2 (0.7%) patients with hs-cTnI below the LoQ and 7 (1.4%) patients with hs-cTnI < 5 ng/L. Accounting for time from symptom onset or ECG ischemia did not further improve sensitivity. CONCLUSION The Siemens ADVIA Centaur hs-cTnI assay has high sensitivity and NPV to rule out AMI with a single blood test in the ED. At the LoQ cut-off a sensitivity > 99% can be achieved. At a 5 ng/L cut-off it may be possible to rule out AMI for over 50% patients.
Collapse
Affiliation(s)
- Richard Body
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, United Kingdom; Cardiovascular Sciences Research Group, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester M13 9PL, United Kingdom; Healthcare Sciences Department, Manchester Metropolitan University, Oxford Road, Manchester, United Kingdom.
| | - Niall Morris
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Oxford Road, Manchester M13 9WL, United Kingdom; Cardiovascular Sciences Research Group, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester M13 9PL, United Kingdom
| | - Paul Collinson
- Department of Chemical Pathology, St George's NHS Foundation Trust, Blackshaw Road, Totting, London SW17 0QT, United Kingdom
| |
Collapse
|
33
|
Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: 'The Ottawa Troponin Pathway'. PLoS One 2020; 15:e0226892. [PMID: 31923216 PMCID: PMC6953858 DOI: 10.1371/journal.pone.0226892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 12/08/2019] [Indexed: 11/19/2022] Open
Abstract
Background Serial conventional cardiac troponin (cTn) measurements 6–9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway. Methods We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cut-off cTnI values (45, 100 and 250ng/L). Results 1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI≤45 ng/L; and 155 (9.2%) of the 213 patients with one value≥100ng/L but both<250ng/L or ≤20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with≥20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8–100%) and 94.6% specificity (95% CI 93.3–95.6%). Addition of the HEART score improved the sensitivity to 100% (95% CI 95.9–100%) and decreased the specificity to 26.5% (95% CI 24.3–28.7%). Conclusion The OTP with conventional cTnI 3-hours apart, should lead to better NSTEMI identification particularly those with values >99th percentile, standardize management and reduce the ED LOS.
Collapse
|
34
|
Ashburn NP, Stopyra JP, Mahler SA. News From Lake Wobegon … Clinician Gestalt Debunked? Acad Emerg Med 2020; 27:80-82. [PMID: 31336399 DOI: 10.1111/acem.13837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Simon A. Mahler
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| |
Collapse
|
35
|
Eriksson D, Khoshnood A, Larsson D, Lundager-Forberg J, Mokhtari A, Ekelund U. Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30 Days in Patients With Acute Chest Pain. J Emerg Med 2019; 58:1-10. [PMID: 31780182 DOI: 10.1016/j.jemermed.2019.09.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 09/24/2019] [Accepted: 09/28/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results. OBJECTIVE The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days. METHODS This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE. RESULTS Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors. CONCLUSIONS No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.
Collapse
Affiliation(s)
- David Eriksson
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ardavan Khoshnood
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - David Larsson
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Arash Mokhtari
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden; Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
36
|
Mahler SA, Lenoir KM, Wells BJ, Burke GL, Duncan PW, Case LD, Herrington DM, Diaz-Garelli JF, Futrell WM, Hiestand BC, Miller CD. Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circulation 2019; 138:2456-2468. [PMID: 30571347 DOI: 10.1161/circulationaha.118.036528] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome. METHODS A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ≥21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data. RESULTS Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33). CONCLUSIONS HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.
Collapse
Affiliation(s)
- Simon A Mahler
- Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC.,Department of Implementation Science (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC.,Department of Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Kristin M Lenoir
- Department of Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian J Wells
- Department of Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Gregory L Burke
- Public Health Sciences (G.L.B.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Pamela W Duncan
- Departments of Neurology, Sticht Center on Aging, Gerontology, and Geriatric Medicine (P.W.D.), Wake Forest School of Medicine, Winston-Salem, NC
| | - L Douglas Case
- Department of Biostatistical Sciences (K.M.L., B.J.W., L.D.C.), Wake Forest School of Medicine, Winston-Salem, NC
| | - David M Herrington
- Department of Internal Medicine, Division of Cardiovascular Medicine (D.M.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jose-Franck Diaz-Garelli
- Department of Physiology and Pharmacology (J.-F.D.-G.), Wake Forest School of Medicine, Winston-Salem, NC.,Clinical and Translational Science Institute (J.-F.D.-G., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Wendell M Futrell
- Clinical and Translational Science Institute (J.-F.D.-G., W.M.F.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Chadwick D Miller
- Department of Emergency Medicine (S.A.M., B.C.H., C.D.M.), Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
37
|
Tada M, Azuma H, Yamada N, Kano KI, Nagai H, Maeda S, Ishida H, Aoyama T, Okada R, Kawano T, Kobuchi T, Uzui H, Matano H, Iwasaki H, Maeno K, Shimada Y, Yoshida H, Ando M, Murakami Y, Iwakami N, Kishimoto S, Iwami T, Tada H, Chapman A, Mills N, Hayashi H, Furukawa TA, Watanabe N. A comprehensive validation of very early rule-out strategies for non-ST-segment elevation myocardial infarction in emergency departments: protocol for a multicentre prospective cohort study. BMJ Open 2019; 9:e026985. [PMID: 31481550 PMCID: PMC6731951 DOI: 10.1136/bmjopen-2018-026985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Recent advances in troponin sensitivity enabled early and accurate judgement of ruling-out myocardial infarction, especially non-ST elevation myocardial infarction (NSTEMI) in emergency departments (EDs) with development of various prediction-rules and high-sensitive-troponin-based strategies (hs-troponin). Reliance on clinical impression, however, is still common, and it remains unknown which of these strategies is superior. Therefore, our objective in this prospective cohort study is to comprehensively validate the diagnostic accuracy of clinical impression-based strategies, prediction-rules and hs-troponin-based strategies for ruling-out NSTEMIs. METHODS AND ANALYSIS In total, 1500 consecutive adult patients with symptoms suggestive of acute coronary syndrome will be prospectively recruited from five EDs in two tertiary-level, two secondary-level community hospitals and one university hospital in Japan. The study has begun in July 2018, and recruitment period will be about 1 year. A board-certified emergency physician will complete standardised case report forms, and independently perform a clinical impression-based risk estimation of NSTEMI. Index strategies to be compared will include the clinical impression-based strategy; prediction rules and hs-troponin-based strategies for the following types of troponin (Roche Elecsys hs-troponin T; Abbott ARCHITECT hs-troponin I; Siemens ADVIA Centaur hs-troponin I; Siemens ADVIA Centaur sensitive-troponin I). The reference standard will be the composite of type 1 MI and cardiac death within 30 days after admission to the ED. Outcome measures will be negative predictive value, sensitivity and effectiveness, defined as the proportion of patients categorised as low risk for NSTEMI. We will also evaluate inter-rater reliability of the clinical impression-based risk estimation. ETHICS AND DISSEMINATION The study is approved by the Ethics Committees of the Kyoto University Graduate School and Faculty of Medicine and of the five hospitals where we will recruit patients. We will disseminate the study results through conference presentations and peer-reviewed journals.
Collapse
Affiliation(s)
- Masafumi Tada
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| | - Hiroyuki Azuma
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hideya Nagai
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Shigenobu Maeda
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroshi Ishida
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Takahiko Aoyama
- Cardiology, Vascular Center, Fukui Prefectural Hospital, Fukui, Japan
| | - Ryota Okada
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Takahisa Kawano
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Taketsune Kobuchi
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine, Fukui University Hospital, Fukui, Japan
| | - Hideyuki Matano
- Department of Emergency Medicine, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Hose Iwasaki
- Department of Emergency Medicine, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Koji Maeno
- Department of Cardiology, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Yoshimitsu Shimada
- Department of Emergency Medicine, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Hiroyuki Yoshida
- Department of Cardiology, Japanese Red Cross Fukui Hospital, Fukui, Japan
| | - Masaki Ando
- Department of Emergency Medicine, Nagoya City East Medical Center, Nagoya, Japan
| | - Yoshimasa Murakami
- Department of Cardiovascular Medicine, Nagoya City East Medical Center, Nagoya, Japan
| | - Naotsugu Iwakami
- Department of Research Promotion and Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sanae Kishimoto
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| | - Taku Iwami
- Department of Health Service, Kyoto University, Kyoto, Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Fukui University Hospital, Fukui, Japan
| | - Andrew Chapman
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Nicholas Mills
- British Heart Foundation Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Hiroyuki Hayashi
- Department of Emergency Medicine, Fukui University Hospital, Fukui, Japan
| | - Toshi A Furukawa
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| | - Norio Watanabe
- Department of Human Behavior and Health Promotion, Kyoto University, Kyoto, Japan
| |
Collapse
|
38
|
Morris N, Reynard C, Body R. The low accuracy of the non-ST-elevation myocardial infarction electrocardiograph criteria of the fourth universal definition of myocardial infarction. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919866364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: The electrocardiograph has been integral to the diagnosis of acute coronary syndromes since the mid-20th Century and is an important initial investigation that chest pain patients undergo on presentation to the Emergency Department. The Fourth Universal Definition of Myocardial Infarction recommends using dichotomous cut-offs to identify ischaemic electrocardiographs. Objectives: We aimed to summarise the existing knowledge to inform emergency clinicians about the diagnostic accuracy of the new guidelines. Methods: We performed a systematic review and a narrative analysis due to the heterogeneity of the studies. Results: We were able to obtain diagnostic characteristics for 10 papers. The ST-depression criteria were highly specific but poorly sensitive in five papers, with a specificity of 97.2%–99.3% and a sensitivity of 16.6%–20.0%. The remaining papers reported a higher sensitivity of 25.7%–58.6% but a lower specificity of 86.0%–91.2%. T wave inversion demonstrated poor specificity; the papers that looked at 0.1 mV T wave inversion demonstrated a sensitivity of 26.9%–46.8% and a specificity of 68.6%–86.4%. Conclusion: The heterogeneous evidence database demonstrates that the Fourth universal definition’s diagnostic performance varies wildly. Apart from two outlying papers, ST-depression has suboptimal sensitivity but high specificity. T wave inversion appears to be more sensitive yet less specific.
Collapse
Affiliation(s)
- Niall Morris
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester, UK
- Manchester University Foundation Hospital NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Charles Reynard
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Manchester University Foundation Hospital NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard Body
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
- Manchester University Foundation Hospital NHS Trust, Manchester Academic Health Science Centre, Manchester, UK
- Manchester Metropolitan University, Manchester, UK
| |
Collapse
|
39
|
Innes GD. Can a HEART Pathway Improve Safety and Diagnostic Efficiency for Patients With Chest Pain? Ann Emerg Med 2019; 74:181-184. [DOI: 10.1016/j.annemergmed.2019.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Indexed: 11/30/2022]
|
40
|
Implementation of an Early Discharge Protocol and Chest Pain Clinic for Low-Risk Chest Pain in the Emergency Department. Crit Pathw Cardiol 2019; 17:1-5. [PMID: 29432369 DOI: 10.1097/hpc.0000000000000136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most of the patients presenting to emergency department with chest pain are at low risk of adverse events. Identifying high-risk patients can be challenging and resource intensive. METHODS We created a protocol to assist early discharge of low-risk adults with chest pain from emergency department. Also a chest pain clinic (CPC) was started for cardiology follow-up within 72 hours. In a retrospective cohort study, primary outcome of major adverse cardiac events (MACEs) of death, myocardial infarction, or revascularization was compared between CPC patients and those hospitalized for observation. In addition, rate of observation admissions and MACE were compared in the pre- and postintervention periods using piecewise regression and multiple logistic regression, respectively. RESULTS A total of 1422 patients were admitted for observation, and 290 were seen in CPC in the 1-year postintervention period. Thirty-day MACE was very low (0.7% in observation and 0.3% in CPC) postintervention. A total of 3637 patients were admitted for observation over the 2-year preintervention period. Thirty-day-adjusted MACE rate was not significantly different between pre- and postintervention periods (0.4% vs. 0.6%, P = 0.3), also monthly observation admissions did not change significantly; however, utilization of stress testing (57.2% vs. 41.0%, P < 0.001) and cardiac catheterization (2.3% vs. 1.6%, P = 0.036) was reduced. CONCLUSION Chest pain patients admitted for observation and risk stratification are at very low risk of 30-day MACE. An intervention based on a chest pain protocol and availability of early cardiology follow-up did not change the admission rate of these patients. This intervention was not associated with increased risk of adverse outcomes.
Collapse
|
41
|
Stopyra JP, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM, Burke GL, Miller CD, Mahler SA. The HEART Pathway Randomized Controlled Trial One-year Outcomes. Acad Emerg Med 2019; 26:41-50. [PMID: 29920834 DOI: 10.1111/acem.13504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. METHODS Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests. RESULTS A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36). CONCLUSIONS The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.
Collapse
Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Robert F. Riley
- The Christ Hospital Heart and Vascular Center and Lindner Center for Research and Education Cincinnati OH
| | - Brian C. Hiestand
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Gregory B. Russell
- Department of Biostatistical Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - James W. Hoekstra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Cedric W. Lefebvre
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Bret A. Nicks
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - David M. Cline
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Kim L. Askew
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Stephanie B. Elliott
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - David M. Herrington
- Department of Biostatistical Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - Gregory L. Burke
- Department of Internal Medicine Division of Cardiology Wake Forest School of Medicine Winston‐Salem NC
- Public Health Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - Chadwick D. Miller
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Simon A. Mahler
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
- Departments of Implementation Science and Epidemiology and Prevention Wake Forest School of Medicine Winston‐Salem NC
| |
Collapse
|
42
|
Goto Y, Funada A, Maeda T, Okada H, Goto Y. Field termination-of-resuscitation rule for refractory out-of-hospital cardiac arrests in Japan. J Cardiol 2018; 73:240-246. [PMID: 30580892 DOI: 10.1016/j.jjcc.2018.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/30/2018] [Accepted: 12/08/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR. METHODS We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA. RESULTS Recursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group. CONCLUSIONS Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.
Collapse
Affiliation(s)
- Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan.
| | - Akira Funada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Tetsuo Maeda
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Hirofumi Okada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yumiko Goto
- Department of Cardiology, Yawata Medical Center, Komatsu, Japan
| |
Collapse
|
43
|
Wamala H, Aggarwal L, Bernard A, Scott IA. Comparison of nine coronary risk scores in evaluating patients presenting to hospital with undifferentiated chest pain. Int J Gen Med 2018; 11:473-481. [PMID: 30588062 PMCID: PMC6296689 DOI: 10.2147/ijgm.s183583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction We compared performance of nine risk scores for coronary heart disease (CHD) among patients presenting to an emergency department (ED) with undifferentiated chest pain of possible coronary origin. Methods A retrospective study was undertaken of adult patients presenting with chest pain to atertiary hospital ED with no electrocardiographs or troponin results diagnostic of ischemic chest pain (ICP) or acute coronary syndrome at ED presentation, and no clearly evident noncoronary diagnosis. Risk scores were applied using cut-points distinguishing low- from high-risk patients according to discharge diagnosis of noncardiac chest pain (NCCP) or ICP, respectively. A lower odds ratio (OR) for ICP denoted lower risk for ICP. Score performance was compared using area under receiver–operator characteristic curves (AUC) and predictive values. Results A total of 401 patients were studied, of whom 123 (30.7%) had ICP as final diagnosis. Among the nine risk scores, those with greatest ability to detect low-risk patients were The North American Chest Pain Rule (NACPR) score (OR=0.35, 95% CI=0.27–0.46); History, ECG, Age, Risk Factors, and Troponin (HEART) score (OR=0.43; 95% CI=0.35–0.52); and Thrombolysis in Myocardial Infarction (TIMI) score (OR=0.49; 95% CI=0.41–0.58). Discrimination between patients with NCCP and those with ICP was greatest for HEART score (AUC=0.82; 95% CI=0.78–0.86) and lowest for Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT) score (AUC=0.63; 95% CI=0.58–0.69). In excluding ICP, ADAPT had negative predictive value (NPV) 100% (miss rate 0%) but classified only 1.7% of patients as low risk, compared to NACPR with NPV 98% (miss rate 2%), classifying 10.2% as low risk, and HEART with NPV 94% (miss rate 6%), classifying 32.4% as low risk. Conclusion The NACPR risk score maximized yield of low-risk patients with lowest miss rate for ICP, while HEART score classified highest proportion of low-risk patients but with a higher miss rate.
Collapse
Affiliation(s)
- Henry Wamala
- Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Leena Aggarwal
- Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Anne Bernard
- Queensland Facility for Advanced Bioinformatics, University of Queensland, Brisbane, QLD, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD, Australia, .,Southside School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia,
| |
Collapse
|
44
|
Oliver JJ, Streitz MJ, Hyams JM, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. An external validation of the HEART pathway among Emergency Department patients with chest pain. Intern Emerg Med 2018; 13:1249-1255. [PMID: 29512019 DOI: 10.1007/s11739-018-1809-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/25/2018] [Indexed: 12/27/2022]
Abstract
The impact of an outpatient disposition strategy for patients with HEART score 0-3 (HEART pathway) on HEART score prognostic accuracy is unclear. Our objective is to perform an external validation the HEART score in the setting of recent implementation of the HEART pathway. We conducted an external validation study of the HEART pathway among patients presenting to our ED with chest pain 6 weeks after institutional implementation of a HEART pathway outpatient disposition pathway. We reviewed the charts of 625 consecutive patients with chest pain. Data abstracted included all elements of the HEART score to include history, electrocardiogram (ECG) read, patient age, patient risk factors, and troponin levels. We also reviewed each patient's record for evidence of major adverse cardiac events (MACE) to include mortality, myocardial infarction, or coronary revascularization over 6 weeks following their initial ED visit. We double-abstracted 10% of the charts for quality assurance purposes. Of 625 charts, 449 patients met all criteria for study inclusion. Of these, 25 subjects (5.56%) experience 6-week MACE. No subject with a score of 3 or less has a MACE at 6 weeks (100% sensitivity, 38.7% specificity). The area under the receiver operator curve (AUROC) is 0.898 (95% confidence interval 0.847-0.950). Kappa coefficients for inter-rater reliability range from 0.62 for the history component of the HEART score to 1.0 for troponin. A low HEART score (0-3) maintains excellent sensitivity for predicting 6-week MACE in the setting of an outpatient disposition pathway for these patients.
Collapse
Affiliation(s)
- Joshua James Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA.
- , 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78216, USA.
| | - Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | | | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, San Antonio, TX, 78234, USA
| |
Collapse
|
45
|
Yang SM, Chan CH, Chan TN. HEART pathway and Emergency Department Assessment of Chest Pain Score–Accelerated Diagnostic Protocol application in a local emergency department of Hong Kong: An external prospective validation study. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918812321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: The conventional chest pain protocol using thrombolysis in myocardial infarction score as the risk stratifying tool may not perform well in the emergency department in which a mix of low- and high-risk patients are encountered. Newer chest pain scores such as HEART pathway and Emergency Department Assessment of Chest Pain Score–Accelerated Diagnostic Protocol (EDACS-ADP) are found to have high sensitivity with good specificity. Objectives: This study aims to validate and compare two chest pain scores: HEART pathway and EDACS-ADP in the Accident and Emergency Department of a local hospital in Hong Kong. Methods: A prospective cohort study was carried out at the Accident and Emergency Department of Kwong Wah Hospital in Hong Kong from 1 June 2016 to 31 May 2017. Patients ⩾18 years old with chest pain lasting 5 min or more who were observed with chest pain protocol on observation ward were recruited. Results: A total of 238 patients were recruited; 231 eligible patients completed follow-up. There were five patients with major adverse cardiac events in 30 days of follow-up. The sensitivity, specificity, and negative predictive values of HEART pathway and EDACS-ADP were 100%, 74.3%, 100% and 100%, 73.5.0% and 100%, respectively. Both scores had almost the same performance in terms of major adverse cardiac events at 30 days (area under the curve = 0.87). Conclusion: Our study showed both EDACS-ADP (modified) and HEART pathway achieved high sensitivity (~100%) for detecting major adverse cardiac events in 30 days while being able to discharge more than 70% of patients as low risk for early discharge.
Collapse
Affiliation(s)
- Siu Ming Yang
- Department of Accident and Emergency, Kwong Wah Hospital, Kowloon, Hong Kong
| | - Chi Ho Chan
- Department of Accident and Emergency, Kwong Wah Hospital, Kowloon, Hong Kong
| | - Tung Ning Chan
- Department of Accident and Emergency, Kwong Wah Hospital, Kowloon, Hong Kong
| |
Collapse
|
46
|
Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown MD, Brown MD, Wolf SJ, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Harrison NE, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Nazarian DJ, Proehl JA, Promes SB, Shah KH, Shih RD, Silvers SM, Smith MD, Thiessen ME, Tomaszewski CA, Valente JH, Wall SP, Cantrill SV, Hirshon JM, Schulz T, Whitson RR. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes. Ann Emerg Med 2018; 72:e65-e106. [DOI: 10.1016/j.annemergmed.2018.07.045] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
47
|
Streitz MJ, Oliver JJ, Hyams JM, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain. Intern Emerg Med 2018; 13:727-748. [PMID: 28895038 DOI: 10.1007/s11739-017-1743-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/19/2017] [Indexed: 01/16/2023]
Abstract
Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient's electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0-10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838-0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification.
Collapse
Affiliation(s)
- Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA.
| | - Joshua James Oliver
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | | | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| |
Collapse
|
48
|
Nakashima T, Tahara Y. Achieving the earliest possible reperfusion in patients with acute coronary syndrome: a current overview. J Intensive Care 2018; 6:20. [PMID: 29568528 PMCID: PMC5856388 DOI: 10.1186/s40560-018-0285-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 02/21/2018] [Indexed: 01/26/2023] Open
Abstract
Acute coronary syndrome (ACS) remains one of the leading causes of mortality worldwide. Appropriate management of ACS will lead to a lower incidence of cardiac arrest. Percutaneous coronary intervention (PCI) is the first-line treatment for patients with ACS. PCI techniques have become established. Thus, the establishment of a system of health care in the prehospital and emergency department settings is needed to reduce mortality in patients with ACS. In this review, evidence on how to achieve earlier diagnosis, therapeutic intervention, and decision to reperfuse with a focus on the prehospital and emergency department settings is systematically summarized. The purpose of this review is to generate current, evidence-based consensus on scientific and treatment recommendations for health care providers who are the initial points of contact for patients with signs and symptoms suggestive of ACS.
Collapse
Affiliation(s)
- Takahiro Nakashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565 Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, 565-8565 Japan
| |
Collapse
|
49
|
Hyams JM, Streitz MJ, Oliver JJ, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study. J Emerg Med 2018; 54:549-557. [PMID: 29478861 DOI: 10.1016/j.jemermed.2017.12.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 12/04/2017] [Accepted: 12/17/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. OBJECTIVE To compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). METHODS We conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. RESULTS The admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7-68.2%), vs. 48.3% (95% CI 43.7-53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7-21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33-0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. CONCLUSIONS The HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.
Collapse
Affiliation(s)
- Jessica M Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - Matthew J Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - Joshua J Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - Richard M Wood
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | | | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - Robert M Barnwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - Michael D April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| |
Collapse
|
50
|
|