Evaluation of the patient with acute chest pain

A prospective observational study on the efficacy of procalcitonin as a diagnostic test to exclude lower urinary tract infection and to minimize antibiotic overuse

Background

Urinary tract infection (UTI) stands out as the third-most common infection following gastrointestinal and respiratory tract infections. Over the past decade, the biomarker procalcitonin (PCT) has gained prominence to facilitate the detection of bacterial infections and reduce excessive antibiotic exposure.

Objective

The objective of this study was to mitigate the overuse of antibiotics, by promoting the noninitiation or early discontinuation of empirical antibiotics, which would significantly help minimize the proliferation of multidrug-resistant bacteria.

Methodology

A prospective observational study was carried out at the tertiary care center in the Department of General Medicine of Kalinga Institute of Medical Sciences, Bhubaneswar, involving 200 patients with symptoms of lower UTI such as increased frequency, urgency, burning micturition, retention, and suprapubic tenderness with or without positive urinalysis. Detailed demographic profiles along with symptoms at the time of admission were recorded in a pretested structured format. To determine a positive diagnosis of UTI, signs and symptoms of UTI with or without urinary cultures were tested. The PCT level was estimated using enhanced chemiluminescence technique. Other routine tests such as complete blood count, renal function test, liver function test, urine routine microscopy, culture, chest X-ray, and ultrasonography abdomen pelvis were done and recorded. All patients, who had an initial serum PCT level of < 0.5 ng/mL, were kept under observation with only conservative and symptomatic treatments. Patients were further reviewed for improvement in symptoms and repeat urine microscopy. All patients, who had an initial serum PCT level of > 0.5 ng/mL, were initiated with antibiotics as per the culture and sensitivity reports. Patients were followed up for improvement in symptoms with reports of repeated urinalysis.

Results

Our study reported the fact that 9.5% of the patients with initial serum PCT ≥ 0.5 ng/mL showed no improvement in symptoms despite starting antibiotics while significantly higher number of symptomatic patients (60%) with initial serum PCT < 0.5 ng/ml showed improvement in symptoms with conservative treatment without antibiotics.

Conclusion

A lower PCT level rules out bacterial invasion and thus can be used as a novel marker in antibiotic stewardship.

Pre-hospital rule-out of non-ST-segment elevation acute coronary syndrome by a single troponin: final one-year outcomes of the ARTICA randomised trial

BACKGROUND AND AIMS

The healthcare burden of acute chest pain is enormous. In the randomised ARTICA trial we showed that pre-hospital identification of low-risk patients and rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with point-of-care (POC) troponin measurement reduces 30-day healthcare costs with low major adverse cardiac events (MACE) incidence. Here we present the final one-year results of the ARTICA trial.

METHODS

Low-risk patients with suspected NSTE-ACS were randomised to pre-hospital rule-out with POC troponin measurement or emergency department (ED) transfer. Primary one-year outcome was healthcare costs. Secondary outcomes were safety, quality of life (QoL) and cost-effectiveness. Safety was defined as one-year MACE, consisting of ACS, unplanned revascularisation or all-cause death. QoL was measured with EuroQol-5D-5 L questionnaires. Cost-effectiveness was defined as one-year healthcare costs difference per QoL difference.

RESULTS

Follow-up was completed in all 863 patients. Healthcare costs were significantly lower in the pre-hospital strategy (€1932±€2784 vs €2649±€2750), mean difference €717 (95% confidence interval [CI] €347 to €1087; P < 0.001). In the total population, one-year MACE rate was comparable between groups (5.1% [22/434] in the pre-hospital strategy vs 4.2% [18/429] in the ED strategy; P = 0.54). In the ruled-out ACS population, one-year MACE remained low (1.7% [7/419] vs 1.4% [6/417]), risk difference 0.2% (95% CI -1.4% to 1.9%; P = 0.79). QoL showed no significant difference between strategies.

CONCLUSIONS

Pre-hospital rule-out of NSTE-ACS with POC troponin testing in low-risk patients is cost-effective, expressed by a sustainable healthcare costs reduction and no significant effect on QoL. One-year MACE remained low for both strategies. Trial registration: Clinicaltrials.gov: NCT05466591, International Clinical Trials Registry Platform: NTR7346.

Endothelial function predicts 5-year adverse outcome in patients hospitalized in an emergency department chest pain unit

BACKGROUND

Although endothelial function is a marker for cardiovascular risk, endothelial dysfunction assessment is not routinely used in daily clinical practice. A growing challenge has emerged in identifying patients prone to cardiovascular events. We aim to investigate whether abnormal endothelial function may be associated with adverse 5-year outcomes in patients presenting to a chest pain unit (CPU).

METHODS

Following endothelial function testing using EndoPAT 2000 in 300 consecutive patients without a history of coronary artery disease, patients underwent coronary computerized tomographic angiography (CCTA) or single-photon emission computed tomography according to availability.

RESULTS

Mean 10-year Framingham risk score (FRS) was 6.6 ± 5.9%; mean 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 7.1 ± 7.2%; median reactive hyperemia index (RHI) as a measure of an endothelial function 2.0 and mean was 2.0 ± 0.4. During a 5-year follow-up, the 30 patients who developed major adverse cardiovascular events (MACE), including all-cause mortality, nonfatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting, and percutaneous coronary interventions, had higher 10-year FRS (9.6 ± 7.8 vs. 6.3 ± 5.6%; P  = 0.032), higher 10-year ASCVD risk (10.4 ± 9.2 vs. 6.7 ± 6.9%; P  = 0.042), lower baseline RHI (1.6 ± 0.5 vs. 2.1 ± 0.4; P  < 0.001) and a greater degree of coronary atherosclerotic lesions (53 vs. 3%, P  < 0.001) on CCTA compared with patients without MACE. Multivariate analysis demonstrated that RHI below the median was an independent predictor of 5-year MACE (odds ratio 5.567, 95% confidence interval 1.955-15.853; P  = 0.001).

CONCLUSION

Our findings suggest that noninvasive endothelial function testing may contribute to clinical efficacy in triaging patients in the CPU and in predicting 5-year MACE.

CLINICAL TRIALSGOV IDENTIFIER

NCT01618123.

The D-Dimer to Troponin Ratio Is a Novel Marker for the Differential Diagnosis of Thoracic Acute Aortic Syndrome from Non-ST Elevation Myocardial Infarction

BACKGROUND

Thoracic acute aortic syndrome (AAS) and non-ST elevation myocardial infarction (NSTEMI) have similar clinical presentations, making them difficult to differentiate. This study aimed to identify useful biomarkers for the differential diagnosis of thoracic AAS and NSTEMI.

METHODS

This was a retrospective observational study.

PARTICIPANTS

consecutive adult patients who visited the emergency department for acute chest pain between January 2015 and December 2021 diagnosed with thoracic AAS or NSTEMI. Clinical variables, including D-dimer (μg/mL) and high-sensitivity troponin T (ng/mL, hs-TnT) levels, were compared between the groups.

RESULTS

A total of 52 (30.1%) and 121 (69.9%) patients were enrolled in the thoracic AAS and NSTEMI groups, respectively. Logistic regression analysis revealed that the D-dimer to hs-TnT (D/T) ratio (odds ratio (OR), 1.038; 95% confidence interval (CI), 1.020-1.056; p < 0.001) and the thrombolysis in myocardial infarction (TIMI) score (OR, 0.184; 95% CI, 0.054-0.621; p = 0.006) were associated with thoracic AAS. The D/T ratio had an area under the receiver operating characteristic curve (AUC) of 0.973 (95% CI, 0.930-0.998), and the optimal cutoff value was 81.3 with 91.4% sensitivity and 96.2% specificity. The TIMI score had an AUC of 0.769 (95% CI, 0.644-0.812), and the optimal cutoff value was 1.5 with 96.7% sensitivity and 38.5% specificity.

CONCLUSION

the D/T ratio may be a simple and useful parameter for differentiating thoracic AAS from NSTEMI.

Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial

AIMS

Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care (POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients.

METHODS AND RESULTS

This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 [95% confidence interval (CI): 353-869; P < 0.001]. In the total population, MACE were comparable between groups [3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89]. In the ruled-out ACS population, MACE were very low [0.5% (2/419) vs. 1.0% (4/417)], with a risk difference of -0.5% (95% CI -1.6%-0.7%; P = 0.41) in favour of the pre-hospital strategy.

CONCLUSION

Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346.

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

BACKGROUND

More than half of the world's population lives in Asia. With current life expectancies in Asian countries, the burden of cardiovascular disease is increasing exponentially. Overcrowding in the emergency departments (ED) has become a public health problem. Since 2015, the European Society of Cardiology recommends the use of a 0/1-h algorithm based on high-sensitivity cardiac troponin (hs-cTn) for rapid triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, these algorithms are currently not recommended by Asian guidelines due to the lack of suitable data.

METHODS

The DROP-Asian ACS is a prospective, stepped wedge, cluster-randomized trial enrolling 4260 participants presenting with chest pain to the ED of 12 acute care hospitals in five Asian countries (UMIN; 000042461). Consecutive patients presenting with suspected acute coronary syndrome between July 2022 and Apr 2024 were included. Initially, all clusters will apply "usual care" according to local standard operating procedures including hs-cTnT but not the 0/1-h algorithm. The primary outcome is the incidence of major adverse cardiac events (MACE), the composite of all-cause death, myocardial infarction, unstable angina, or unplanned revascularization within 30 days. The difference in MACE (with one-sided 95% CI) was estimated to evaluate non-inferiority. The non-inferiority margin was prespecified at 1.5%. Secondary efficacy outcomes include costs for healthcare resources and duration of stay in ED.

CONCLUSIONS

This study provides important evidence concerning the safety and efficacy of the 0/1-h algorithm in Asian countries and may help to reduce congestion of the ED as well as medical costs.

Triple rule-out computed tomography angiography: Evaluation of acute chest pain in COVID-19 patients in the emergency department

BACKGROUND

The aim of this study was to define clinical evidence supporting that triple rule-out computed tomography angiography (TRO CTA) is a comprehensive and feasible diagnostic tool in patients with novel coronavirus disease 2019 (COVID-19) who were admitted to the emergency department (ED) for acute chest pain. Optimizing diagnostic imaging strategies in COVID-19 related thromboembolic events, will help for rapid and noninvasive diagnoses and results will be effective for patients and healthcare systems in all aspects.

AIM

To define clinical evidence supporting that TRO CTA is a comprehensive and feasible diagnostic tool in COVID-19 patients who were admitted to the ED for acute chest pain, and to assess outcomes of optimizing diagnostic imaging strategies, particularly TRO CTA use, in COVID-19 related thromboembolic events.

METHODS

TRO CTA images were evaluated for the presence of coronary artery disease, pulmonary thromboembolism (PTE), or acute aortic syndromes. Statistical analyses were used for evaluation of significant association between the variables. A two tailed P-value < 0.05 was considered statistically significant.

RESULTS

Fifty-three patients were included into the study. In 31 patients (65.9%), there was not any pathology, while PTE was diagnosed in 11 patients. There was no significant relationship between the rates of pathology on CTA and history of hypertension. On the other hand, the diabetes mellitus rate was much higher in the acute coronary syndrome group, particularly in the PTE group (8/31 = 25.8% vs 6/16 = 37.5%, P = 0.001). The rate of dyslipidemia was significantly higher in the group with pathology on CTA while compared to those without pathology apart from imaging findings of the pneumonia group (62.5% vs 38.7%, P < 0.001). Smoking history rates were similar in the groups. Platelets, D-dimer, fibrinogen, C-reactive protein, and erythrocyte sedimentation rate values were higher in COVID-19 cases with additional pathologies.

CONCLUSION

TRO CTA is an effective imaging method in evaluation of all thoracic vascular systems at once and gives accurate results in COVID-19 patients.

The prognostic implications of ST-segment and T-wave abnormalities in patients undergoing regadenoson stress SPECT myocardial perfusion imaging

BACKGROUND

The prognostic implications of ST-segment and T-wave (ST/T) abnormalities in patients undergoing stress SPECT-myocardial perfusion imaging (MPI) are not well defined.

METHODS AND RESULTS

This was a single-center, retrospective cohort study of consecutive patients who underwent regadenoson stress SPECT-MPI. Patients with baseline electrocardiogram (ECG) abnormalities that impede ST/T analysis or those with known coronary artery disease were excluded. Patients were categorized as having primary ST abnormalities, secondary ST/T abnormalities due to ventricular hypertrophy or right bundle branch block, T-wave abnormalities, or normal ECG. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of cardiac death or myocardial infarction. Among 6,059 subjects, 1912 (32%) had baseline ST/T abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST/T abnormalities compared to those with normal ECG (HR 2.05; 95% confidence interval [CI], 1.04-4.05; P = 0.039). No significant difference in MACE was observed among patients with primary ST abnormalities (HR 1.64; CI 0.87-3.06; P = 0.124) or T-wave abnormalities (HR 1.15; CI 0.62-2.16; P = 0.658) compared with patients who had normal ECG. Among patients with secondary ST/T changes, abnormal MPI was not associated with a significant increase in MACE rates compared to normal MPI (HR 1.18; CI 0.31-4.58; P = 0.808). However, abnormal MPI was associated with higher MACE rates among patients with primary ST abnormalities (HR 4.50; CI 1.44-14.10; P = 0.005) and T-wave abnormalities (HR 3.74; CI 1.20-11.68; P = 0.015). Similarly, myocardial ischemia on regadenoson stress SPECT-MPI was not associated with a significant increase in MACE rates in patients with secondary ST/T abnormalities (HR 1.45; CI 0.38-5.61; P = 0.588), while it was associated with a higher incidence of MACE in patients with primary ST abnormalities (HR 3.012; CI 0.95-9.53; P = 0.049) and T-wave abnormalities (HR 5.06; CI 1.60-15.96; P = 0.002).

CONCLUSION

While patients with secondary ST/T abnormalities had significantly higher MACE risk, abnormal MPI or presence of myocardial ischemia on regadenoson SPECT-MPI in this group does not add prognostic information. Patients with primary ST abnormalities and T-wave abnormalities do not seem to have a significantly higher MACE risk compared to those with normal ECG; however, abnormal MPI or presence of myocardial ischemia, in these groups, correlates with higher MACE rates.

A New Risk Score for Patients With Acute Chest Pain and Normal High Sensitivity Troponin

Objective: To investigate a new risk score for patients who suffered from acute chest pain with normal high-sensitivity troponin I (hs-TnI) levels.

Methods: In this study, patients with acute chest pain who were admitted to the emergency department (ED) of our hospital had been recruited. Hs-TnI was measured in serum samples drawn on admission to the ED. The end point was the occurrence of major adverse cardiac events (MACE) within 3 months. Predictor variables were selected by logistic regression analysis, and external validity was assessed in this study. Furthermore, validation was performed in an independent cohort, i.e., 352 patients (validation cohort).

Results: A total of 724 patients were included in the derivation cohort. The results showed that four predictor variables were significant in the regression analysis—male, a history of chest pain, 60 years of age or older and with three or more coronary artery disease (CAD) risk factors. A total of 105 patients in the validation cohort had serious adverse cardiac events. The validation cohort showed a homogenous pattern with the derivation cohort when patients were stratified by score. The area under the curve (AUC) of the receiver operating characteristic (ROC) in the derivation cohort was 0.80 (95% CI: 0.76–0.83), while in the validation cohort, it was 0.79 (95% CI: 0.75–0.82).

Conclusion: A new risk score was developed for acute chest pain patients without known CAD and ST-segment deviation and with normal hs-TnI and may aid MACE risk assessment and patient triage in the ED.

Double rule-out technique for evaluation of acute chest pain using 128-row multidetector CT

AIM

To evaluate the feasibility and image quality of the double rule-out (DRO) technique using 128-row multidetector computed tomography (CT) for simultaneous evaluation of the aorta and coronary arteries in patients with acute non-specific chest pain.

MATERIALS AND METHODS

Sixty-eight patients underwent electrocardiography (ECG)-gated coronary CT followed by non-ECG-gated abdominal CT. The contrast-to-noise ratio and signal-to-noise ratio between the vessels and adjacent perivascular fat tissue were calculated for both the aorta and coronary arteries. Dose-length products were recorded. Two blinded readers graded the image quality of the aorta and coronary arteries on a two-point and a four-point scale, respectively. In addition, the severity of coronary stenosis was independently analysed for each coronary vessel.

RESULTS

The average attenuation was more than 350 HU for the aorta and >330 HU for the coronary arteries. The average (±standard deviation) volume of contrast media was 69.5 ± 12.5 ml. Interobserver agreement on the image quality of aortic and coronary data sets was perfect and substantial, respectively. There was almost perfect interobserver agreement for the all observations of the severity of coronary stenosis.

CONCLUSION

The DRO technique with a standard volume (approximately 70 ml) of contrast media is useful for acute chest pain evaluation in patients suspected of having acute aortic syndrome or acute coronary syndrome. It is also accurate and safe while maintaining the average CT attenuation of the aorta and coronary arteries >330 HU.

Improving Communication with Patients Discharged from the Emergency Department with Noncardiac Chest Pain: A Scoping Review with Narrative Synthesis

Background

This scoping review with narrative synthesis aimed to analyze scholarly peer-reviewed articles reporting on improving communication with patients discharged from the emergency department with noncardiac chest pain and qualitatively narrate on and summarize items that can be used in guiding communication with patients discharged from the emergency department with noncardiac chest pain.

Methods

The databases of EMBASE/PubMed, Scopus, COCHRANE, CInAHL/EBESCO, UW libraries, and Google Scholar were searched using relevant MeSH and key terms up to February 06, 2020. The selected articles were analyzed for their contents. Items guiding discharge communication were summarized qualitatively.

Results

Twenty-five articles were eligible for full review. These were published in between 1994 and 2020. Of those, 16 (64.0%) originated from the United States and 4 (16%) used some interventional design. A total of 45 different items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain were identified from the studies included in this review. Items were grouped under 6 categories that were related to initial assessment (8 items), information on diagnosis (7 items), information on discharge (9 items), follow-up suggestions (7 items), symptoms that promote return to the emergency department (7 items), and treatment plan (7 items).

Conclusion

Communication with patients discharged from the emergency department with noncardiac chest pain can be improved. Results of this investigation might be helpful in guiding quality improvement projects aimed for further improvement of communication with patients discharged from the emergency department with noncardiac chest pain.

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

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.

The interobserver agreement of the HEART-score, a multicentre prospective study

BACKGROUND AND IMPORTANCE

Chest pain is one of the most common presentations to the emergency department (ED). The HEART-score is used to assess the 30-day risk of developing a major adverse cardiac event (MACE). The HEART-score enables clinicians to classify patients in low, intermediate, or high-risk groups though little is known as to whether this can be done reliably and reproducibly in a prehospital setting.

OBJECTIVE

The aim of this study was to compare the interobserver agreement of the HEART-score between ambulance nurses and ED physicians.

DESIGN, SETTINGS, AND PARTICIPANTS

Patients ≥18 years, with chest pain of suspected cardiac origin presented by ambulance to the EDs of four regional hospitals, were prospectively enrolled between October 2018 and April 2019.

OUTCOMES MEASURE AND ANALYSIS

The primary endpoint was interobserver agreement of the HEART-scores calculated by ambulance nurses compared to those calculated by ED physicians. Agreement was measured using Cohen's Kappa (K) both for overall HEART-score and dichotomized HEART categories. A secondary endpoint was the occurrence of a MACE at 30 days after inclusion.

MAIN RESULTS

A total of 307 patients were enrolled of which 166 patients were male (54%). The mean age was 64.8 years. In 23% (95% confidence interval, 18-27), patients were scored in the low-risk category by both ambulance nurses and ED physicians. The K for the overall HEART-score compared between ambulance nurses and ED physicians was 0.514. The K for the low-risk category versus intermediate and high-risk category was 0.591. Both are defined as 'moderate'. MACE within 30 days occurred in 64 patients (21%). In the low-risk group as defined by the ambulance nurses, there was a 7% risk of MACE compared to an average 5% MACE risk in the ED physician group.

CONCLUSIONS

The moderate interobserver agreement of the HEART-score does not currently support the use of the HEART-score by ambulance nurses in a prehospital setting. Training for prehospital nurses is vital to ensure that they are able to calculate the HEART-score accurately.

Telemetry Bed Usage for Patients with Low-Risk Chest Pain: An Updated Review of the Literature for the Clinician

BACKGROUND

Telemetry monitoring in patients with low-risk chest pain continues to be highly used despite a 2011 literature review and recommendations by the Clinical Practice Committee (CPC) of the American Academy of Emergency Medicine that did not find quality data to support its use.

OBJECTIVE

To update the medical literature review on the utility of telemetry monitoring in patients with low-risk chest pain and to offer evidence-based recommendations to emergency physicians.

METHODS

A PubMed literature search was performed for systematic reviews in English relevant to low-risk chest pain between 2011 and 2019 and then expanded to all citations by removing the systematic review criteria. Studies identified then underwent a structured review from which results could be evaluated in the context of the associated 2011 literature review and CPC recommendations.

RESULTS

The initial search yielded 2 potentially relevant studies, although none directly addressed telemetry. The expanded search resulted in 76 abstracts that were screened. Two addressed telemetry, including the last CPC statement, which were reviewed and recommendations given.

CONCLUSIONS

No further quality data were identified to support the use of telemetry monitoring in patients with low-risk chest pains. Telemetry monitoring is unlikely to benefit patients with low-risk chest pain with a low-risk HEART Score.

The predictive value of the HEART and GRACE scores for major adverse cardiac events in patients with acute chest pain

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.

Facility Variation in Troponin Ordering Within the Veterans Health Administration

BACKGROUND

Current United States guidelines recommend troponin as the preferred biomarker in assessing for acute coronary syndrome, but recommendations are limited about which patients to test. Variations in troponin ordering may influence downstream health care utilization.

METHODS

We performed a cross-sectional analysis of 3,308,131 emergency department (ED) visits in all 121 acute care facilities within the Veterans Health Administration from 2015 to 2017. We quantified the degree to which case mix and facility characteristics accounted for variations in facility rates in troponin ordering. We then assessed the association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization [inpatient admissions, noninvasive testing (stress tests, echocardiograms), and invasive procedures (coronary angiograms, percutaneous coronary interventions, and coronary artery bypass grafting surgeries)].

RESULTS

The proportion of ED visits with troponin orders ranged from 2.2% to 64.5%, with a median of 37.1%. Case mix accounted for 9.5% of the variation in troponin orders; case mix and differences in facility characteristics accounted for 34.6%. Facilities in the highest quartile of troponin ordering, as compared with those in the lowest quartile, had significantly higher rates of inpatient admissions, stress tests, echocardiograms, coronary angiograms, and percutaneous coronary intervention.

CONCLUSIONS

Significant variation in troponin utilization exists across Veterans Health Administration facilities and that variation is not well explained by case mix alone. Facilities with higher rates of troponin ordering were associated with more downstream resource utilization.

Spontaneous Intra-Cerebral Haemorrhage Presenting with Chest Pain in a Healthy Young Man

Spontaneous, non-traumatic intra-cerebral haemorrhage is the second most common type of stroke and is associated with significant morbidity and mortality. It is defined as the presence of blood within the cerebral parenchyma without prior injury or surgery. The purpose of this work is to describe an atypical presentation of spontaneous intra-cerebral haemorrhage in a healthy young adult. A literature review was also carried out.

LEARNING POINTS

Spontaneous intra-cerebral haemorrhage is a challenge in daily practice due to the wide range of clinical symptoms on presentation.Chest pain mimicking acute myocardial infarction is an atypical presentation of intra-cerebral haemorrhage.In the primary care setting, misdiagnosis of a patient with spontaneous cerebral haemorrhage with chest discomfort suggesting cardiac aetiology and prompting antiplatelet/aspirin therapy could result in disaster.Taking a detailed history and conducting a thorough neurological examination is important in every clinical encounter and may trigger diagnostic suspicion.

Combined stress myocardial CT perfusion and coronary CT angiography as a feasible strategy among patients presenting with acute chest pain to the emergency department

BACKGROUND

A combined approach of myocardial CT perfusion (CTP) with coronary CT angiography (CTA) was shown to have better diagnostic accuracy than coronary CTA alone. However, data on cost benefits and length of stay when compared to other perfusion imaging modalities has not been evaluated. Therefore, we aim to perform a feasibility study to assess direct costs and length of stay of a combined stress CTP/CTA and use SPECT myocardial perfusion imaging (SPECT-MPI) as a benchmark, among chest pain patients at intermediate-risk for acute coronary syndrome (ACS) presenting to the emergency department (ED).

METHODS

This is a prospective two-arm clinical trial (NCT02538861) with 43 patients enrolled in stress CTP/CTA arm (General Electric Revolution CT) and 102 in SPECT-MPI arm. Mean age of the study population was 65 ​± ​12 years; 56% were men. We used multivariable linear regression analysis to compare length of stay and direct costs between the two modalities.

RESULTS

Overall, 9 out of the 43 patients (21%) with CTP/CTA testing had an abnormal test. Of these 9 patients, 7 patients underwent invasive coronary angiography and 6 patients were found to have obstructive coronary artery disease. Normal CTP/CTA test was found in 34 patients (79%), who were discharged home and all patients were free of major adverse cardiac events at 30 days. The mean length of stay was significantly shorter by 28% (mean difference: 14.7 ​h; 95% CI: 0.7, 21) among stress CTP/CTA (20 ​h [IQR: 16, 37]) compared to SPECT-MPI (30 ​h [IQR: 19, 44.5]). Mean direct costs were significantly lower by 44% (mean difference: $1535; 95% CI: 987, 2082) among stress CTA/CTP ($1750 [IQR: 1474, 2114] compared to SPECT-MPI ($2837 [IQR: 2491, 3554]).

CONCLUSION

Combined stress CTP/CTA is a feasible strategy for evaluation of chest pain patients presenting to ED at intermediate-risk for ACS and has the potential to lead to shorter length of stay and lower direct costs.

Emergency Department Chest Pain Patients With or Without Ongoing Pain: Characteristics, Outcome, and Diagnostic Value of the Electrocardiogram

BACKGROUND

In emergency department (ED) chest pain patients, it is believed that the diagnostic accuracy of the electrocardiogram (ECG) for acute coronary syndrome (ACS) is higher during ongoing than abated chest pain.

OBJECTIVES

We compared patient characteristics and the diagnostic performance of the ECG in ED patients presenting with ongoing, vs. abated, chest pain.

METHODS

In total, 1132 unselected ED chest pain patients were analyzed. The patient characteristics and diagnostic accuracy for index visit ACS of the emergency physicians' interpretation of the ECG was compared in patients with and without ongoing chest pain. Logistic regression analysis was performed to control for possible confounders.

RESULTS

Patients with abated chest pain (n = 508) were older, had more comorbidities, and had double the risk of index visit ACS (15%) and major adverse cardiac events (MACE) at 30 days (15.6%) compared with patients with ongoing pain (n = 631; ACS 7.3%, 30-day MACE 7.4%). Sensitivity of the ECG for ACS was 24% in patients with ongoing pain and 35% in those without, specificity was 97% in both groups, negative predictive value was 94% and 89%, respectively, and positive likelihood ratio 10.6 and 7.8, respectively. When the diagnostic performance was controlled for confounders, there was no significant difference between the groups.

CONCLUSION

Our results indicate that ED chest pain patients with ongoing pain at arrival are younger, healthier, and have less ACS and 30-day MACE than patients with abated pain, but that there is no difference in the diagnostic accuracy of the ECG for ACS between the two groups.

Clinical Impact of Atypical Chest Pain and Diabetes Mellitus in Patients with Acute Myocardial Infarction from Prospective KAMIR-NIH Registry

Atypical chest pain and diabetic autonomic neuropathy attract less clinical attention, leading to underdiagnosis and delayed treatment. To evaluate the long-term clinical impact of atypical chest pain and diabetes mellitus (DM), we categorized 11,159 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into four groups (atypical DM, atypical non-DM, typical DM, and typical non-DM). The primary endpoint was defined as patient-oriented composite endpoint (POCE) at 2 years including all-cause death, any myocardial infarction (MI), and any revascularization. Patients with atypical chest pain showed higher 2-year mortality than those with typical chest pain in both DM (29.5% vs. 11.4%, p < 0.0001) and non-DM (20.4% vs. 6.3%, p < 0.0001) groups. The atypical DM group had the highest risks of POCE (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.48–2.10), all-cause death (HR 2.23, 95% CI 1.80–2.76) and any MI (HR 2.34, 95% CI 1.51–3.64) in the adjusted model. In conclusion, atypical chest pain was significantly associated with mortality in patients with AMI. Among four groups, the atypical DM group showed the worst clinical outcomes at 2 years. Application of rapid rule in/out AMI protocols would be beneficial to improve clinical outcomes.

Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association

This paper provides an update on the European Society of Cardiology task force report on the management of chest pain. Its main purpose is to provide an update on the decision algorithms and diagnostic pathways to be used in the emergency department for the assessment and triage of patients with chest pain symptoms suggestive of acute coronary syndromes.

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments

OBJECTIVE

To determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED).

METHODS

All adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach.

RESULTS

Overall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of 'immediate review' or 'within 10 min review' (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively.

CONCLUSIONS

In the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

A cardiac computed tomography first strategy to evaluate chest pain in a rural setting: outcomes and cost implications

INTRODUCTION

Chest pain continues to be a major burden on the healthcare system with more than eight million patients being evaluated in the emergency department (ED) setting annually at a cost of greater than 10 billion dollars. Missed chest pain diagnoses for ischemia are the leading cause of malpractice lawsuits for ED physicians. The use of cardiac computed tomography angiography (CCTA) to assess acute chest pain was adopted at the Chickasaw Nation Medical Center to attempt to accurately diagnose low to intermediate risk chest pain and potentially reduce the cost of chest pain evaluation to the system while still transferring appropriate high-risk patients.

PATIENTS AND METHODS

Patients presenting to the ED with low to moderate risk chest pain were evaluated with at least two negative troponin levels, an ECG, and in most instances overnight observation followed by CCTA in the morning if eligible. High-risk patients were transported to a tertiary care facility with cardiac catheterization capabilities. Medical records were checked to determine if any adverse events had occurred during follow-up. Adverse events were defined as myocardial infarction, death, and/or revascularization. Mean follow-up was 28 months.

RESULTS

Of the 368 patients studied, 29 patients were transferred due to findings of at least moderate obstructive disease. Of those 29 patients transferred, 11 patients underwent revascularization (10 underwent percutaneous coronary intervention and one underwent coronary artery bypass grafting). The average coronary artery calcium score for patients transferred was 96.1. The average coronary artery calcium score for patients undergoing revascularization was 174.6. Six patients had normal coronary arteries on catheterization. The remaining 12 patients had the moderate obstructive disease by catheterization that was not physiologically significant by either invasive fractional flow reserve or in two instances, negative stress perfusion testing. At 24 months, two patients had undergone revascularization and one patient had died suddenly.

CONCLUSION

The cost savings associated with a CCTA first strategy to evaluate chest pain were ~$1 200 244.10. For a self-insured health system such as the Chickasaw Nation, these are very important cost savings.

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis

OBJECTIVE

The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain.

METHODS

We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined.

RESULTS

We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI = 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%), but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%-99.0%) for prediction of MI.

CONCLUSIONS

The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.

Value of early rest myocardial perfusion imaging with SPECT in patients with chest pain and non-diagnostic ECG in emergency department

Evaluation of atypical presentation of angina chest pain in emergency department is difficult. Hospitalization of this patient may impose additional costs and waste the time, early discharge may lead to miss the patients. The aim of this study was to determine volubility of Single Photon Emission Computed Tomography (SPECT) in management of patients admitted to emergency department with atypical manifestations of angina pain, un-diagnostic Electrocardiogram (ECG) and negative enzyme. Half of 100 patients admitted to emergency department with atypical chest pain and un-diagnostic ECG who were candidate for admission, underwent ECG gated resting SPECT. According to the results of SPECT, low risk patient discharged after negative stress SPECT. All discharged patients were followed up for major cardiac events (cardiac death, nonfatal myocardial infarction and repeat admission for congestive heart failure) for 12 months. According to rest SPECT Myocardial Perfusion Imaging (MPI), about 70% of patients in case group was low risk and 30% of them had moderate or high risk. Case group represented lower hospitalization rate and lower need for Coronary Artery Angiography (CAG) in comparison with control group. Mean cost in case group was significantly lower than control group (175.15$ vs. 391.33$, P < 0.001). In one year follow- up no cases of mortality or major cardiovascular events as cardiac infraction were found in discharged patients in case group. our study showed that rest SPECT fulfillment in admitted patients in emergency department was validated method for assessing patients' risk which avoids unnecessary hospitalizations and additional costs.

Chest pain CT in the Emergency Department: evaluating the coronary arteries even when not specifically asked for?

Background Computed tomography (CT) for excluding acute aortic syndrome (AAS) and pulmonary embolism (PE) simultaneously in patients with chest pain could be used to exclude coronary artery disease (CAD). Purpose To evaluate the frequency of further testing for CAD in patients receiving a CT in the emergency department (ED) for simultaneous evaluation for AAS and PE. Material and Methods This retrospective study was conducted over a three-year period including all patients with acute chest pain visiting our ED. All patients were included that received an electrocardiography (ECG)-gated CT of the entire chest enquiring simultaneously for AAS and PE. Those patients were followed up for 30 days after their initial ED visit whether they received further testing for CAD. Results Within the study period, a total of 157 patients with acute chest pain received a chest pain CT for simultaneous evaluation of both AAS and PE. Image quality was deemed sufficient to evaluate the coronary arteries in 80% of the patients. Thirty-seven patients (24%) underwent additional testing for CAD within 30 days of their ED visit, including catheter coronary angiography (n = 25), cardiac-stress single-photon emission-CT (n = 6), and cardiac magnetic resonance imaging (MRI) (n = 6). Conclusion Of patients presenting to the ED with acute chest pain who received a chest pain CT for simultaneous evaluation of AAS and PE, 24% had further imaging for CAD within 30 days of the initial ED visit. Immediate evaluation of the coronary arteries as part of a chest pain CT should be considered here for not delaying diagnosis.

Burden of Non-cardiac Patients on the Emergency Room of a Rural Cardiac Center in Sindh, Pakistan

Introduction The number of cardiac patients increases on a daily basis, and emergency departments bear much of the burden of non-cardiac patients due to pathological fears of the aftermath of the disease. Therefore, this study aimed to determine the burden of non-cardiac patients on the emergency department of a cardiac center in a rural area of Sindh, Pakistan. Methods This cross-sectional study was conducted at the emergency department of Chandka Medical College Hospital in Larkana. Consecutive patients who presented with cardiac symptoms with no previous history of cardiac disease were included. After a brief history, physical examination, electrocardiogram, and a cardiac enzyme assessment, patients were categorized as cardiac or non-cardiac. Data were analyzed using IBM SPSS Statistics for Windows, Version 21.0. (IBM Corp., Armonk, NY, US) and p ≤0.05 was statistically significant. Results Of the 204 patients included, 112 (59.8%) were men, and the mean age was 47 ± 16 years. Most patients (n = 146; 71.6%) were diagnosed as non-cardiac. The non-cardiac diagnosis was significantly more common among patients without diabetes (n = 123, 77.4% vs. n = 23, 51.1%; p = 0.001), without chest pains (n = 93, 81.6% vs. n = 53, 58.9%; p< 0.001), and without shortness of breath (n = 107, 75.9% vs. n = 39, 61.9%; p = 0.041). Conclusion More than two-thirds of the patients were found to have a non-cardiac mechanism behind their symptoms. A major proportion of the emergency room's cardiology department is occupied by non-cardiac patients. Owing to its direct and indirect implication on an otherwise struggling health system, we suggest chest pain units should be developed to decrease the workload and provide better care to cardiac patients.

Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels

Background

Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing.

Methods

918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics.

Results

MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25–40.96), 16.43 (6.36–42.45), 2.33 (1.22–4.42) and 1.10 (1.01–1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease.

Conclusions

Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.

Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study

STUDY OBJECTIVE

We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low-risk chest pain.

METHODS

We created a Web-based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin-level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3-item Fear of Malpractice scale.

RESULTS

Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety-five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms "very low risk" and "low risk" only when their probability estimates were less than 1%.

CONCLUSION

The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.

Emergency Department Increased use of Observation Care for Elderly Medicare Patients

Background

Over the past decade, a growing number of older Medicare beneficiaries visit the Emergency Department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ≥ 65 years with Medicare insurance who are placed in the hospital, observation care, or discharged following an ED visit.

Methods

We conducted a retrospective cohort study using data from a nationally representative 5% sample of Medicare patients age ≥ 65 years during the year 2013. We performed multiple generalized estimating equation (GEE) logistic regression analyses to assess the relationship between placement in a hospital vs. discharge, observation care vs. discharge, and observation care vs. admission.

Results

Of 537,455 Medicare beneficiaries age ≥ 65 years who visited an ED in 2013, 48.0% (N= 258,083) were discharged, 10.5% (N=56,184) placed in observation care, and 41.5% (N=223,188) were admitted to the inpatient service following the ED visit. The top 2 diagnoses associated with placement in the hospital vs. discharge were ischemic heart disease and renal disease. Patients with symptomatic diagnoses such as chest pain and dizziness were more likely to be placed in observation care following an ED visit as compared to admission to the hospital.

Conclusion

Compared to prior studies, we found a greater number of older Medicare ED patients placed in observation care and a lower number admitted to the hospital. Most common diagnoses of placement in observation care were symptom-based as compared to being admitted to the hospital which were disease-based.

Comparison of clinical-based and ECG-based triage of acute chest pain in the Emergency Department

In the Emergency Department, chest pain triage systems are based on either clinical features or ECG recording. In this prospective, single-center, observational study, we aimed to compare the diagnostic performance of these triage systems in distinguishing acute coronary syndromes (ACS) from diseases of mild severity. Patients were sorted into the triage systems based on collected data at admission and on a systematic 12-lead ECG performed at triage. The final diagnosis was determined after a 30-day follow-up. For ACS, we determined a high-acuity triage score (Level 1 or 2) as being adequate, and for mild severity diseases a low-acuity triage score (Level 3, 4 or 5) as being adequate. The diagnostic performance of all studied systems was moderate (AUC from 0.644 to 0.694), with no statistically significant difference found between them. However, characteristics of the systems differed because the clinical-based systems had a higher sensitivity (87-91%) but lower specificity (32-39%) compared with the ECG-based system (sensitivity 62% and specificity 64%). A higher sensitivity limits the risk of a patient with acute coronary syndrome staying unsafely in the waiting room, while a higher specificity prevents overcrowding. ECG at triage also ensures that no STEMIs or high-risk NSTEMIs are missed. Based on these findings, each Emergency Depatment could more accurately select the triage system that fits their local particularities.

Is Telemetry Monitoring Useful in Patients Admitted With Suspected Acute Coronary Syndrome?

Patients with a chief complaint of chest pain are frequently monitored by telemetry for evaluation of acute coronary syndrome (ACS). However, there is insufficient evidence to support this practice in younger patients without coronary artery disease (CAD). The objective is to assess outcomes of patients younger than 50 years of age and monitored by telemetry. Consecutive medical records of patients admitted for chest pain between January 1, 2009, and June 30, 2010, were reviewed. Patients were excluded who had a CAD history, an abnormal initial troponin, or an abnormal initial electrocardiogram. The remaining patients’ charts were evaluated for adverse events such as death, dysrhythmias, ST-elevation myocardial infarction, or upgrade to a higher level of care. Ultimately, 814 patients were selected for study. No study participants suffered a significant adverse event. When being evaluated for ACS, patients younger than 50 without a history of CAD may not benefit from telemetry monitoring.

Long-Term Prognosis of Low-Risk Women Presenting to the Emergency Department with Chest Pain

BACKGROUND

Prognosis of low-risk women presenting to the emergency department (ED) with chest pain has not been clarified. We assessed early and long-term outcomes of such patients and determined the need for predischarge testing.

METHODS

Retrospective assessment of consecutive low-risk women presenting to the ED with chest pain evaluated in a chest pain unit (CPU). Criteria of low risk: age ≤51 years; no history of cardiovascular disease, diabetes, or smoking; negative initial electrocardiogram (ECG); and cardiac troponin. Predischarge testing (treadmill or stress imaging) was performed at the discretion of the CPU attending physician.

RESULTS

The study group comprised 214 consecutive women. Predischarge testing was performed in 142 patients (66%, age 43.9 years) and 72 patients (34%, age 43.1 years) had no predischarge testing. Predischarge testing comprised exercise treadmill (n = 102, 72%) or stress imaging (n = 40, 28%). Length of stay with no predischarge testing was 4.1 hours, compared with 8.6 hours with predischarge testing (P = .04). There were no cardiovascular events in the index presentation; during a 5-year interval (100% follow-up), there were 2 cardiovascular events (fatal heart failure, 1 patient; fatal stroke, 1 patient [total, 2/214, 0.93%]).

CONCLUSIONS

Low-risk women presenting to the ED with chest pain have an excellent short- and long-term prognosis. A majority of patients did not receive predischarge testing, and their length of stay was reduced by >50% compared with those with predischarge testing. These findings suggest that such patients may not require predischarge testing for disposition from a CPU, which can reduce length of stay, decrease cost, and improve resource utilization.

Diagnostic Evaluation of Nontraumatic Chest Pain in Athletes

This article is a clinically relevant review of the existing medical literature relating to the assessment and diagnostic evaluation for athletes complaining of nontraumatic chest pain. The literature was searched using the following databases for the years 1975 forward: Cochrane Database of Systematic Reviews; CINAHL; PubMed (MEDLINE); and SportDiscus. The general search used the keywords chest pain and athletes. The search was revised to include subject headings and subheadings, including chest pain and prevalence and athletes. Cross-referencing published articles from the databases searched discovered additional articles. No dissertations, theses, or meeting proceedings were reviewed. The authors discuss the scope of this complex problem and the diagnostic dilemma chest pain in athletes can provide. Next, the authors delve into the vast differential and attempt to simplify this process for the sports medicine physician by dividing potential etiologies into cardiac and noncardiac conditions. Life-threatening causes of chest pain in athletes may be cardiac or noncardiac in origin, which highlights the need for the sports medicine physician to consider pathology in multiple organ systems simultaneously. This article emphasizes the importance of ruling out immediately life threatening diagnoses, while acknowledging the most common causes of noncardiac chest pain in young athletes are benign. The authors propose a practical algorithm the sports medicine physician can use as a guide for the assessment and diagnostic work-up of the athlete with chest pain designed to help the physician arrive at the correct diagnosis in a clinically efficient and cost-effective manner.

Acute coronary syndrome risk prediction of rapid emergency medicine scoring system in acute chest pain. An observational study of patients presenting with chest pain in the emergency department in Central Saudi Arabia

OBJECTIVES

To assess the diagnostic validity of the rapid emergency medical score (REMS) for the risk stratification of acute coronary syndrome (ACS) from non-cardiogenic chest pain. Methods: An observational cross-sectional study was carried out among patients presenting with chest pain to the Emergency Department of Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia, for 6 months from January to June 2016. All patients, included through non-probability convenience sampling, were assessed using standard protocols for the physiological parameters of the REMS, and ACS was confirmed through electrocardiography, cardiac enzyme testing, and angiography (if needed). Data were analyzed using Statistical Package for Social Sciences software version 15 (SPSS Inc, Chicago, IL, USA). The validity of REMS was determined using a cutoff value of 17. Results: In total, 176 (70.4%) of patients were men with a mean age of 49±8.5 years. The mean REM score of the patients was 9.3±4.5, and a sensitivity of 81.6%, specificity of 90.05%, positive predictive value of 66.67%, and a negative predictive value of 95.26% were obtained. Conclusion: Rapid emergency medical score is a simple and fairly valid tool that may be used for diagnosis of ACS with limited resources in emergency medicine.

Outcomes in Patients With Chest Pain Discharged After Evaluation Using a High-Sensitivity Troponin T Assay

BACKGROUND

Most patients with chest pain are discharged from the emergency department (ED) with the diagnosis "unspecified chest pain." It is unknown if evaluation with a high-sensitivity troponin T (hsTnT) assay affects prognosis in this large population.

OBJECTIVES

The aim was to investigate whether the introduction of an hsTnT assay is associated with reduced incidence of major adverse cardiac events (MACEs) and cardiovascular (CV) risk profile in patients with chest pain discharged from the ED.

METHODS

The study included 65,696 patients with "unspecified chest pain" discharged from 16 Swedish hospital EDs between 2006 and 2013 in which an hsTnT assay was introduced as the clinical routine. Patients evaluated with a conventional and an hsTnT assay were compared regarding the occurrence of 30-day MACE and CV risk profile based on information from national registries. Patients directly discharged and those discharged after an initial admission were analyzed separately.

RESULTS

Fewer directly discharged patients experienced a MACE when evaluated with an hsTnT compared with a conventional assay (0.6% vs. 0.9%; odds ratio [OR]: 0.7; 95% confidence interval [CI]: 0.57 to 0.83). In contrast, more patients discharged after an initial admission experienced a MACE when evaluated with an hsTnT (7.2% vs. 3.4%; OR: 2.18; 95% CI: 1.76 to 2.72). Admitted patients had a higher general CV risk profile when evaluated with hsTnT, whereas directly discharged patients had a lower general CV risk profile with the same test.

CONCLUSIONS

Patients directly discharged from the ED with unspecified chest pain experienced fewer MACEs and had a better risk profile when evaluated with hsTnT. Our findings suggest that more true at-risk patients were identified and admitted. The implementation of hsTnT assays in Swedish hospitals has improved evaluations in the ED.

Correlation of Reciprocal Changes and QRS Amplitude in ECG to Left Ventricular Dysfunction, Wall Motion Score and Clinical Outcome in First Time ST Elevation Myocardial Infarction

INTRODUCTION

Electrocardiogram (ECG) is the simplest tool for diagnosing ST Elevation Myocardial Infarction (STEMI). We can use a12 lead ECG for prognostication purposes also.

AIM

The aim of the study was to find out the role of ECG as a prognostic marker in terms of clinical outcome and wall motion abnormality.

MATERIALS AND METHODS

It was a prospective study done in PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India, from January 2014 to September 2014. Patients aged above 18 years admitted with first episode of ST EMI as per the inclusion and exclusion criteria were recruited for the study. Presence of reciprocal changes and QRS amplitude was measured from ECG. Presence of Left Ventricular Dysfunction (LVD) and wall motion score were calculated from ECG along with clinical outcome during first follow up visit. Statistical analysis was done using SPSS software. Probability was calculated using chi-square test, independent t-test and ANOVA analysis.

RESULTS

A total of 120 patients were recruited for the study of which six were excluded based on the exclusion criteria. Among 114 patients analysed, 55 had reciprocal changes; 38 of them developed LVD which was statistically significant (p=0.002). Of the 78 patients with Anterior Wall Myocardial Infarction (AWMI), 35 had reciprocal changes; 15 (42.9%) of them had NYHA Class 1 symptoms, 14 (40%) had Class II and 4 (11%) had class III symptoms at follow up. The association was statistically significant (p=0.001). Similar statistically significant association was found in patients with Inferior Wall Myocardial Infarction (IWMI) who had reciprocal changes and NYHA symptoms at follow up (p=0.004). The mean wall motion score in patients with AWMI and reciprocal changes was 24.83 ± 4.1; whereas, without reciprocal changes was 23.98 ± 3.6; the association was not statistically significant. The mean QRS amplitude of all patients with LVD was 33.25 ±16.34. The association between QRS amplitude and LVD was not statistically significant. The overall mean wall motion score was 24.86 ± 3.91. The association between QRS amplitude and wall motion score was statistically significant (r value = 0.210). The association between QRS amplitude and wall motion score was statistically significant when we analysed AWMI (r= -0.147, p=0.199) and IWMI (r= -0.359, p=0.031) separately.

CONCLUSION

ECG can be used as a tool for prognostication in acute STEMI. The presence of reciprocal changes in the ECG can signify poorer outcome on follow up. Lower QRS amplitude can be used as a predictor of larger infarct.

Clinical evaluation of myocardial involvement in acute myopericarditis in young adults

BACKGROUND

Myocardial involvement in young adults has various causes. Acute myopericarditis is one of the myocardial involvements in young adults. It is easy to confuse with acute ST-elevation myocardial infarction because of the electrocardiographic features. This study aims to investigate a number of imaging techniques and clinical features for acute myopericarditis in young adults (<30 years of age).

METHODS

This retrospective study included 147 patients selected from the 2147 patients at the age of <30 with acute chest pain admitted into emergency service between 2010 and 2016. Of 147 patients, 77 patients were diagnosed with acute myopericarditis (group I) (between 18 and 30 aged) and 70 patients had ST-elevation myocardial infarction (group II). The echocardiographic pictures and information of the patients in both groups were rechecked in terms of impaired segmental wall-motion abnormalities, pericardial effusion, and additional features.

RESULTS

The patients in group I had focal echobright, which was defined as myocardial brightness in the left ventricle regions, especially in posterior and lateral wall. Focal echobright was observed in the 75 of 77 cases of acute myopericarditis in transthoracic echocardiogram. This sign was confirmed by cardiac magnetic resonance imaging. Focal echobright sensitivity was 95%; its specificity was 93%; its predictive was 95.2%. Pericardial effusion (83%) was observed in group I behind posterior wall. Its specificity was 81%; its sensitivity was 65%; predictivity was 73%.

CONCLUSIONS

Pericardial effusion and myocardial focal echobright in echocardiography can be quite sensitive indicators for acute myopericarditis in young adults.

Fragmented QRS and abnormal creatine kinase-MB are predictors of coronary artery disease in patients with angina and normal electrocardiographys

BACKGROUND/AIMS

Patients with symptoms of coronary artery disease (CAD) often display normal tracings or only nonspecific changes on electrocardiography (ECG). The aim of this study was to explore strategic elements of the ECG and other potential factors that are predictive of CAD in this scenario.

METHODS

This was an observational study of 142 patients with the chief complaint of chest pain, each of whom presented with a normal ECG and was subjected to emergency coronary angiography (CAG). Two population subsets were identified: those patients (n = 97) with no significant stenotic lesions and those (n = 45) with the significant stenotic lesions of CAD.

RESULTS

Those patients with normal or nonspecific ECGs and CAD (15.8%) were more likely to have left circumflex artery involvement (20% vs. 7%). In patients with normal ECGs and CAD (vs. normal CAG), male sex (86.7% vs. 68%, p = 0.023), creatine kinase-MB (CK-MB) levels > 10 U/L (13 vs. 10, p = 0.025), and fragmented QRS (fQRS) (38.6% vs. 21.6%, p = 0.042) occurred with greater frequency. In multivariable analysis, the following variables were significant predictors of CAD, given a normal ECG: male sex (odds ratio [OR], 2.593; 95% confidence interval [CI], 1.068 to 5.839); CK-MB (OR, 2.497; 95% CI, 0.955 to 7.039); and W- or M-shaped QRS complex (OR, 2.306; 95% CI 0.988 to 5.382).

CONCLUSIONS

In our view, male sex, elevated CK-MB (> 10 U/L), and fQRS complexes are suspects for CAD in patients with angina and unremarkable ECGs and should be considered screening tests.

Triple rule-out CT angiography protocol with restricting field of view for detection of pulmonary thromboembolism and aortic dissection in emergency department patients: simulation of modified CT protocol for reducing radiation dose

Background Triple rule-out computed tomography (TRO CT) is a CT protocol designed to simultaneously evaluate the coronary, aorta, and pulmonary arteries. Purpose To evaluate potential diagnostic performance of TRO CT with restricted volume coverage for detection of pulmonary thromboembolism (PTE) and aortic dissection (AD). Material and Methods This study included 1224 consecutive patients with acute chest pain who visited the emergency department and underwent TRO CT using a 128-slice dual-source CT. Image data were reconstructed according to the display field of view (DFOV) of coronary CT angiography (CCTA) and TRO CT protocols in each patient. The presence of PTE and AD was evaluated by independent observers in each DFOV. The radiation dose was calculated to evaluate the potential benefits by restricting z-axis coverage to cardiac scan range instead of the whole thorax. Results Among all patients, 22 cases with PTE (1.9%) and nine cases with AD (0.8%) were found. Except for one PTE case, all cases were detected on both DFOV of TRO CT and CCTA. Mean effective dose for evaluation of entire thorax and cardiac scan coverage were 5.9 ± 1.1 mSv and 3.5 ± 0.7 mSv, respectively. Conclusion Isolated PTE and AD outside the CCTA DFOV rarely occur. Therefore, modified TRO CT protocol using cardiac scan coverage can be adopted to detect PTE and AD with reduced radiation dose.

Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Less than half of patients with a chest pain history indicative of acute coronary syndrome have a diagnostic electrocardiogram (ECG) on initial presentation to the emergency department. The physician must dissect the ECG for elusive, but perilous, characteristics that are often missed by machine analysis. ST depression is interpreted and often suggestive of ischemia; however, when exclusive to leads V1–V3 with concomitant tall R waves and upright T waves, a posterior infarction should first and foremost be suspected. Likewise, diffuse ST depression with elevation in aVR should raise concern for left main- or triple-vessel disease and, as with the aforementioned, these ECG findings are grounds for acute reperfusion therapy. Even in isolation, certain electrocardiographic findings can suggest danger. Such is true of the lone T-wave inversion in aVL, known to precede an inferior myocardial infarction. Similarly, something as ordinary as an upright and tall T wave or a biphasic T wave can be the only marker of ischemia. ECG abnormalities, however subtle, should give pause and merit careful inspection since misinterpretation occurs in 20–40% of misdiagnosed myocardial infarctions.

The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India

There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.