Association of Early Stress Testing with Outcomes for Emergency Department Evaluation of Suspected Acute Coronary Syndrome

The Changing Role of Chest Pain in the Emergency Department Observation Unit

BACKGROUND

This study objective was to describe changes in the utilization of a protocol-driven emergency department observation unit (EDOU) for chest pain over time.

METHODS

This is a retrospective serial cross-sectional study of data from a clinical data warehouse of a single integrated healthcare system. We estimated long-term trends (2009-2019) in EDOU visits at 4 system hospitals, using monthly proportions as the main outcome, and month of visit as the exposure variable, accounting for age and sex. Rate changes associated with compulsory use of the History, EKG, Age, Risk factors, Troponin (HEART) score in 2016 were analyzed.

RESULTS

There were 83,168 EDOU admissions among 1.3 million ED visits during the study interval, with an average admission rate of 5.9% of ED visits. The most common conditions were chest pain (41.2%), transient ischemic attack (7.8%), dehydration (6.3%), syncope (5.8%), and abdominal pain (5.2%). In each hospital, there was a temporal annual decline in the proportion of EDOU visits for chest pain protocols ranging from -7.9% to -2.8%, an average rate of -3.3% per year (95% CI, -4.6% to -2.0%) or a 54% (from 54% to 25%) relative decline in over the 11-year study interval. This decline was significantly steeper in younger middle-aged patients (ages 39-49). The HEART score intervention had a small impact on baseline decline of -3.1% at the 2 intervention hospitals, reducing it by -1.5% (95% CI, -2.2% to -0.8%).

CONCLUSIONS

Utilization of the EDOU for chest pain decreased over time, with corresponding increases in other conditions. This decline preceded the introduction of the HEART score.

Prognostic value of resting myocardial contrast echocardiography: a meta-analysis

BACKGROUND

Resting myocardial perfusion (MP) and wall motion (WM) imaging during real time myocardial contrast echocardiography (MCE) improves the detection of coronary artery disease (CAD). However, its prognostic role in different clinical settings (emergency department and outpatient setting) remains unclear.

METHODS

A systematic search in PubMed and Embase databases, and the Cochrane library, was conducted to evaluate the role of resting MP and WM in predicting major adverse cardiac events (MACE), including death, nonfatal myocardial infarction (NFMI) and urgent revascularization in patients presenting to either outpatient clinics or emergency departments with suspected symptomatic CAD. Summary receiver operating characteristic (SROC) curves, sensitivity and specificity plots were applied to assess diagnostic performance using RevMan 5.3.

RESULTS

Seven studies met criteria, including 3668 patients (six with follow up ranging from two days to 2.6 years). The relative risk (RR) for predicting MACE in patients with both abnormal resting MP and WM was 6.1 (95% CI, 5.1-7.2) and 14.3 (95% CI, 10.3-19.8) for death/NFMI, when compared to normal resting MP and WM patients. Having both abnormal resting MP and WM was also more predictive of MACE (RR 1.7; 95% CI 1.5-1.9) and death/NFMI (RR, 2.2; 95% CI, 1.8-2.7) when compared to abnormal WM with normal resting MP.

CONCLUSION

In this meta-analysis of both ED and outpatient clinic presentations for suspected CAD, having both a resting regional MP and WM abnormality identifies the highest risk patient for adverse events.

The distribution of cardiac diagnostic testing for acute coronary syndrome in the Brazilian healthcare system: A national geospatial evaluation of health access

BACKGROUND

Little is known about the utilization of cardiac diagnostic testing in Brazil and how such testing is related with local rates of acute coronary syndrome (ACS)-related mortality.

METHODS AND RESULTS

Using data from DATASUS, the public national healthcare database, absolute counts of diagnostic tests performed were calculated for each of the 5570 municipalities and mapped. Spatial error regression and geographic weighted regression models were used to describe the geographic variation in the association between ACS mortality, income, and access to diagnostic testing. From 2008 to 2014, a total of 4,653,884 cardiac diagnostic procedures were performed in Brazil, at a total cost of $271 million USD. The overall ACS mortality rate during this time period was 133.8 deaths per 100,000 inhabitants aged 20 to 79. The most commonly utilized test was the stress ECG (3,015,993), followed by catheterization (862,627), scintigraphy (669,969) and stress echocardiography (105,295). The majority of these procedures were conducted in large urban centers in more economically developed regions of the country. Increased access to testing and increased income were not uniformly associated with decreased ACS mortality, and tremendous geographic heterogeneity was observed in the relationship between these variables.

CONCLUSIONS

The majority of testing for ACS in Brazil is conducted at referral centers in developed urban settings. Stress ECG is the dominant testing modality in use. Increased access to diagnostic testing was not consistently associated with decreased ACS mortality across the country.