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Stephensen L, Greenslade J, Starmer K, Starmer G, Stone R, Bonnin R, Brazzale A, Drahm‐Butler T, Campbell V, Davis T, Mowatt E, Brown N, Proctor K, Ashover S, Milburn T, McCormack L, Graves N, Gatton M, Mahoney R, Parsonage W, Cullen L. Clinical characteristics of Aboriginal and Torres Strait Islander emergency department patients with suspected acute coronary syndrome. Emerg Med Australas 2022; 35:442-449. [PMID: 36410371 DOI: 10.1111/1742-6723.14138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/30/2022] [Accepted: 10/26/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe the demographics, presentation characteristics, clinical features and cardiac outcomes for Aboriginal and Torres Strait Islander patients who present to a regional cardiac referral centre ED with suspected acute coronary syndrome (ACS). METHODS This was a single-centre observational study conducted at a regional referral hospital in Far North Queensland, Australia from November 2017 to September 2018 and January 2019 to December 2019. Study participants were 278 Aboriginal and Torres Strait Islander people presenting to an ED and investigated for suspected ACS. The main outcome measure was the proportion of patients with ACS at index presentation and differences in characteristics between those with and without ACS. RESULTS ACS at presentation was diagnosed in 38.1% of patients (n = 106). The mean age of patients with ACS was 53.5 years (SD 9.5) compared with 48.7 years (SD 12.1) in those without ACS (P = 0.001). Patients with ACS were more likely to be male (63.2% vs 39.0%, P < 0.001), smokers (70.6% vs 52.3%, P = 0.002), have diabetes (56.6% vs 38.4%, P = 0.003) and have renal impairment (24.5% vs 10.5%, P = 0.002). CONCLUSIONS Aboriginal and Torres Strait Islander patients with suspected ACS have a high burden of traditional cardiac risk factors, regardless of whether they are eventually diagnosed with ACS. These patients may benefit from assessment for coronary artery disease regardless of age at presentation.
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Affiliation(s)
- Laura Stephensen
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Katrina Starmer
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
- Royal Flying Doctor Service Cairns Base Cairns Queensland Australia
| | - Greg Starmer
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Richard Stone
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Robert Bonnin
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Anthony Brazzale
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Tileah Drahm‐Butler
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Virginia Campbell
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Tania Davis
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Elizabeth Mowatt
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Nathan Brown
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | - Karlie Proctor
- Cairns Hospital, Cairns Hinterland, Hospital and Health Service Cairns Queensland Australia
| | - Sarah Ashover
- Promoting Value‐Based Care in the Emergency Department Clinical Excellence Queensland, Queensland Health Brisbane Queensland Australia
| | - Tanya Milburn
- Promoting Value‐Based Care in the Emergency Department Clinical Excellence Queensland, Queensland Health Brisbane Queensland Australia
| | - Louise McCormack
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
| | | | - Michelle Gatton
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Ray Mahoney
- School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
- Australian e‐Health Research Centre Commonwealth Scientific and Industrial Research Organisation Canberra Australian Capital Territory Australia
- College of Medicine and Public Health Flinders University Adelaide South Australia Australia
| | - William Parsonage
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health Queensland University of Technology Brisbane Queensland Australia
| | - Louise Cullen
- Royal Brisbane and Women's Hospital Metro North Health Brisbane Queensland Australia
- Faculty of Medicine The University of Queensland Brisbane Queensland Australia
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Cullen L, Stephensen L, Greenslade J, Starmer K, Starmer G, Stone R, Bonnin R, Brazzale A, Drahm-Butler T, Campbell V, Davis T, Mowatt E, Brown NJ, Proctor K, Ashover S, Milburn T, McCormack L, Graves N, Parsonage W. Emergency Department Assessment of Suspected Acute Coronary Syndrome Using the IMPACT Pathway in Aboriginal and Torres Strait Islander People. Heart Lung Circ 2022; 31:1029-1036. [PMID: 35337734 DOI: 10.1016/j.hlc.2022.02.010] [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: 11/28/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The Improved Assessment of Chest pain Trial (IMPACT) pathway is an accelerated strategy for the assessment of emergency patients presenting with suspected acute coronary syndrome (ACS). The objective of this study was to report outcomes for Aboriginal and Torres Strait Islander patients deemed low-, intermediate-, or high-risk according to this pathway. DESIGN This was a prospective observational trial conducted between November 2017 and December 2019. SETTING Regional hospital in Far North Queensland. PARTICIPANTS Aboriginal and Torres Strait Islander people presenting to the Emergency Department with suspected ACS were asked to participate. Participants were stratified as low-, intermediate- or high-risk of ACS according to the IMPACT pathway. High-and intermediate risk patients were managed according to the IMPACT pathway. Management of low-risk patients included additional inpatient cardiac testing, which was not part of the original IMPACT pathway. MAIN OUTCOME MEASURES The primary outcome was acute coronary syndrome within 30-days. Secondary outcomes included length of stay and prevalence of objective testing. RESULTS A total of 155 participants were classified as either at low-risk (n=18 11.6%), intermediate-risk (n=87 56.1%), or high-risk (n=50 32.3%) of ACS. Thirty-day (30-day) ACS occurred in 29 (18.6%) patients, which included 26 (52.0%) high-risk patients and three (3.4%) intermediate-risk patients. No patients in the low-risk group were diagnosed with ACS during their index presentation or by 30-days. Median hospital length-of-stay was 11.9 hours (interquartile range [IQR] 5.3-20.2 hrs) for low- and 15.5 hours (IQR 5.9-29.2 hrs) for intermediate-risk patients. CONCLUSION The IMPACT pathway, which has been associated with reduced LOS in other settings, could be safely implemented for patients of Aboriginal and Torres Strait Islander origin, classifying two-thirds as low- or intermediate risk. However, a clinically significant proportion of Aboriginal and Torres Strait Islander patients experience cardiac events, which supports the need to provide early objective testing for coronary artery disease.
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Affiliation(s)
- Louise Cullen
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Qld, Australia.
| | - Laura Stephensen
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Metro North Hospital and Health Service, Queensland Health, Australia
| | - Jaimi Greenslade
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Qld, Australia
| | - Katrina Starmer
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Greg Starmer
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Richard Stone
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Robert Bonnin
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Anthony Brazzale
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | | | - Virginia Campbell
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Tania Davis
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Elizabeth Mowatt
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Nathan J Brown
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Karlie Proctor
- Cairns Hospital, Cairns - Gimuy, Waluburra Yidinji Country, Qld, Australia
| | - Sarah Ashover
- Metro North Hospital and Health Service, Queensland Health, Australia; PROV-ED, Clinical Excellence Queensland, Queensland Health, Australia
| | - Tanya Milburn
- Metro North Hospital and Health Service, Queensland Health, Australia; PROV-ED, Clinical Excellence Queensland, Queensland Health, Australia
| | - Louise McCormack
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia
| | | | - William Parsonage
- Royal Brisbane and Women's Hospital, Brisbane - Turrabul, Yugara Country, Qld, Australia; Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Qld, Australia
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Korol S, Wsol A, Reshetnik A, Krasyuk A, Marushchenko K, Puchalska L. Evaluation and Comparison of the STIMUL Extended and Simplified Risk Scores for Predicting Two-Year Death in Patients Following ST-Segment Elevation Myocardial Infarction. Medicina (B Aires) 2021; 57:medicina57121349. [PMID: 34946294 PMCID: PMC8707946 DOI: 10.3390/medicina57121349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/30/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The management of ST-segment elevation myocardial infarction (STEMI) requires a patient’s long-term risk to be estimated. The objective of this study was to develop extended and simplified models of two-year death risk estimation following STEMI that include and exclude cardiac troponins as prognostic factors and to compare their performance with each other. Materials and Methods: Extended and simplified multivariable logistic regression models were elaborated using 1103 patients with STEMI enrolled and followed up in the STIMUL (ST-segment elevation Myocardial Infarctions in Ukraine and their Lethality) registry. Results: The extended STIMUL risk score includes seven independent risk factors: age; Killip class ≥ II at admission; resuscitated cardiac arrest; non-reperfused infarct-related artery; troponin I ≥ 150.0 ng/L; diabetes mellitus; and history of congestive heart failure. The exclusion of cardiac troponin in the simplified model did not influence the predictive value of each factor. Both models divide patients into low, moderate, and high risk groups with a C-statistic of 0.89 (95% CI 0.84–0.93; p < 0.001) for the extended STIMUL model and a C-statistic of 0.86 (95% CI 0.83–0.99; p < 0.001) for the simplified model. However, the addition of the level of troponin I to the model increased its prognostic value by 10.7%. Conclusions: The STIMUL extended and simplified risk estimation models perform well in the prediction of two-year death risk following STEMI. The simplified version may be useful when clinicians do not know the value of cardiac troponins among the population of STEMI patients.
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Affiliation(s)
- Svitlana Korol
- Department of Military Therapy of the Ukrainian Military Medical Academy, 01015 Kyiv, Ukraine; (S.K.); (A.K.); (K.M.)
| | - Agnieszka Wsol
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-091 Warsaw, Poland;
- Correspondence: ; Tel.: +48-22-116-6113
| | - Alexander Reshetnik
- Department of Nephrology and Intensive Care Medicine, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Alexander Krasyuk
- Department of Military Therapy of the Ukrainian Military Medical Academy, 01015 Kyiv, Ukraine; (S.K.); (A.K.); (K.M.)
| | - Kateryna Marushchenko
- Department of Military Therapy of the Ukrainian Military Medical Academy, 01015 Kyiv, Ukraine; (S.K.); (A.K.); (K.M.)
| | - Liana Puchalska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-091 Warsaw, Poland;
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Ke J, Chen Y, Wang X, Wu Z, Chen F. Indirect comparison of TIMI, HEART and GRACE for predicting major cardiovascular events in patients admitted to the emergency department with acute chest pain: a systematic review and meta-analysis. BMJ Open 2021; 11:e048356. [PMID: 34408048 PMCID: PMC8375746 DOI: 10.1136/bmjopen-2020-048356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The study aimed to compare the predictive values of the thrombolysis in myocardial infarction (TIMI); History, Electrocardiography, Age, Risk factors and Troponin (HEART) and Global Registry in Acute Coronary Events (GRACE) scoring systems for major adverse cardiovascular events (MACEs) in acute chest pain (ACP) patients admitted to the emergency department (ED). METHODS We systematically searched PubMed, Embase and the Cochrane Library from their inception to June 2020; we compared the following parameters: sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), diagnostic OR (DOR) and area under the receiver operating characteristic curves (AUC). RESULTS The pooled sensitivity and specificity for TIMI, HEART and GRACE were 0.95 and 0.36, 0.96 and 0.50, and 0.78 and 0.56, respectively. The pooled PLR and NLR for TIMI, HEART and GRACE were 1.49 and 0.13, 1.94 and 0.08, and 1.77 and 0.40, respectively. The pooled DOR for TIMI, HEART and GRACE was 9.18, 17.92 and 4.00, respectively. The AUC for TIMI, HEART and GRACE was 0.80, 0.80 and 0.70, respectively. Finally, the results of indirect comparison suggested the superiority of values of TIMI and HEART to those of GRACE for predicting MACEs, while there were no significant differences between TIMI and HEART for predicting MACEs. CONCLUSIONS TIMI and HEART were superior to GRACE for predicting MACE risk in ACP patients admitted to the ED.
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Affiliation(s)
- Jun Ke
- Department of Emergency, Fujian Provincial Hospital, Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fuzhou, China
| | - Yiwei Chen
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Xiaoping Wang
- Department of Emergency, Fujian Provincial Hospital, Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fuzhou, China
| | - Zhiyong Wu
- Department of Cardiology, Fujian Provincial Hospital, Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, China
| | - Feng Chen
- Department of Emergency, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, China
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Huang Z, Wang K, Yang D, Gu Q, Wei Q, Yang Z, Zhan H. The predictive value of the HEART and GRACE scores for major adverse cardiac events in patients with acute chest pain. Intern Emerg Med 2021; 16:193-200. [PMID: 32451931 DOI: 10.1007/s11739-020-02378-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/13/2020] [Indexed: 12/26/2022]
Abstract
The history, electrocardiogram, age, risk factors, troponin (HEART) and global registry of acute coronary events (GRACE) scoring systems are commonly used to risk stratify patients with chest pain. This study investigated the application of these scores in predicting the short-term risk of a major adverse cardiac event (MACE) in patients with chest. A total of 509 patients were analyzed. All patients were followed up for 30 days after visiting our emergency department. At 30 days post-admission, the primary outcome (MACE) was recorded in 92 patients (18.1%), 88 (95.6%) of whom had experienced an acute myocardial infarction. Thirty-seven (40.2%) of the patients with a MACE underwent percutaneous coronary intervention and six patients (6.5%) died. The HEART and GRACE scores were both significantly higher in patients who developed a MACE than in those without (P < 0.05). The HEART and GRACE scores had c-statistic values of 0.811 (95% CI 0.774-0.844) and 0.648 (95% CI 0.603-0.688), respectively. The Hosmer-Lemeshow statistic revealed that the HEART and GRACE scores had values of 8.68 (P = 0.39) and 10.45 (P = 0.11), respectively. The percentages of patients with HEART scores of 0-3, 4-6, and 7-10 were 3.0%, 26.2%, and 46.3%, respectively, in those with a MACE within 30 days. The findings show that while both scoring systems are useful, the HEART score is superior to the GRACE score for predicting the occurrence of MACE within 30 days in patients with chest pain.
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Affiliation(s)
- Zhenhua Huang
- Department of Emergency Medicine, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China
| | - Keke Wang
- Department of Emergency Medicine, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China
| | - Daya Yang
- Department of Cardiology, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China
| | - Qianlin Gu
- Department of Emergency Medicine, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China
| | - Qiuxia Wei
- Department of Emergency Medicine, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China
| | - Zhen Yang
- Department of Emergency Medicine, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China.
| | - Hong Zhan
- Department of Emergency Medicine, The First Affiliated Hospital, Sun Yet-Sen University, 510080, Guangzhou, People's Republic of China.
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Ruangsomboon O, Thirawattanasoot N, Chakorn T, Limsuwat C, Monsomboon A, Praphruetkit N, Surabenjawong U, Riyapan S, Nakornchai T. The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients. Int J Cardiol 2020; 322:23-28. [PMID: 32882291 DOI: 10.1016/j.ijcard.2020.08.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/12/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients. METHODS A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures. RESULTS Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2-97.6%) and 97.2% (95%CI 93.2-98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8-85.2%) and 53.9% (95%CI 46.2-61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68-0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge. CONCLUSION The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.
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Affiliation(s)
- Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand.
| | - Netiporn Thirawattanasoot
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Chok Limsuwat
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Apichaya Monsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Nattakarn Praphruetkit
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Usapan Surabenjawong
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Tanyaporn Nakornchai
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
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An Updated Healthcare System-Wide Clinical Pathway for Managing Patients With Chest Pain and Acute Coronary Syndromes. Crit Pathw Cardiol 2020; 18:167-175. [PMID: 31725507 DOI: 10.1097/hpc.0000000000000189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical pathways reinforce best practices and help healthcare institutions standardize care delivery. The NewYork-Presbyterian/Columbia University Irving Medical Center has used such a pathway for the management of patients with chest pain and acute coronary syndromes for almost 2 decades. A multidisciplinary panel of stakeholders serially updates the algorithm according to new data and recently published guidelines. Herein, we present the 2019 version of the clinical pathway. We explain the rationale for changes to the algorithm and describe our experience expanding the pathway to all the 8 affiliated institutions within the NewYork Presbyterian healthcare system.
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Examining the translational success of an initiative to accelerate the assessment of chest pain for patients in an Australian emergency department: a pre-post study. BMC Health Serv Res 2020; 20:419. [PMID: 32404106 PMCID: PMC7222586 DOI: 10.1186/s12913-020-05296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 05/05/2020] [Indexed: 12/14/2022] Open
Abstract
Background The Improved assessment of chest pain trial (IMPACT) protocol is an accelerated strategy for the risk stratification and management of patients presenting to the emergency department (ED) with chest pain. This study sought to describe the adoption, sustainability and health services implications of implementing the IMPACT protocol. Methods This was a study of adult patients in a large Australian tertiary hospital who had serial troponin testing commenced within the ED. Data from two periods were utilized; the pre-implementation period (8th April 2012 to 5th April 2014) and the post-implementation period (6th April 2014 to 2nd April 2016). The primary outcome was the proportion of patients undergoing accelerated care. Secondary endpoints were ED assessment time, hospital length of stay, and costs. Data were compared in the pre- and post-implementation periods. Results The proportion of patients receiving accelerated care increased from 3% in the pre- to 34% in the post-intervention period. This increase occurred rapidly after implementation of IMPACT and was sustained over a 2-year period. For patients with troponin concentrations <99th percentile, the mean ED assessment time reduced from 12.3 h in the pre- to 10.1 h in the post-implementation period. Mean hospital length of stay was similar in the pre- and post-implementation periods (82.4 and 80.9 h). The average cost of chest pain assessment reduced from $3520 pre implementation to $3204 post implementation; a $316 reduction per patient. Conclusions The IMPACT protocol was rapidly adopted and utilised after implementation into standard care. The initial increase in the proportion of patients undergoing accelerated assessment, followed by a plateau towards the end of the study period indicate adoption and sustainability of the IMPACT protocol over a two-year period. Modest reductions in length of stay and cost were seen after implementation. Given the large number of patients investigated for chest pain, such reductions may have substantial impact on the overall healthcare system.
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Zheng W, Wang G, Ma J, Wu S, Zhang H, Zheng J, Xu F, Wang J, Chen Y. Evaluation and comparison of six GRACE models for the stratification of undifferentiated chest pain in the emergency department. BMC Cardiovasc Disord 2020; 20:199. [PMID: 32334528 PMCID: PMC7183650 DOI: 10.1186/s12872-020-01476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), while in hospital (IH), within 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). We aimed to perform the first comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACEs) in patients with acute chest pain in the emergency department (ED). Methods Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 from the EDs of two public hospitals in China. The 30-day MACEs included death, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest and cardiogenic shock. The correlation, calibration, discrimination, reclassification and diagnostic accuracy at certain cutoff values of six GRACE models were evaluated. Comparisons with the History, ECG, Age, Risk Factors, and Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores were conducted. Results A total of 2886 patients were analyzed, with 590 (20.4%) patients experiencing outcomes. The GRACE (IHDthMI), GRACE (IH6mDthMI), GRACE (IHDth), GRACE (IH6mDth), GRACE (OH6mDth) and GRACE (OH6mDthMI) showed positive linear correlations with the actual MACE rates (r ≥ 0.568, P < 0.001). All these models had good calibration (Hosmer-Lemeshow test, P ≥ 0.073) except GRACE (IHDthMI) (P < 0.001). The corresponding C-statistics were 0.83(0.81,0.84), 0.82(0.81,0.83), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71), respectively, first two of which were comparable to HEART (0.82, 0.80–0.83) and superior to TIMI (0.71, 0.69–0.73). With a sensitivity ≥95%, GRACE (IHDthMI) ≤81 and GRACE (IH6mDthMI) ≤79 identified 868(30%) and 821(28%) patients as low risk, respectively, which were significantly better than other GRACEs and HEART ≤3(22%). With a specificity ≥95%, GRACE (IHDthMI) > 186 and GRACE (IH6mDthMI) > 161 could recognize 12% and 11% patients as high risk, which were greater than other GRACEs, HEART ≥8(9%) and TIMI ≥5(8%). Conclusions In this Chinese setting, certain strengths of GRACE models beyond HEART and TIMI scores were still noteworthy for stratifying chest pain patients. The validation and reasonable application of appropriate GRACE models in the evaluation of undifferentiated chest pain should be recommended.
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Affiliation(s)
- Wen Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Guangmei Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jingjing Ma
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Shuo Wu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - He Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiali Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China. .,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China. .,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China. .,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China.
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Wu CC, Hsu WD, Wang YC, Kung WM, Tzeng IS, Huang CW, Huang CY, Li YC. An Innovative Scoring System for Predicting Major Adverse Cardiac Events in Patients With Chest Pain Based on Machine Learning. IEEE ACCESS 2020. [DOI: 10.1109/access.2020.3004405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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11
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12
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HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2019; 74:187-203. [DOI: 10.1016/j.annemergmed.2018.12.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 11/12/2018] [Accepted: 12/05/2018] [Indexed: 01/26/2023]
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13
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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.
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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,
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Moumneh T, Richard-Jourjon V, Friou E, Prunier F, Soulie-Chavignon C, Choukroun J, Mazet-Guilaumé B, Riou J, Penaloza A, Roy PM. Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients. Intern Emerg Med 2018; 13:1111-1119. [PMID: 29500619 DOI: 10.1007/s11739-018-1803-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 02/25/2018] [Indexed: 01/19/2023]
Abstract
In patients consulting in the Emergency Department for chest pain, a HEART score ≤ 3 has been shown to rule out an acute coronary syndrome (ACS) with a low risk of major adverse cardiac event (MACE) occurrence. A negative CARE rule (≤ 1) that stands for the first four elements of the HEART score may have similar rule-out reliability without troponin assay requirement. We aim to prospectively assess the performance of the CARE rule and of the HEART score to predict MACE in a chest pain population. Prospective two-center non-interventional study. Patients admitted to the ED for non-traumatic chest pain were included, and followed-up at 6 weeks. The main study endpoint was the 6-week rate of MACE (myocardial infarction, coronary angioplasty, coronary bypass, and sudden unexplained death). 641 patients were included, of whom 9.5% presented a MACE at 6 weeks. The CARE rule was negative for 31.2% of patients, and none presented a MACE during follow-up [0, 95% confidence interval: (0.0-1.9)]. The HEART score was ≤ 3 for 63.0% of patients, and none presented a MACE during follow-up [0% (0.0-0.9)]. With an incidence below 2% in the negative group, the CARE rule seemed able to safely rule out a MACE without any biological test for one-third of patients with chest pain and the HEART score for another third with a single troponin assay.
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Affiliation(s)
- Thomas Moumneh
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France.
| | | | - Emilie Friou
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | - Fabrice Prunier
- Institut MITOVASC, Service de Cardiologie, CHU d'Angers, Université d'Angers, Angers, France
| | - Caroline Soulie-Chavignon
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | | | - Betty Mazet-Guilaumé
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | - Jérémie Riou
- Unité de Formation-Recherche Santé, Université d'Angers, MINT INSERM, UMR 6021, Angers, France
| | - Andréa Penaloza
- Service de Médecine d'Urgence, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Pierre-Marie Roy
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
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15
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Zègre-Hemsey JK, Burke LA, DeVon HA. Patient-reported symptoms improve prediction of acute coronary syndrome in the emergency department. Res Nurs Health 2018; 41:459-468. [PMID: 30168588 DOI: 10.1002/nur.21902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 07/23/2018] [Indexed: 11/06/2022]
Abstract
Early diagnosis is critical in the management of patients with acute coronary syndrome (ACS), particularly ST-elevation myocardial infarction (STEMI), because effective therapies are time-dependent. Aims of this secondary analysis were to determine: (i) the prognostic value of symptoms for an ACS diagnosis in conjunction with electrocardiographic (ECG) and troponin results; and (ii) if any of 13 symptoms were associated with prehospital delay in those presenting to the emergency department (ED) with potential ACS. Patients receiving a cardiac evaluation in the ED were eligible for the study. Thirteen patient-reported symptoms were assessed in triage. Prehospital delay time was calculated as the time from symptom onset until registration in the ED. A total of 1,064 patients were enrolled in five EDs. The sample was 62% male, 70% white, and had a mean age of 60.2 years. Of 474 participants diagnosed with ACS, 118 (25%) had STEMI; 251 (53%) had non-ST elevation myocardial infarction (NSTEMI); and 105 (22%) had unstable angina. Sweating (OR = 1.42 CI [1.01, 2.00]) and shoulder pain (OR = 1.64 CI [1.13, 2.38]) added to the predictive value of an ACS diagnosis when combined with ECG and troponin results. Shortness of breath (OR = 0.71 CI [0.50, 1.00]) and unusual fatigue (OR = 0.60 CI [0.42, 0.84]) were predictive of a non-ACS diagnosis. Sweating predicted shorter prehospital delay (HR = 1.35, CI [1.10, 1.67]); shortness of breath (HR = 0.73 CI [0.60, 0.89]) and unusual fatigue (HR = 0.72, CI [0.57, 0.90]) were associated with longer prehospital delay. Patient-reported symptoms are significantly associated with ACS diagnoses and prehospital delay. Sweating and shoulder pain combined with ECG signs of ischemia may improve the timely detection of ACS in the ED.
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Affiliation(s)
- Jessica K Zègre-Hemsey
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Larisa A Burke
- Office of Research Facilitation, College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | - Holli A DeVon
- College of Nursing, Biobehavioral Health Sciences, University of Illinois at Chicago, Chicago, Illinois
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Greenslade JH, Chung K, Parsonage WA, Hawkins T, Than M, Pickering JW, Cullen L. Modification of the Thrombolysis in Myocardial Infarction risk score for patients presenting with chest pain to the emergency department. Emerg Med Australas 2017; 30:47-54. [PMID: 29232768 DOI: 10.1111/1742-6723.12913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/31/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop a modified Thrombolysis in Myocardial Infarction (TIMI) score to effectively risk stratify patients presenting to the ED with chest pain. METHODS A prospective observational study was conducted at two metropolitan EDs. Data were obtained during patient interview. The primary outcome was major adverse cardiovascular events (MACE) within 30 days of presentation. Two separate modifications of the TIMI score were developed. These scores were compared to the original TIMI in terms of the area under the receiver operating characteristic curve and diagnostic accuracy statistics (sensitivity, specificity, positive and negative predictive values). RESULTS Of 1760 patients, 364 (20.7%) experienced 30 day MACE. The first modified TIMI score was a simplified TIMI (s-TIMI) including four variables: age ≥65 years, three or more risk factors, high-sensitivity troponin (hs-cTnI) and electrocardiogram changes. The second score included the same four variables plus two Global Registry of Acute Coronary Events (GRACE) variables (systolic blood pressure and estimated glomerular filtration rate). This score was termed the GRACE TIMI (g-TIMI). s-TIMI had a lower sensitivity compared to the original TIMI score (93.41 and 96.98%), but higher specificity (45.49 and 24.50%). The g-TIMI had a sensitivity of 98.90% and specificity of 14.90%. CONCLUSIONS Attempts to modify the TIMI score yielded two scores with added predictive utility in comparison to the original TIMI model. The addition of GRACE variables (g-TIMI) increased sensitivity for MACE, but decreased the specificity of the model. The s-TIMI score yielded good specificity but had sensitivity that would not be acceptable by emergency physicians. The s-TIMI may be useful as part of an accelerated chest pain protocol.
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Affiliation(s)
- Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Kimberly Chung
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - William A Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Tracey Hawkins
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Martin Than
- Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Cullen L, Greenslade JH, Hawkins T, Hammett C, O'Kane S, Ryan K, Parker K, Schluter J, Dalton E, Brown AF, Than M, Peacock WF, Jaffe A, O'Rourke PK, Parsonage WA. Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes. Med J Aust 2017; 207:195-200. [PMID: 28987132 DOI: 10.5694/mja16.01351] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/21/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain. DESIGN, SETTING AND PARTICIPANTS IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS. INTERVENTION High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing. MAIN OUTCOME MEASURES The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS). RESULTS The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients. CONCLUSIONS The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12611000206921.
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Affiliation(s)
| | | | | | | | | | | | - Kate Parker
- Royal Brisbane and Women's Hospital, Brisbane, QLD
| | | | - Emily Dalton
- Royal Brisbane and Women's Hospital, Brisbane, QLD
| | | | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | - W Frank Peacock
- Baylor College of Medicine, Houston, TX, United States of America
| | - Allan Jaffe
- Mayo Clinic, Rochester, MN, United States of America
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Parsonage WA, Milburn T, Ashover S, Skoien W, Greenslade JH, McCormack L, Cullen L. Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project. Med J Aust 2017; 207:201-205. [PMID: 28987133 DOI: 10.5694/mja16.01479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/28/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain. DESIGN Quasi-experimental design, with interrupted time series analysis for the period October 2013 - November 2015. Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland. INTERVENTION Implementation of the ADP by structured clinical re-design. MAIN OUTCOME MEASURES Primary outcome: hospital LOS. SECONDARY OUTCOMES ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS). RESULTS Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74-0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72-0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3-78.5%) to 54.9% (95% CI, 44.7-67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions. CONCLUSIONS Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.
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Affiliation(s)
| | | | | | - Wade Skoien
- Royal Brisbane and Women's Hospital, Brisbane, QLD
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Integrating heart rate variability, vital signs, electrocardiogram, and troponin to triage chest pain patients in the ED. Am J Emerg Med 2017; 36:185-192. [PMID: 28743479 DOI: 10.1016/j.ajem.2017.07.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Current triage methods for chest pain patients typically utilize symptoms, electrocardiogram (ECG), and vital sign data, requiring interpretation by dedicated triage clinicians. In contrast, we aimed to create a quickly obtainable model integrating the objective parameters of heart rate variability (HRV), troponin, ECG, and vital signs to improve accuracy and efficiency of triage for chest pain patients in the emergency department (ED). METHODS Adult patients presenting to the ED with chest pain from September 2010 to July 2015 were conveniently recruited. The primary outcome was a composite of revascularization, death, cardiac arrest, cardiogenic shock, or lethal arrhythmia within 72-h of presentation to the ED. To create the chest pain triage (CPT) model, logistic regression was done where potential covariates comprised of vital signs, ECG parameters, troponin, and HRV measures. Current triage methods at our institution and modified early warning score (MEWS) were used as comparators. RESULTS A total of 797 patients were included for final analysis of which 146 patients (18.3%) met the primary outcome. Patients were an average age of 60years old, 68% male, and 56% triaged to the most acute category. The model consisted of five parameters: pain score, ST-elevation, ST-depression, detrended fluctuation analysis (DFA) α1, and troponin. CPT model>0.09, CPT model>0.15, current triage methods, and MEWS≥2 had sensitivities of 86%, 74%, 75%, and 23%, respectively, and specificities of 45%, 71%, 48%, and 78%, respectively. CONCLUSION The CPT model may improve current clinical triage protocols for chest pain patients in the ED.
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 205:128-33. [PMID: 27465769 DOI: 10.5694/mja16.00368] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/10/2016] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 25:895-951. [PMID: 27465769 DOI: 10.1016/j.hlc.2016.06.789] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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Roche TE, Gardner G, Jack L. The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study. BMC Health Serv Res 2017; 17:445. [PMID: 28655309 PMCID: PMC5488347 DOI: 10.1186/s12913-017-2395-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 06/16/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities. METHODS This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care. RESULTS The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models. CONCLUSIONS There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).
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Affiliation(s)
- Tina E. Roche
- School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059 Australia
- Queensland University of Technology, Institute of Health and Biomedical Innovation Victoria Park Road, Victoria Park Road, Kelvin Grove, QLD 4059 Australia
- Emergency Department, Stanthorpe Health Services, PO Box 273, Stanthorpe, QLD 4380 Australia
| | - Glenn Gardner
- Queensland University of Technology, Institute of Health and Biomedical Innovation Victoria Park Road, Victoria Park Road, Kelvin Grove, QLD 4059 Australia
- Emergency Department, Stanthorpe Health Services, PO Box 273, Stanthorpe, QLD 4380 Australia
| | - Leanne Jack
- Queensland University of Technology, School of Nursing Victoria Park Road, Kelvin Grove, QLD 4059 Australia
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Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores. Am J Emerg Med 2017; 35:704-709. [DOI: 10.1016/j.ajem.2017.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/02/2016] [Accepted: 01/02/2017] [Indexed: 12/26/2022] Open
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Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol 2017; 227:656-661. [DOI: 10.1016/j.ijcard.2016.10.080] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 10/28/2016] [Indexed: 02/06/2023]
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Wang H, Watson K, Robinson RD, Domanski KH, Umejiego J, Hamblin L, Overstreet SE, Akin AM, Hoang S, Shrivastav M, Collyer M, Krech RN, Schrader CD, Zenarosa NR. Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit. Crit Pathw Cardiol 2016; 15:145-151. [PMID: 27846006 DOI: 10.1097/hpc.0000000000000090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare and evaluate the performance of the HEART, Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI) scores to predict major adverse cardiac event (MACE) rates after index placement in an emergency department observation unit (EDOU) and to determine the need for observation unit initiation of emergent cardiac imaging tests, that is, noninvasive cardiac stress tests and invasive coronary angiography. METHODS A prospective observational single center study was conducted from January 2014 through June 2015. EDOU chest pain patients were included. HEART, GRACE, and TIMI scores were categorized as low (HEART ≤ 3, GRACE ≤ 108, and TIMI ≤1) versus elevated based on thresholds suggested in prior studies. Patients were followed for 6 months postdischarge. The results of emergent cardiac imaging tests, EDOU length of stay (LOS), and MACE occurrences were compared. Student t test was used to compare groups with continuous data, and χ testing was used for categorical data analysis. RESULTS Of 986 patients, emergent cardiac imaging tests were performed on 62%. A majority of patients were scored as low risk by all tools (85% by HEART, 81% by GRACE, and 80% by TIMI, P < 0.05). The low-risk patients had few abnormal cardiac imaging test results as compared with patients scored as intermediate to high risk (1% vs. 11% in HEART, 1% vs. 9% in TIMI, and 2% vs. 4% in GRACE, P < 0.05). The average LOS was 33 hours for patients with emergent cardiac imaging tests performed and 25 hours for patients without (P < 0.05). MACE occurrence rate demonstrated no significant difference regardless of whether tests were performed emergently (0.31% vs. 0.97% in HEART, 0.27% vs. 0.95% in TIMI, and 0% vs. 0.81% in GRACE, P > 0.05). CONCLUSIONS Chest pain risk stratification via clinical decision tool scores can minimize the need for emergent cardiac imaging tests with less than 1% MACE occurrence, especially when the HEART score is used.
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Affiliation(s)
- Hao Wang
- From the *Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX; †Department of Emergency Medicine, Parkland Health and Hospital System, Dallas, TX; ‡Division of Emergency and Disaster Global Health, Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX; §Department of Emergency Medicine, Texas Health Huguley Hospital, Burleson, TX; ¶Texas College of Osteopathic Medicine, UNT Health Science Center, Fort Worth, TX; and ‖Research Institute, John Peter Smith Health Network, Fort Worth, TX
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Sakamoto JT, Liu N, Koh ZX, Fung NXJ, Heldeweg MLA, Ng JCJ, Ong MEH. Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department. Int J Cardiol 2016; 221:759-64. [DOI: 10.1016/j.ijcard.2016.07.147] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/09/2016] [Indexed: 02/07/2023]
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Roche T, Jennings N, Clifford S, O'connell J, Lutze M, Gosden E, Hadden NF, Gardner G. Review article: Diagnostic accuracy of risk stratification tools for patients with chest pain in the rural emergency department: A systematic review. Emerg Med Australas 2016; 28:511-24. [DOI: 10.1111/1742-6723.12622] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 05/03/2016] [Accepted: 05/11/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Tina Roche
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane Queensland Australia
- Emergency Department, Stanthorpe Health Services; Brisbane Queensland Australia
| | - Natasha Jennings
- Emergency and Trauma Centre; The Alfred; Melbourne Victoria Australia
| | - Stuart Clifford
- Emergency Department, Mudgee Health Service; Sydney New South Wales Australia
| | - Jane O'connell
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane Queensland Australia
| | - Matthew Lutze
- Emergency Department; St George Hospital; Sydney New South Wales Australia
- School of Nursing, The University of Sydney; Sydney New South Wales Australia
| | - Edward Gosden
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane Queensland Australia
| | - N Fionna Hadden
- Emergency Department, Stanthorpe Health Services; Brisbane Queensland Australia
| | - Glenn Gardner
- Institute of Health and Biomedical Innovation; Queensland University of Technology; Brisbane Queensland Australia
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Greek Acute Coronary Syndrome Score for the Prediction of In-hospital and 30-Day Mortality of Patients With an Acute Coronary Syndrome. J Cardiovasc Nurs 2016; 30:456-63. [PMID: 25203239 DOI: 10.1097/jcn.0000000000000187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Risk evaluation of patients hospitalized with acute coronary syndrome (ACS) may contribute to their short-term prognosis improvement. The aim of this work was to develop a prediction index (score) for the risk assessment of 30-day death of ACS patients, using clinical and biological measurements at hospital admission. METHODS A sample of 6 Greek hospitals was selected, and almost all consecutive 2172 ACS patients from October 2003 to September 2004 were enrolled. Sociodemographic, biochemical, clinical, and lifestyle characteristics were recorded. Using as components age, systolic blood pressure, white blood cell count, creatine kinase-MB, and creatinine levels at the time of admission and the time between the onset of symptoms and presentation at hospital, a risk score (Greek Acute Coronary Syndrome score; range, 6-36) was developed and tested against in-hospital and 30-day outcome of the patients. RESULTS The Greek Acute Coronary Syndrome score showed strong discriminating ability for in-hospital mortality (area under the receiver operating characteristic curve, 0.812; 95% confidence interval, 0.750-0.874; P < .001) and 30-day death after hospitalization (area under the receiver operating characteristic curve, 0.720; 95% confidence interval, 0.724-0.837; P < .001). The optimal value of the score, which discriminates those who will die in-hospital from survivors, was 24, and that for those who will die within 30 days after discharge was 22. The score's classification ability was confirmed using 100 bootstrap samples and remained similar among several subgroups of patients (younger or older, men or women, type of ACS, and diabetes status). CONCLUSIONS The suggested risk score using routinely collected clinical and biological data may be a useful tool in clinical practice for decision making regarding further management, not only during hospitalization but also in the postdischarge period.
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Nikolaou N, Arntz H, Bellou A, Beygui F, Bossaert L, Cariou A. Das initiale Management des akuten Koronarsyndroms. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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30
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Collinson P. High-sensitivity troponin measurements: challenges and opportunities for the laboratory and the clinician. Ann Clin Biochem 2015; 53:191-5. [DOI: 10.1177/0004563215619946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Paul Collinson
- Departments of Clinical Blood Sciences and Cardiology, St George’s Hospital and Medical School, London, UK
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Sawyer KN, Shah P, Qu L, Kurz MC, Clark CL, Swor RA. Triple Rule Out versus CT Angiogram Plus Stress Test for Evaluation of Chest Pain in the Emergency Department. West J Emerg Med 2015; 16:677-82. [PMID: 26587090 PMCID: PMC4644034 DOI: 10.5811/westjem.2015.6.25958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/01/2015] [Accepted: 06/30/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Undifferentiated chest pain in the emergency department (ED) is a diagnostic challenge. One approach includes a dedicated chest computed tomography (CT) for pulmonary embolism or dissection followed by a cardiac stress test (TRAD). An alternative strategy is a coronary CT angiogram with concurrent chest CT (Triple Rule Out, TRO). The objective of this study was to describe the ED patient course and short-term safety for these evaluation methods. Methods This was a retrospective observational study of adult patients presenting to a large, community ED for acute chest pain who had non-diagnostic electrocardiograms (ECGs) and normal biomarkers. We collected demographics, ED length of stay, hospital costs, and estimated radiation exposures. We evaluated 30-day return visits for major adverse cardiac events. Results A total of 829 patients underwent TRAD, and 642 patients had TRO. Patients undergoing TRO tended to be younger (mean 52.3 vs 56.5 years) and were more likely to be male (42.4% vs. 30.4%). TRO patients tended to have a shorter ED length of stay (mean 14.45 vs. 21.86 hours), to incur less cost (median $449.83 vs. $1147.70), and to be exposed to less radiation (median 7.18 vs. 16.6mSv). No patient in either group had a related 30-day revisit. Conclusion Use of TRO is feasible for assessment of chest pain in the ED. Both TRAD and TRO safely evaluated patients. Prospective studies investigating this diagnostic strategy are needed to further assess this approach to ED chest pain evaluation.
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Affiliation(s)
- Kelly N Sawyer
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Payal Shah
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Lihua Qu
- William Beaumont Hospital, Research Institute Center for Outcomes Research, Royal Oak, Michigan
| | - Michael C Kurz
- University of Alabama School of Medicine, Department of Emergency Medicine, Birmingham, Alabama
| | - Carol L Clark
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
| | - Robert A Swor
- William Beaumont Hospital, Department of Emergency Medicine, Royal Oak, Michigan
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Nikolaou NI, Arntz HR, Bellou A, Beygui F, Bossaert LL, Cariou A, Danchin N. European Resuscitation Council Guidelines for Resuscitation 2015 Section 8. Initial management of acute coronary syndromes. Resuscitation 2015; 95:264-77. [DOI: 10.1016/j.resuscitation.2015.07.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Cullen L, Greenslade J, Merollini K, Graves N, Hammett CJ, Hawkins T, Than MP, Brown AF, Huang CB, Panahi SE, Dalton E, Parsonage WA. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust 2015; 202:427-32. [DOI: 10.5694/mja14.00472] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 02/05/2015] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Emily Dalton
- Royal Brisbane and Women's Hospital, Brisbane, QLD
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Utility of Routine Exercise Stress Testing among Intermediate Risk Chest Pain Patients Attending an Emergency Department. Heart Lung Circ 2015; 24:879-84. [PMID: 25991394 DOI: 10.1016/j.hlc.2015.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 03/25/2015] [Accepted: 03/27/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND To assess the utility of routine exercise stress testing (EST) in patients at intermediate risk of acute coronary syndrome (ACS) according to the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (HFA/CSANZ) guidelines. METHOD Prospective observational study of patients presenting to the Emergency Department (ED) with chest pain suggestive of ACS between November 2008 and July 2014. Participants included 1205 patients who presented to the ED with chest pain suggestive of ACS and who met the HFA/CSANZ intermediate risk criteria. The outcome was diagnosis of ACS occurring on presentation or within 30 days of presentation to the ED. ACS included acute myocardial infarction and unstable angina pectoris. RESULTS Twenty (1.66%) of the intermediate risk patients were diagnosed with ACS. Of the 777 patients who underwent EST, eight had ACS. EST identified all ACS cases except for one patient with a negative test, who was ultimately diagnosed with ACS following angiography. 164 patients deemed inappropriate to undergo EST underwent an alternative form of objective testing, of which 12 were positive for ACS. 264 patients underwent no objective testing. CONCLUSION EST stratifies intermediate risk patients to a near zero short-term risk of ACS. However, the overall yield of EST within this group of patients is extremely low. Intermediate risk patients with normal zero and six hour biomarkers have a very low probability of ACS, and over half of these patients ultimately diagnosed with ACS in this group were deemed unsuitable for EST anyway. Future research should focus on the identification of patients who do not require EST and the inclusion of routine EST within the HFA/CSANZ guidelines should be reconsidered.
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Scott AC, Bilesky J, Lamanna A, Cullen L, FT Brown A, Denaro C, Parsonage W. Limited utility of exercise stress testing in the evaluation of suspected acute coronary syndrome in patients aged less than 40 years with intermediate risk features. Emerg Med Australas 2014; 26:170-6. [DOI: 10.1111/1742-6723.12222] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2013] [Indexed: 01/23/2023]
Affiliation(s)
- Adam C Scott
- Department of Cardiology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- School of Public Health; Queensland University of Technology; Brisbane Queensland Australia
| | - Jennifer Bilesky
- Department of Emergency Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Arvin Lamanna
- Department of Cardiology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - Louise Cullen
- School of Public Health; Queensland University of Technology; Brisbane Queensland Australia
- Department of Emergency Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - Anthony FT Brown
- Department of Emergency Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- School of Medicine; University of Queensland; Brisbane Queensland Australia
| | - Charles Denaro
- Department of Internal Medicine; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - William Parsonage
- Department of Cardiology; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
- School of Medicine; University of Queensland; Brisbane Queensland Australia
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Burkett E, Marwick T, Thom O, Kelly AM. A comparative analysis of risk stratification tools for emergency department patients with chest pain. Int J Emerg Med 2014; 7:10. [PMID: 24506937 PMCID: PMC3922183 DOI: 10.1186/1865-1380-7-10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/29/2014] [Indexed: 11/17/2022] Open
Abstract
Background Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). Methods This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Results Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi2 (3) = 67.21, N = 276, p < 0.0001]. Conclusion The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.
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Affiliation(s)
| | | | | | - Anne-Maree Kelly
- School of Public Health, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
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