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Oikonomou EK, Aminorroaya A, Dhingra LS, Partridge C, Velazquez EJ, Desai NR, Krumholz HM, Miller EJ, Khera R. Real-world evaluation of an algorithmic machine-learning-guided testing approach in stable chest pain: a multinational, multicohort study. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:303-313. [PMID: 38774380 PMCID: PMC11104476 DOI: 10.1093/ehjdh/ztae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/20/2024] [Indexed: 05/24/2024]
Abstract
Aims An algorithmic strategy for anatomical vs. functional testing in suspected coronary artery disease (CAD) (Anatomical vs. Stress teSting decIsion Support Tool; ASSIST) is associated with better outcomes than random selection. However, in the real world, this decision is rarely random. We explored the agreement between a provider-driven vs. simulated algorithmic approach to cardiac testing and its association with outcomes across multinational cohorts. Methods and results In two cohorts of functional vs. anatomical testing in a US hospital health system [Yale; 2013-2023; n = 130 196 (97.0%) vs. n = 4020 (3.0%), respectively], and the UK Biobank [n = 3320 (85.1%) vs. n = 581 (14.9%), respectively], we examined outcomes stratified by agreement between the real-world and ASSIST-recommended strategies. Younger age, female sex, Black race, and diabetes history were independently associated with lower odds of ASSIST-aligned testing. Over a median of 4.9 (interquartile range [IQR]: 2.4-7.1) and 5.4 (IQR: 2.6-8.8) years, referral to the ASSIST-recommended strategy was associated with a lower risk of acute myocardial infarction or death (hazard ratioadjusted: 0.81, 95% confidence interval [CI] 0.77-0.85, P < 0.001 and 0.74 [95% CI 0.60-0.90], P = 0.003, respectively), an effect that remained significant across years, test types, and risk profiles. In post hoc analyses of anatomical-first testing in the Prospective Multicentre Imaging Study for Evaluation of Chest Pain (PROMISE) trial, alignment with ASSIST was independently associated with a 17% and 30% higher risk of detecting CAD in any vessel or the left main artery/proximal left anterior descending coronary artery, respectively. Conclusion In cohorts where historical practices largely favour functional testing, alignment with an algorithmic approach to cardiac testing defined by ASSIST was associated with a lower risk of adverse outcomes. This highlights the potential utility of a data-driven approach in the diagnostic management of CAD.
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Affiliation(s)
- Evangelos K Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Arya Aminorroaya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Lovedeep S Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Caitlin Partridge
- Yale Center for Clinical Investigation, 2 Church Street South, New Haven, 06519 CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street 5th Floor, New Haven, 06510 CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street 5th Floor, New Haven, 06510 CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, 100 College Street, New Haven, 06511 CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, 06510 CT, USA
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Hu X, Fanous E, Jackson NJ, Daso GI, Liang I, McCullough LB, Cooper RJ, Horwich TB, Watson KE, Shah JB, Shahandeh N, Calfon Press MA. Impact of COVID-19 Pandemic on Sex and Racial Disparities in Chest Pain Presentation and Management Through the Emergency Department. Cardiol Res 2024; 15:90-98. [PMID: 38645824 PMCID: PMC11027781 DOI: 10.14740/cr1586] [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: 10/17/2023] [Accepted: 12/04/2023] [Indexed: 04/23/2024] Open
Abstract
Background Sex and racial disparities in the presentation and management of chest pain persist, however, the impact of coronavirus disease 2019 (COVID-19) on these disparities have not been studied. We sought to determine whether the COVID-19 pandemic contributed to pre-existing sex and racial disparities in the presentation, management, and outcomes of patients presenting to the emergency department (ED) with chest pain. Methods We conducted an observational cohort study with retrospective data collection of patients between January 1, 2016, and May 1, 2022. This was a single study conducted at a quaternary academic medical center of all patients who presented to the ED with a complaint of chest pain or chest pain equivalent symptoms. Patient were further segregated into different groups based on sex (male, female), race, ethnicity (Asian, Black, Hispanic, White, and other), and age (18 - 40, 41 - 65, > 65). We compared diagnostic evaluations, treatment decisions, and outcomes during prespecified time points before, during, and after the COVID-19 pandemic. Results This study included 95,764 chest pain encounters. Total chest pain presentations to the ED fell about 38% during the early pandemic months. Females presented significantly less than males during initial COVID-19 (48% vs. 52%, P < 0.001) and Asian females were least likely to present. There was an increase in the total number of troponins and echocardiograms ordered during peak COVID-19 across both sexes, but females were still less likely to have these tests ordered across all timepoints. The number of coronary angiograms did not increase during peak COVID-19, and females were less likely to undergo coronary angiogram during all timepoints. Finally, females with chest pain were less likely to be diagnosed with acute myocardial infarction (AMI) during all timepoints, while in-hospital deaths were similar between males and females during all timepoints. Conclusions During COVID-19, females, especially Asian females, were less likely to present to the ED for chest pain. Non-White patients were less likely to present to the ED compared to White patients prior to and during the pandemic. Disparities in management and outcomes of chest pain encounters remained similar to pre-COVID-19, with females receiving less cardiac workup and AMI diagnoses than males, but in-hospital mortality remaining similar between groups and timepoints.
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Affiliation(s)
- Xuchen Hu
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Elias Fanous
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Nicholas J. Jackson
- Department of Medicine - Statistics, University of California, Los Angeles, CA 90095, USA
| | - Gabrielle I. Daso
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Icy Liang
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Lynnell B. McCullough
- Department of Emergency Medicine, University of California, Los Angeles, CA 90095, USA
| | - Richelle J. Cooper
- Department of Emergency Medicine, University of California, Los Angeles, CA 90095, USA
| | - Tamara B. Horwich
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Karol E. Watson
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Janki B. Shah
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Negeen Shahandeh
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
| | - Marcella A. Calfon Press
- Department of Medicine - Cardiology, University of California, Los Angeles, CA 90095, USA
- UCLA Cardiovascular Center, Los Angeles, CA 90095, USA
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Barron R, Mader TJ, Knee A, Wilson D, Wolfe J, Gemme SR, Dybas S, Soares WE. Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial. Ann Emerg Med 2024; 83:123-131. [PMID: 38245227 DOI: 10.1016/j.annemergmed.2023.03.016] [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: 09/07/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 01/22/2024]
Abstract
STUDY OBJECTIVE Clinical decision aids can decrease health care disparities. However, many clinical decision aids contain subjective variables that may introduce clinician bias. The HEART score is a clinical decision aid that estimates emergency department (ED) patients' cardiac risk. We sought to explore patient and clinician gender's influence on HEART scores. METHODS In this secondary analysis of a prospective observational trial, we examined a convenience sample of adult ED patients at one institution presenting with acute coronary syndrome symptoms. We compared ED clinician-generated HEART scores with researcher-generated HEART scores blinded to patient gender. The primary outcome was agreement between clinician and researcher HEART scores by patient gender overall and stratified by clinician gender. Analyses used difference-in-difference (DiD) for continuous score and prevalence-adjusted, bias-adjusted Kappa (PABAK) for binary (low versus moderate/high risk) score comparison. RESULTS All 336 clinician-patient pairs from the original study were included. In total, 47% (158/336) of patients were women, and 52% (174/336) were treated by a woman clinician. The DiD between clinician and researcher HEART scores among men versus women patients was 0.24 (95% CI -0.01 to 0.48). Compared with researchers, men clinicians assigned a higher score to men versus women patients (DiD 0.51 [95% CI 0.16 to 0.87]), whereas women clinicians did not (DiD 0.00 [95% CI -0.33 to 0.33]). Agreement was the highest among women clinicians (PABAK 0.72; 95% CI 0.61 to 0.81) and lowest among men clinicians assessing men patients (PABAK 0.47; 95% CI 0.29 to 0.66). CONCLUSION Patient and clinician gender may influence HEART scores. Researchers should strive to understand these influences in developing and implementing this and other clinical decision aids.
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Affiliation(s)
- Rebecca Barron
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA.
| | - Timothy J Mader
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Alexander Knee
- Department of Medicine, UMass Chan Medical School-Baystate, Springfield, MA; Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Donna Wilson
- Epidemiology Biostatistics Research Core, Office of Research, Baystate Medical Center, Springfield, MA
| | - Jeannette Wolfe
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Seth R Gemme
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - William E Soares
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
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Titus BR, Ream KS, Rehman T, Allen LA. Sex-disparities in chest pain workup: a retrospective cohort review of a university based clinical decision pathway. BMC Cardiovasc Disord 2023; 23:620. [PMID: 38114900 PMCID: PMC10729513 DOI: 10.1186/s12872-023-03610-3] [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: 05/26/2023] [Accepted: 11/13/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Females have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification. METHODS We conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex. RESULTS A total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs. 16%, p = 0.01) and PCI (18% vs. 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (8% vs. 3%, p = 0.001). CONCLUSIONS We identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient's presentation.
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Affiliation(s)
- Benjamin R Titus
- Internal Medicine Residency, University of Colorado, Aurora, United States.
| | - Karen S Ream
- Division of Cardiology, University of Colorado, Aurora, United States
| | - Tehreem Rehman
- Department of Emergency Medicine, Mount Sinai Hospital, New York City, United States
| | - Larry A Allen
- Division of Cardiology, University of Colorado, Aurora, United States
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5
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Aarts GWA, Camaro C, Rodwell L, Adang EMM, van Hout R, Brok G, Hoare A, de Pooter FPC, de Wit W, Cramer GE, van Kimmenade RRJ, Ouwendijk E, Rutten M, Zegers E, van Geuns RJM, Gomes MER, Damman P, van Royen N. Differences in risk and costs between prehospital identified low-risk men and women with chest pain. Open Heart 2023; 10:e002390. [PMID: 38011992 PMCID: PMC10685936 DOI: 10.1136/openhrt-2023-002390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 10/26/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Prehospital rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in low-risk patient with a point-of-care troponin measurement reduces healthcare costs with similar safety to standard transfer to the hospital. Risk stratification is performed identical for men and women, despite important differences in clinical presentation, risk factors and age between men and women with NSTE-ACS. Our aim was to compare safety and healthcare costs between men and women in prehospital identified low-risk patients with suspected NSTE-ACS. METHODS In the Acute Rule-out of non-ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART (History, ECG, Age, Risk factors and Troponin) score assessment and a single poInt of CAre troponin randomised trial, the HEAR (History, ECG, Age and Risk factors) score was assessed by ambulance paramedics in suspected NSTE-ACS patients. Low-risk patients (HEAR score ≤3) were included. In this substudy, men and women were compared. Primary endpoint was 30-day major adverse cardiac events (MACE), secondary endpoints were 30-day healthcare costs and the scores for the HEAR score components. RESULTS A total of 863 patients were included, of which 495 (57.4%) were women. Follow-up was completed in all patients. In the total population, MACE occurred in 6.8% of the men and 1.6% of the women (risk ratio (RR) 4.2 (95% CI 1.9 to 9.2, p<0.001)). In patients with ruled-out ACS (97% of the total population), MACE occurred in 1.4% of the men and in 0.2% of the women (RR 7.0 (95% CI 2.0 to 14.2, p<0.001). Mean healthcare costs were €504.55 (95% CI €242.22 to €766.87, p<0.001) higher in men, mainly related to MACE. CONCLUSIONS In a prehospital population of low-risk suspected NSTE-ACS patients, 30-day incidence of MACE and MACE-related healthcare costs were significantly higher in men than in women. TRIAL REGISTRATION NUMBER NCT05466591.
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Affiliation(s)
| | - Cyril Camaro
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Laura Rodwell
- Department for Health Evidence, Radboudumc Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Eddy M M Adang
- Department for Health Evidence, Radboudumc Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roger van Hout
- Ambulance Service, Safety Region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Gijs Brok
- Ambulance Service, Safety Region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Anouk Hoare
- Ambulance Service, Witte Kruis, Houten, The Netherlands
| | - Frank P C de Pooter
- Ambulance Service Noord- en Oost-Gelderland, Witte Kruis, Elburg, The Netherlands
| | - Walter de Wit
- Ambulance Service Zeeland, Witte Kruis, Goes, The Netherlands
| | | | | | - Eva Ouwendijk
- General Practitioner Centre Nijmegen and Boxmeer, Nijmegen, The Netherlands
| | - Martijn Rutten
- General Practitioner Cooperative Noord-Limburg, Venlo, The Netherlands
| | - Erwin Zegers
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Marc E R Gomes
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
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6
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Luntz A, Creary K, Bruessow D. Managing patients with sex-, race-, or ethnicity-based cardiovascular health inequities. JAAPA 2023; 36:16-24. [PMID: 37306606 DOI: 10.1097/01.jaa.0000937264.73482.83] [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: 06/13/2023]
Abstract
ABSTRACT Cardiovascular health inequities are experienced among cisgender women, gender minorities, Black and Indigenous people, and people with lower socioeconomic status. Early identification and treatment of patients at risk for disparate and adverse cardiac health outcomes are essential.
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Affiliation(s)
- Allison Luntz
- Allison Luntz is a PA surgical resident at Norwalk Hospital/Yale Physician Assistant Surgical Residency in Norwalk, Conn. Kashif Creary is assistant director of PA services at NYU Langone Hospital-Brooklyn in New York City, N.Y. Diane Bruessow is director of justice, equity, diversity, and inclusion in the Yale PA Online Program and assistant professor adjunct in the Department of Internal Medicine at Yale School of Medicine in New Haven, Conn., and a clinically practicing PA in transgender medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Onal EG, Knier K, Hunt AW, Knudsen JM, Nestler DM, Campbell RL, Thompson KM, Sunga KL, Walker LE, Madsen BE, Sadosty AT, McGregor AJ, Mullan AF, Jeffery MM, Bellamkonda VR. Comparison of emergency department throughput and process times between male and female patients: A retrospective cohort investigation by the Reducing Disparities Increasing Equity in Emergency Medicine Study Group. J Am Coll Emerg Physicians Open 2022; 3:e12792. [PMID: 36187504 PMCID: PMC9512773 DOI: 10.1002/emp2.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Health equity for all patients is an important characteristic of an effective healthcare system. Bias has the potential to create inequities. In this study, we examine emergency department (ED) throughput and care measures for sex-based differences, including metrics such as door-to-room (DTR) and door-to-healthcare practitioner (DTP) times to look for potential signs of systemic bias. Methods We conducted an observational cohort study of all adult patients presenting to the ED between July 2015 and June 2017. We collected ED operational, throughput, clinical, and demographic data. Differences in the findings for male and female patients were assessed using Poisson regression and generalized estimating equations (GEEs). A priori, a clinically significant time difference was defined as 10 min. Results A total of 106,011 adult visits to the ED were investigated. Female patients had 8-min longer median length-of-stay (LOS) than males (P < 0.01). Females had longer DTR (2-min median difference, P < 0.01), and longer DTP (5-min median difference, P < 0.01). Females had longer median door-to-over-the-counter analgesia time (84 vs. 80, P = 0.58), door-to-advanced analgesia (95 vs. 84, P < 0.01), door-to-PO (by mouth) ondansetron (70 vs. 62, P = 0.02), and door-to-intramuscular/intravenous antiemetic (76 vs. 69, P = 0.02) times compared with males. Conclusion Numerous statistically significant differences were identified in throughput and care measures-mostly these differences favored male patients. Few of these comparisons met our criteria for clinical significance.
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Affiliation(s)
- Ege G. Onal
- Department of BioengineeringUniversity of Illinois at Urbana‐ChampaignUrbanaIllinoisUSA
- Summer Foundations in Research FellowMayo Clinic Graduate School of Biomedical SciencesMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Kit Knier
- Mayo Clinic Alix School of MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
- Mayo Clinic Medical Scientist Training ProgramMayo Clinic Graduate School of Biomedical SciencesMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Alexander W. Hunt
- Undergraduate Research Experience ProgramMayo Clinic Graduate School of Biomedical SciencesMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - John M. Knudsen
- Office of Health Disparities ResearchMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - David M. Nestler
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Ronna L. Campbell
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Kristine M. Thompson
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceJacksonvilleFloridaUSA
| | - Kharmene L. Sunga
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
- Office of EquityInclusionand DiversityMayo ClinicRochesterMinnesotaUSA
| | - Laura E. Walker
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Bo E. Madsen
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Annie T. Sadosty
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | - Alyson J. McGregor
- Sex and Gender Equity CommitteeSociety of Academic Emergency MedicineDes PlainesIllinoisUSA
- Division of Sex and Gender in Emergency MedicineDepartment of Emergency MedicineAlpert Medical SchoolBrown UniversityProvidenceRhode IslandUSA
| | - Aidan F. Mullan
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - Molly M. Jeffery
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
- Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
| | - Venkatesh R. Bellamkonda
- Department of Emergency MedicineMayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
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8
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Raisi-Estabragh Z, Kobo O, Elbadawi A, Velagapudi P, Sharma G, Bullock-Palmer RP, Petersen SE, Mehta LS, Ullah W, Roguin A, Sun LY, Mamas MA. Differential Patterns and Outcomes of 20.6 Million Cardiovascular Emergency Department Encounters for Men and Women in the United States. J Am Heart Assoc 2022; 11:e026432. [PMID: 36073628 DOI: 10.1161/jaha.122.026432] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.
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Affiliation(s)
- Zahra Raisi-Estabragh
- National Institute for Heart Research Barts Biomedical Research Centre, Centre for Advanced Cardiovascular Imaging William Harvey Research Institute, Queen Mary University London London United Kingdom.,Barts Heart Centre, St Bartholomew's Hospital, Barts Health National Health Service Trust London United Kingdom
| | - Ofer Kobo
- Keele Cardiovascular Research Group Keele University Keele United Kingdom.,Department of Cardiology Hillel Yaffe Medical Center Hadera Israel
| | - Ayman Elbadawi
- Department of Cardiovascular Medicine and Division of Cardiology, Baylor College of Medicine Houston TX
| | | | - Garima Sharma
- Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease Johns Hopkins University School of Medicine and Hospital Baltimore MD
| | | | - Steffen E Petersen
- National Institute for Heart Research Barts Biomedical Research Centre, Centre for Advanced Cardiovascular Imaging William Harvey Research Institute, Queen Mary University London London United Kingdom.,Barts Heart Centre, St Bartholomew's Hospital, Barts Health National Health Service Trust London United Kingdom.,Health Data Research UK London United Kingdom.,Alan Turing Institute London United Kingdom
| | - Laxmi S Mehta
- Division of Cardiology, Department of Internal Medicine The Ohio State University Columbus OH
| | - Waqas Ullah
- Thomas Jefferson University Hospitals Philadelphia PA
| | - Ariel Roguin
- Department of Cardiology Hillel Yaffe Medical Center Hadera Israel
| | - Louise Y Sun
- Division of Cardiac Anesthesiology University of Ottawa Heart Institute Ottawa Ontario Canada.,School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group Keele University Keele United Kingdom.,Institute of Population Health University of Manchester United Kingdom
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9
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Role of HEART score in prediction of coronary artery disease and major adverse cardiac events in patients presenting with chest pain. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh220213038s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Chest pain (CP) diagnostics accuracy remains
debatable for both general practitioners (GP) or emergency department (ED)
physicians for patients in HEART score (HS) low- and intermediate-risk
groups which prompted us to review our electronic database for all patients
admitted via our center?s ED during 2014 to 2020 for CP and suspect acute
coronary syndrome. Methods. Patients were divided in function of low- or
intermediate-risk HS and assessed during a three month follow up for
angiogram results, MACE, lab results and echo parameters. Results. Of 585
patients included, low-risk HS group (21,4%, 36% were women) had significant
coronary disease on angiogram in 68%, while for intermediate-risk HS group
(78.6%, with 32.6% women) it was for 18.4% of patients (p < 0,0005). Area
under the ROC curve of HS in detecting patients with ischemic heart disease
as a cause of CP was 0.771 (95% CI:0.772-0.820) with best cut-off point HS
was calculated at 3.5. Sensitivity and specificity were 89.2% and 57.6%
respectively. Adjusting for sex, lab results and HS, AUROC curve of this
model was 0.828 (95% CI:0.786-0.869; p < 0,0005) with cut-off of 77.95.
Sensitivity and specificity were 84,9% and 68% respectively. In the
three-month follow-up post-discharge, there was a significant difference in
MACE between groups (low-vs. intermediate-risk HS was 3.4 vs. 16.7% p <
0.05). Conclusion. HS for our CP patients admitted via our ED by GP and ED
physicians? referral, provides a quick and reliable prediction of ischemic
heart disease and MACE.
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10
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Vargas K, Messman A, Levy PD. Nuances in the Evaluation of Chest Pain in Women. JACC Case Rep 2021; 3:1793-1797. [PMID: 34917956 PMCID: PMC8642734 DOI: 10.1016/j.jaccas.2021.07.035] [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: 07/09/2021] [Accepted: 07/21/2021] [Indexed: 12/03/2022]
Abstract
Although chest pain is the most common presenting symptom for both men and women who ultimately receive diagnoses of acute coronary syndrome, there in are important differences in coronary artery disease pathophysiology that can affect patient care. Using a case-based approach, we provide insight into these and other important considerations that every clinician should think of when treating women with chest pain. (Level of Difficulty: Intermediate.)
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Key Words
- ACS, acute coronary syndrome
- AMI, acute myocardial infarction
- CAD, coronary artery disease
- HEART score, History, ECG, Age, Risk factors, Troponin score
- MACE, major acute coronary event
- MINOCA, myocardial infarction with nonobstructive coronary arteries
- PCI, percutaneous coronary intervention
- SCAD, spontaneous coronary artery dissection
- acute coronary syndrome
- chest pain
- myocardial infarction
- women
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Affiliation(s)
- Kelsey Vargas
- Department of Emergency Medicine, Cleveland Clinic Foundation/Case Western Reserve University, Cleveland, Ohio, USA
| | - Anne Messman
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan, USA.,Integrative Biosciences Center, Wayne State University, Detroit, Michigan, USA
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11
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Check R, Kelly B, Dunn E, Stankewicz H, Hakim J, Arner K, Ridley K, Irick J, Irick M, Agresti D, Jeanmonod R. Patients' sex and race are independent predictors of HEART score documentation by emergency medicine providers. Am J Emerg Med 2021; 51:308-312. [PMID: 34798572 DOI: 10.1016/j.ajem.2021.10.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/23/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION The HEART score is a widely used clinical decision tool that provides emergency providers with objective risk stratification for patients presenting to the emergency department (ED) with undifferentiated chest pain (CP). There is no data as to which patients undergo formal risk stratification with a HEART score, and whether patient demographics influence decisions to apply the HEART score. Our objective was to determine if sex or race independently predict documentation of patients' HEART scores in CP patients. METHODS This is a retrospective cohort study of all patients with a chief complaint of CP who presented to EDs within a single health care system (11 EDs) from September 2018-January 2021. Charts were identified via query of the electronic medical record, and patient age, race, and sex were extracted. The presence or absence of documentation of a HEART score was also recorded. Patient race was categorized as white/non-white. Sex was categorized as male/female. Age was inputted as a continuous variable. We performed logistic regression to determine which variables were associated with documentation of a HEART score. RESULTS 38,277 patients were included in the study. The median patient age was 51 with IQR 36-64, and 18,927 (47.5%) were male. HEART scores were documented in 24,181. Younger age, female sex, and non-white race were all independent predictors of not having HEART score risk stratification documented in the medical record. CONCLUSIONS Women and non-white patients are less likely to receive HEART score risk stratification when presenting with undifferentiated CP, even when controlling for patient age. Further studies should address whether this influences patient centered outcomes.
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Affiliation(s)
- Ronald Check
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Brian Kelly
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Erica Dunn
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Holly Stankewicz
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Jenna Hakim
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Kate Arner
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Kylie Ridley
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Jennifer Irick
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Michael Irick
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Darin Agresti
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America
| | - Rebecca Jeanmonod
- St. Luke's University Hospital and Health Network, Department of Emergency Medicine, Bethlehem, PA, United States of America.
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12
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Sharp AL, Pallegadda R, Baecker A, Park S, Nassery N, Hassoon A, Peterson S, Pitts SI, Wang Z, Zhu Y, Newman-Toker DE. Are Mental Health and Substance Use Disorders Risk Factors for Missed Acute Myocardial Infarction Diagnoses Among Chest Pain or Dyspnea Encounters in the Emergency Department? Ann Emerg Med 2021; 79:93-101. [PMID: 34607739 DOI: 10.1016/j.annemergmed.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/14/2021] [Accepted: 08/23/2021] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE To assess if having a mental health and/or substance use disorder is associated with a missed acute myocardial infarction diagnosis in the emergency department (ED). METHODS This was a retrospective cohort analysis (2009 to 2017) of adult ED encounters at Kaiser Permanente Southern California. We used the validated symptom-disease pair analysis of diagnostic error methodological approach to "look back" and "look forward" and identify missed acute myocardial infarctions within 30 days of a treat-and-release ED visit. We use adjusted logistic regression to report the odds of missed acute myocardial infarction among patients with a history of mental health and/or substance use disorders. RESULTS The look-back analysis identified 44,473 acute myocardial infarction hospital encounters; 574 (1.3%) diagnoses were missed. The odds of missed diagnoses were higher in patients with mental health disorders (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.23 to 1.77) but not in those with substance abuse disorders (OR 1.22, 95% CI 0.91 to 1.62). The highest risk was observed in those with co-occurring disorders (OR 1.90, 95% CI 1.30 to 2.76). The look-forward analysis identified 325,088 chest pain/dyspnea ED encounters; 508 (0.2%) were missed acute myocardial infarctions. No significant associations of missed acute myocardial infarction were revealed in either group (mental health disorder: OR 0.92, 95% CI 0.71 to 1.18; substance use disorder: OR 1.22, 95% CI 0.80 to 1.85). CONCLUSION The look-back analysis identified patients with mental illness at increased risk of missed acute myocardial infarction diagnosis, with the highest risk observed in those with a history of comorbid substance abuse. Having substance use disorders alone did not increase this risk in either cohort. The look-forward analysis revealed challenges in prospectively identifying high-risk patients to target for improvement.
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Affiliation(s)
- Adam L Sharp
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA; Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA.
| | - Rani Pallegadda
- Department of Emergency Medicine, Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, CA; Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Aileen Baecker
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Stacy Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Najlla Nassery
- Department of Internal Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Susan Peterson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samantha I Pitts
- Department of Internal Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics, Johns Hopkins University, Baltimore, MD
| | - Yuxin Zhu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics, Johns Hopkins University, Baltimore, MD
| | - David E Newman-Toker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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A Methodological Appraisal of the HEART Score and Its Variants. Ann Emerg Med 2021; 78:253-266. [PMID: 33933300 DOI: 10.1016/j.annemergmed.2021.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 01/16/2023]
Abstract
We performed a methodological appraisal of the history, electrocardiogram, age, risk factors, and troponin (HEART) score and its variants in the context of Annals of Emergency Medicine's methodological standards for clinical decision rules. We note that this chest pain risk stratification tool was not formally derived, omits sex and other known predictors, has weak interrater reliability, and its 0, 1, and 2 score weightings do not align with their known predictivities. Its summary performance (pooled sensitivities of 96% to 97% with lower confidence interval bounds of 93% to 94%) is below that which emergency physicians state a willingness to accept, below the 98% sensitivity exhibited by baseline practice without the score, and below the 1% to 2% acceptable miss threshold specified by the American College of Emergency Physicians chest pain policy. Two variants (HEART Pathway, HEART-2) have the same inherent structural limitations and demonstrate slightly better but still suboptimal sensitivity. Although a simple prediction tool for chest pain outcomes is appealing, we believe that the widespread use of the HEART score and its variants should be reconsidered.
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