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Hannan Hazari MA, Laxman Rao K, Tazneem B, Rafeeq S, Fatima SR, Jabeen S, Kavya K. CORRELATION OF COMORBIDITIES AND OUTCOME IN CAD PATIENTS: A NOVEL TANGENTS SCORE STUDY. MILITARY MEDICAL SCIENCE LETTERS 2024. [DOI: 10.31482/mmsl.2024.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
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Jercălău CE, Andrei CL, Brezeanu LN, Darabont RO, Guberna S, Catană A, Lungu MD, Ceban O, Sinescu CJ. Lymphocyte-to-Red Blood Cell Ratio-The Guide Star of Acute Coronary Syndrome Prognosis. Healthcare (Basel) 2024; 12:1205. [PMID: 38921319 PMCID: PMC11203887 DOI: 10.3390/healthcare12121205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Beneath the surface of the acute ST-elevation myocardial infarction (STEMI) iceberg lies a hidden peril, obscured by the well-known cardiovascular risk factors that tip the iceberg. Before delving into the potential time bomb these risk factors represent, it is crucial to recognize the obscured danger lurking under the surface. What secrets does the STEMI iceberg hold? To unveil these mysteries, a closer look at the pathophysiology of STEMI is imperative. Inflammation, the catalyst of the STEMI cascade, sets off a chain reaction within the cardiovascular system. Surprisingly, the intricate interplay between red blood cells (RBC) and lymphocytes remains largely unexplored in previous research. MATERIALS AND METHODS The study encompassed 163 patients diagnosed with STEMI. Utilizing linear and logistic regression, the lymphocyte-to-red blood cell ratio (LRR) was scrutinized as a potential predictive biomarker. RESULTS There was a statistically significant correlation between LRR and the prognosis of STEMI patients. Building upon this discovery, an innovative scoring system was proposed that integrates LRR as a crucial parameter. CONCLUSIONS Uncovering novel predictive markers for both immediate and delayed complications in STEMI is paramount. These markers have the potential to revolutionize treatment strategies by tailoring them to individual risk profiles, ultimately enhancing patient outcomes.
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Affiliation(s)
- Cosmina Elena Jercălău
- Department of Cardiology, “Bagdasar Arseni” Emergency Hospital, University of Medicine and Pharmacy “Carol Davila”, 011241 Bucharest, Romania; (R.O.D.); (A.C.); (C.J.S.)
| | - Cătălina Liliana Andrei
- Department of Cardiology, “Bagdasar Arseni” Emergency Hospital, University of Medicine and Pharmacy “Carol Davila”, 011241 Bucharest, Romania; (R.O.D.); (A.C.); (C.J.S.)
| | - Lavinia Nicoleta Brezeanu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, 022328 Bucharest, Romania;
| | - Roxana Oana Darabont
- Department of Cardiology, “Bagdasar Arseni” Emergency Hospital, University of Medicine and Pharmacy “Carol Davila”, 011241 Bucharest, Romania; (R.O.D.); (A.C.); (C.J.S.)
| | - Suzana Guberna
- Department of Cardiology, Emergency Hospital “Bagdasar-Arseni”, 050474 Bucharest, Romania; (S.G.); (M.D.L.)
| | - Andreea Catană
- Department of Cardiology, “Bagdasar Arseni” Emergency Hospital, University of Medicine and Pharmacy “Carol Davila”, 011241 Bucharest, Romania; (R.O.D.); (A.C.); (C.J.S.)
| | - Maria Diana Lungu
- Department of Cardiology, Emergency Hospital “Bagdasar-Arseni”, 050474 Bucharest, Romania; (S.G.); (M.D.L.)
| | - Octavian Ceban
- Economic Cybernetics and Informatics Department, The Bucharest University of Economic Studies, 010374 Bucharest, Romania;
| | - Crina Julieta Sinescu
- Department of Cardiology, “Bagdasar Arseni” Emergency Hospital, University of Medicine and Pharmacy “Carol Davila”, 011241 Bucharest, Romania; (R.O.D.); (A.C.); (C.J.S.)
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Muacevic A, Adler JR, El Dirani M, Mathew S, Ogwu CI, Kholoki S. Steps To Prevent Mortality in a Patient with Coinciding Severe Sepsis and Cardiogenic Shock Post-Non-ST-Elevation Myocardial Infarction (NSTEMI): A Case Report. Cureus 2022; 14:e32086. [PMID: 36600844 PMCID: PMC9803867 DOI: 10.7759/cureus.32086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/02/2022] Open
Abstract
Severe sepsis is characterized by acute organ dysfunction secondary to an infective source, often requiring emergent medical intervention. The severity of sepsis is determined by a criterion that focuses on the presence of fever, tachycardia, tachypnea, leukocytosis, lactic acidosis, hypotension, evidence of organ failure, and the presence of an infective source. Management of sepsis in patients with a coinciding ischemic event such as a myocardial infarction (MI), is difficult, given the prognosis is poor and there is a high risk for mortality. This case report explores methodical medical measures taken to prevent mortality in an 81-year-old Hispanic male that developed severe sepsis in conjunction with a complicated presentation of a non-ST-elevation myocardial infarction (NSTEMI).
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Kesgün M, Yavuz BG, Satilmis D, Colak S. Comparison of the T-MACS score with the TIMI score in patients presenting to the emergency department with chest pain. Am J Emerg Med 2022; 60:24-28. [PMID: 35878571 DOI: 10.1016/j.ajem.2022.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/27/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Guidelines recommend the use of risk scoring in patients with chest pain. In this study, we aimed to compare the thrombolysis in myocardial infarction risk index (TIMI) score with the Troponin Only Manchester Acute Coronary Syndrome Score (T-MACS) score and to investigate the usability of the T-MACS score in the emergency department. METHODS In our study; The TIMI and T-MACS scores of 310 patients with suspected NSTEMI who applied to the emergency department with chest pain and met the inclusion and exclusion criteria were prospectively evaluated. The primary outcome was MACE at 30 days including acute coronary syndromes, need for revascularization and deaths. Descriptive data and TIMI and T-MACS scores for predicting MACE and ACS was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). ROC (Receiver Operating Characteristic) analysis was also performed to determine TIMI and T-MACS risk class. RESULTS In our study, the mean age of the patients was 49.7 ± 19.4 years, the 1-month mortality rate was 1.3%, majör adverse cardiac event (MACE) rate was 6.5%, and acute coronary syndrome (ACS) rate was 5.5%. T-MACS risk class for predicting MACE sensitivity 100%, selectivity 51.72, PPV 12.5% (for very low risk), NPV was calculated as 100%; sensitivity for TIMI risk class low risk 35%, selectivity 88.97%, PPV was calculated as 17.9%, NPV was calculated as 95.2%. T-MACS high risk class for predicting MACE; sensitivity was 60%, selectivity 99.66%, PPV 92.3% and NPV was 97.3%; TIMI high risk class for predicting MACE; sensitivity was 10%, selectivity was 97.93%, PPV was 25% and NPV was 94%. CONCLUSIONS The findings obtained in this study suggest that the T-MACS score is more successful than the TIMI score in determining the low risk (very low risk for T-MACS score), high risk, and estimated 1-month MACE risk in cases who presented to the emergency department with chest pain.
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Affiliation(s)
- Mücahit Kesgün
- Diyarbakır Dagkapı Hospital, Department of Emergency Medicine, Diyarbakır, Turkey
| | - Burcu Genc Yavuz
- University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey.
| | - Dilay Satilmis
- University of Health Sciences, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
| | - Sahin Colak
- University of Health Sciences, Haydarpasa Numune Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey
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Soeiro ADM, Biselli B, Leal TC, Bossa AS, César MC, Jallad S, Goldstein PG, Guimarães PO, Serrano CV, Nomura CH, Nakamura D, Rochitte CE, Soares PR, Oliveira MTD. Desempenho Diagnóstico da Angiotomografia Computadorizada e da Avaliação Seriada de Troponina Cardíaca Sensível em Pacientes com Dor Torácica e Risco Intermediário para Eventos Cardiovasculares. Arq Bras Cardiol 2021; 118:894-902. [PMID: 35137790 PMCID: PMC9368885 DOI: 10.36660/abc.20210006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/16/2021] [Indexed: 11/21/2022] Open
Abstract
Fundamento A angiotomografia coronária (ATC) tem sido usada para avaliação de dor torácica principalmente em pacientes de baixo risco, e poucos dados existem com pacientes em risco intermediário. Objetivo Avaliar o desempenho de medidas seriadas de troponinas sensíveis e de ATC em pacientes de risco intermediário. Métodos Um total de 100 pacientes com dor torácica, TIMI score 3 ou 4 e troponina negativa foram prospectivamente incluídos. Todos os pacientes foram submetidos à ATC, e aqueles com obstruções ≥ 50% foram encaminhados à cineangiocoronariografia. Pacientes com lesões < 50% recebiam alta hospitalar, receberam alta e foram contatados 30 dias depois por telefonema para avaliação dos desfechos clínicos. Os desfechos foram hospitalização, morte, e infarto agudo do miocárdio em 30 dias. A comparação entre os métodos foi realizada pelo teste de concordância kappa. O desempenho das medidas de troponina e da ATC na detecção de lesões coronárias significativas e desfechos clínicos foi calculado. Os resultados foram considerados estatisticamente significativos quando p <0,05. Resultados Estenose coronária ≥ 50% na ATC foi encontrada em 38% dos pacientes e lesões coronárias significativas na angiografia coronária foram encontradas em 31 pacientes. Dois eventos clínicos foram observados. A análise de concordância Kappa mostrou baixa concordância entre as medidas de troponina e ATC na detecção de lesões coronárias significativas (kappa = 0,022, p = 0,78). O desempenho da ATC para detectar lesões coronárias significativas na angiografia coronária ou para prever eventos clínicos em 30 dias foi melhor que as medidas de troponina sensível (acurácia de 91% versus 60%). Conclusão ATC teve melhor desempenho que as medidas seriadas de troponina na detecção de doença coronariana significativa em pacientes com dor torácica e risco intermediário para eventos cardiovasculares.
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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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Ballarino P, Cervellin G, Trucchi C, Altomonte F, Bertini A, Bonfanti L, Bressan MA, Carpinteri G, Noto P, Gavelli F, Molinari L, Patrucco F, Sainaghi PP, Caristia S, Cavazza M, Gallitelli M, Longo S, Cremonesi P, Orsi A, Ansaldi F, Marino R, Di Somma S, Castello LM, Moscatelli P, Avanzi GC. An Italian registry of chest pain patients in the emergency department: clinical predictors of acute coronary syndrome. Minerva Med 2020; 111:120-132. [PMID: 32338841 DOI: 10.23736/s0026-4806.20.06472-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The aim of this study was to describe the population of patients arriving in several Italian Emergency Departments (EDs) complaining of chest pain suggestive of acute coronary syndrome (ACS) in order to evaluate the incidence of ACS in this cohort and the association between ACS and different clinical parameters and risk factors. METHODS This is an observational prospective study, conducted from the 1st January to the 31st December 2014 in 11 EDs in Italy. Patients presenting to ED with chest pain, suggestive of ACS, were consecutively enrolled. RESULTS Patients with a diagnosis of ACS (N.=1800) resulted to be statistically significant older than those without ACS (NO ACS; N.=4630) (median age: 70 vs. 59, P<0.001), and with a higher prevalence of males (66.1% in ACS vs. 57.5% in NO ACS, P<0.001). ECG evaluation, obtained at ED admission, showed new onset alterations in 6.2% of NO ACS and 67.4% of ACS patients. Multiple logistic regression analysis showed that the following parameters were predictive for ACS: age, gender, to be on therapy for cardio-vascular disease (CVD), current smoke, hypertension, hypercholesterolemia, heart rate, ECG alterations, increased BMI, reduced SaO2. CONCLUSIONS Results from this observational study strengthen the importance of the role of the EDs in ruling in and out chest pain patients for the diagnosis of ACS. The analysis put in light important clinical and risk factors that, if promptly recognized, can help Emergency Physicians to identify patients who are more likely to be suffering from ACS.
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Affiliation(s)
- Paola Ballarino
- Emergency Department, San Martino University Hospital, Genoa, Italy
| | | | - Cecilia Trucchi
- Department of Health Science, University of Genoa, Genoa, Italy
| | | | | | - Laura Bonfanti
- Emergency Department, Parma University Hospital, Parma, Italy
| | - Maria A Bressan
- Emergency Department, San Matteo University Hospital, Pavia, Italy
| | | | - Paola Noto
- Emergency Department, Vittorio Emanuele University Hospital, Catania, Italy
| | - Francesco Gavelli
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
| | - Luca Molinari
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
| | - Filippo Patrucco
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
| | - Pier Paolo Sainaghi
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
| | - Silvia Caristia
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
| | - Mario Cavazza
- Emergency Department, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mauro Gallitelli
- Emergency Department, SS Giovanni e Paolo Hospital, Venice, Italy
| | - Stefania Longo
- Internal Medicine and Emergency Department, Bari University Hospital, Bari, Italy
| | | | - Andrea Orsi
- Department of Health Science, University of Genoa, Genoa, Italy
| | - Filippo Ansaldi
- Department of Health Science, University of Genoa, Genoa, Italy
| | - Rossella Marino
- Department of Medical-Surgery Sciences and Translational Medicine, Sapienza University, Rome, Italy
| | - Salvatore Di Somma
- Department of Medical-Surgery Sciences and Translational Medicine, Sapienza University, Rome, Italy
| | - Luigi M Castello
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy - .,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
| | - Paolo Moscatelli
- Emergency Department, San Martino University Hospital, Genoa, Italy
| | - Gian Carlo Avanzi
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.,Emergency Department, Maggiore della Carità University Hospital, Novara, Italy
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Abstract
OBJECTIVE We examined low risk (LR) patients admitted to our chest pain unit (CPU) with negative cardiac injury markers, normal electrocardiogram, and clinical stability. We hypothesized that there is a sub-group of intermediate risk (IR) patients within the larger LR population. METHODS Criteria for IR were the aforementioned 3 indicators of LR and ≥1 of the following: (1) known coronary artery disease (CAD), (2) men ≥45 yo, women ≥55 yo, and (3) ≥3 cardiac risk factors. We compared patient characteristics, use of pre-discharge testing (PDT), and major adverse cardiac events (MACE). RESULTS IR patients numbered 371, whereas LR patients totaled 70. IR patients were older (61 vs 46 years), more had known CAD (28 vs. 0%), had a higher median number of risk factors (2 vs. 1) and were less likely to be women (49 vs. 81%), all P < 0.0001. IR patients received a greater median number of tests compared with LR patients (1 vs. 0, P < 0.0001). CONCLUSIONS Among the IR group, 16 patients (4%) had a cardiac event at the index CPU visit, 2 (0.5%) experienced MACE at 30-day follow-up, and 2 (0.5%) had MACE at 6 months follow-up. No LR patients had MACE at any point in the study. Thus, the majority of CPU patients are IR, have more risk factors than LR group, and are more likely to receive PDT. IR patients were managed safely in a CPU, while maintaining low rates of MACE post-discharge.
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Riley RF, Miller CD, Russell GB, Soliman EZ, Hiestand BC, Herrington DM, Mahler SA. Usefulness of Serial 12-Lead Electrocardiograms in Predicting 30-Day Outcomes in Patients With Undifferentiated Chest Pain (the ASAP CATH Study). Am J Cardiol 2018; 122:374-380. [PMID: 30196932 DOI: 10.1016/j.amjcard.2018.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/07/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
An initial electrocardiogram (ECG) and serial troponin measurements are both independently and incrementally predictive of acute coronary syndrome in patients presenting with undifferentiated chest pain in the Emergency Department (ED). However, it is unclear if serial (ECGs) add significant to the contemporary diagnostic evaluation of this patient group. The ASAP CATH study was a single center, prospective study that enrolled patients presenting to an ED with undifferentiated chest pain. In addition to standard clinical evaluation, serial ECGs were performed at 90-minute intervals to evaluate whether serial changes suggestive of ischemia developed (Q waves, ST elevation or depression, or T-wave inversion). Total 365 subjects were enrolled from March 2014 to May 2015. Serial ECG changes developed in 6.6% (n = 24 of 365), the most common being the development of T-wave inversion (66.7%, n = 16 of 24). The sensitivity and positive predictive value of serial ECG changes were poor (<30%), with a less areas under the curve (0.55) compared with serial troponins alone (0.83). The addition of serial ECG changes to Thrombolysis In Myocardial Infarction risk scoring showed a decrease in the net reclassification index for major adverse cardiovascular events (-0.04, p <0.1) and was not significant for the prediction of major adverse cardiovascular events and/or acute coronary syndrome in 30 days (-0.003, p = 0.94). In conclusion, routine serial ECG evaluation for patients presenting with undifferentiated chest pain in the ED may not significantly improved diagnostic prognosis beyond current standard evaluation modalities.
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Ko HF, Lee HY, Ho HF. A 2-hour Accelerated Chest Pain Protocol to Assess Patients with Chest Pain Symptoms in an Accident and Emergency Department in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791302000501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The present study is a follow up analysis of ASPECT study. We aimed to prospectively validate a 2-hour accelerated chest pain protocol (ACPP) to assess patients presenting to emergency department with chest pain symptoms suggestive of acute coronary syndrome. Methods This observational study was carried out between June 2009 and July 2010. Patients were included if they were older than 18 years old and presented with at least 5 minutes duration of chest pain. The ACPP included modified Thrombolysis in Myocardial Infarction score, electrocardiograph and point-of-care troponin I at presentation and 2-hour after. Primary endpoint was major adverse cardiac event (MACE) at 45-day of initial hospital attendance. Results A total of 384 Chinese patients were recruited and completed 45-day follow up. Forty-five (11.7%) had 45-d MACE. The ACPP identified 124 (32.3%) low risk patients who could be discharged early. No MACE occurred within 45 days among these patients, giving a sensitivity of 100% (95% CI 90-100), a negative predictive value of 100% (96-100), and a specificity of 36.6% (31.5-42). Conclusions The ACPP is able to identify very low risk chest pain patients who might be suitable for early discharge without increasing risk of developing MACE. The observation period can be shortened to 2-hour of ED presentation. The variables are objective and easily available. This 2-hour Hong Kong Chest Pain Rule is applicable to Chinese population and has the potential to change the current practice in Emergency Departments in Hong Kong and China.
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Chen XH, Jiang HL, Li YM, Chan CPY, Mo JR, Tian CW, Lin PY, Graham CA, Rainer TH. Prognostic values of 4 risk scores in Chinese patients with chest pain: Prospective 2-centre cohort study. Medicine (Baltimore) 2016; 95:e4778. [PMID: 28033243 PMCID: PMC5207539 DOI: 10.1097/md.0000000000004778] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Four risk scores for stratifying patients with chest pain presenting to emergency departments (EDs) (namely Thrombolysis in myocardial infarction [TIMI], Global registry for acute coronary events [GRACE], Banach and HEART) have been developed in Western settings but have never been compared and validated in Chinese patients. We aimed to find out to the number of MACE within 7 days, 30 days, and 6 months after initial ED presentation, and also to compare the prognostic performance of these scores in Chinese patients with suspected cardiac chest pain (CCP) to predict 7-day, 30-day, and 6-month major adverse cardiac events (MACE).A prospective 2-center observational cohort study of consecutive patients presenting with chest pain to the EDs of 2 university hospitals in Guangdong and Hong Kong from 17 March 2012 to 14 August 2013 was conducted. Patients aged ≥18 years with suspected CCP but without ST-segment elevation myocardial infarction (STEMI) were recruited.Of 833 enrolled patients (mean age 65.1 years, SD14.5; 55.6% males), 121 (14.5%) experienced MACE within 6 months (4.8% with safety outcomes and 10.3% with effectiveness outcomes). The HEART score had the largest area under the receiver operating characteristic (ROC) curve for predicting MACE at 7-day, 30-day, and 6-month follow-up [area under curve (AUC) = 0.731, 0.726, and 0.747, respectively. The HEART score also had the largest AUC for predicting effectiveness outcome (AUC = 0.715, 0.704, and 0.721, respectively). However, there was no significant difference in AUC between HEART and TIMI scores. Banach had the largest AUC for predicting safety outcome (AUC = 0.856, 0.837, and 0.850, respectively).The HEART score performed better than the GRACE and Banach scores to predict total MACE and effectiveness outcome in Chinese patients with suspected CCP, whereas the Banach score best predicted safety outcomes.
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Affiliation(s)
- Xiao-Hui Chen
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Hui-Lin Jiang
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Yun-Mei Li
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Cangel Pui Yee Chan
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China
| | - Jun-Rong Mo
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Chao-Wei Tian
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Pei-Yi Lin
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Colin A. Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China
| | - Timothy H. Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China
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Austin C, Kusumoto F. The application of Big Data in medicine: current implications and future directions. J Interv Card Electrophysiol 2016; 47:51-59. [DOI: 10.1007/s10840-016-0104-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
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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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Utility of the QT interval in predicting outcomes in patients presenting to the emergency department with chest pain. Coron Artery Dis 2015; 26:422-4. [PMID: 25851456 DOI: 10.1097/mca.0000000000000249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether prolongation of the heart rate-corrected QT interval (QTc) is an independent risk factor for predicting future acute coronary syndrome (ACS) occurrence or mortality in patients with at least one cardiac risk factor presenting with chest pain to the emergency department (ED). METHODS This is a single-center, retrospective study of patients presenting with chest pain to the ED of Einstein Medical Center, Philadelphia, between 2011 and 2012. Proportional hazards models were used to calculate hazard ratios (HRs) for occurrence of ACS or death within 1 year. Kaplan-Meier curves were used to determine the time to event for QTc low (< 460 ms) versus QTc high (≥ 460 ms) groups. RESULTS A total of 595 patients met the inclusion criteria. Older age, hypertension, diabetes mellitus, and hyperlipidemia were more common in the QTc high group. Patients in the QTc high group were more likely to experience subsequent ACS or death (HR 8.12, 95% confidence interval 4.00-16.72), even after adjusting for traditional cardiac risk factors (HR 7.68, 95% confidence interval 3.57-16.61). CONCLUSION QTc prolongation at ED presentation with chest pain and at least one cardiac risk factor predicts subsequent ACS and death.
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Kelly AM, Klim S. Does undetectable troponin I at presentation using a contemporary sensitive assay rule out myocardial infarction? A cohort study. Emerg Med J 2014; 32:760-3. [DOI: 10.1136/emermed-2014-204442] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/03/2014] [Indexed: 11/04/2022]
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Graham CA, Chan JW, Chan CP, Cattermole GN, Rainer TH. Prospective validation of Thrombolysis in Myocardial Infarction and front door Thrombolysis in Myocardial Infarction risk scores in Chinese patients presenting to the ED with chest pain. Am J Emerg Med 2014; 32:1339-44. [DOI: 10.1016/j.ajem.2014.08.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/11/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022] Open
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Abstract
Cardiovascular disease (CVD) is the most-prevalent noncommunicable disease and leading cause of death globally. Over 80% of deaths from CVD occur in low-income and middle-income countries (LMICs). To limit the socioeconomic impact of CVD, a comprehensive approach to health care is needed. Cardiac rehabilitation delivers a cost-effective and structured exercise, education, and risk reduction programme, which can reduce mortality by up to 25% in addition to improving a patient's functional capacity and lowering rehospitalization rates. Despite these benefits and recommendations in clinical practice guidelines, cardiac rehabilitation programmes are grossly under-used compared with revascularization or medical therapy for patients with CVD. Worldwide, only 38.8% of countries have cardiac rehabilitation programmes. Specifically, 68.0% of high-income and 23% of LMICs (8.3% for low-income and 28.2% for middle-income countries) offer cardiac rehabilitation programmes to patients with CVD. Cardiac rehabilitation density estimates range from one programme per 0.1 to 6.4 million inhabitants. Multilevel strategies to augment cardiac rehabilitation capacity and availability at national and international levels, such as supportive public health policies, systematic referral strategies, and alternative models of delivery are needed.
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Affiliation(s)
- Karam Turk-Adawi
- Cardiovascular Rehabilitation &Prevention, University Health Network, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Nizal Sarrafzadegan
- Isfahan Cardiovascular Research Centre, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Seddigheh Tahereh Research and Treatment Hospital, Khorram Ave, PO Box 81465-1148, Isfahan, Iran
| | - Sherry L Grace
- School of Kinesiology and Health Science, Bethune 368, York University, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada
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Stähli BE, Yonekawa K, Altwegg LA, Wyss C, Hof D, Fischbacher P, Brauchlin A, Schulthess G, Krayenbühl PA, von Eckardstein A, Hersberger M, Neidhart M, Gay S, Novopashenny I, Wolters R, Frank M, Wischnewsky MB, Lüscher TF, Maier W. Clinical criteria replenish high-sensitive troponin and inflammatory markers in the stratification of patients with suspected acute coronary syndrome. PLoS One 2014; 9:e98626. [PMID: 24892556 PMCID: PMC4043791 DOI: 10.1371/journal.pone.0098626] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 05/06/2014] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES In patients with suspected acute coronary syndrome (ACS), rapid triage is essential. The aim of this study was to establish a tool for risk prediction of 30-day cardiac events (CE) on admission. 30-day cardiac events (CE) were defined as early coronary revascularization, subsequent myocardial infarction, or cardiovascular death within 30 days. METHODS AND RESULTS This single-centre, prospective cohort study included 377 consecutive patients presenting to the emergency department with suspected ACS and for whom troponin T measurements were requested on clinical grounds. Fifteen biomarkers were analyzed in the admission sample, and clinical parameters were assessed by the TIMI risk score for unstable angina/Non-ST myocardial infarction and the GRACE risk score. Sixty-nine (18%) patients presented with and 308 (82%) without ST-elevations, respectively. Coronary angiography was performed in 165 (44%) patients with subsequent percutaneous coronary intervention--accounting for the majority of CE--in 123 (33%) patients, respectively. Eleven out of 15 biomarkers were elevated in patients with CE compared to those without. High-sensitive troponin T (hs-cTnT) was the best univariate biomarker to predict CE in Non-ST-elevation patients (AUC 0.80), but did not yield incremental information above clinical TIMI risk score (AUC 0.80 vs 0.82, p = 0.69). Equivalence testing of AUCs of risk models and non-inferiority testing demonstrated that the clinical TIMI risk score alone was non-inferior to its combination with hs-cTnT in predicting CE. CONCLUSIONS In patients presenting without ST-elevations, identification of those prone to CE is best based on clinical assessment based on TIMI risk score criteria and hs-cTnT.
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Affiliation(s)
- Barbara Elisabeth Stähli
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
| | - Keiko Yonekawa
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Lukas Andreas Altwegg
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
| | - Christophe Wyss
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
| | - Danielle Hof
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Brauchlin
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
| | - Georg Schulthess
- Department of Internal Medicine, Hospital Männedorf, Männedorf, Switzerland
| | | | | | - Martin Hersberger
- Institute of Clinical Chemistry and Biochemistry, Childrens Hospital Zurich, Zurich, Switzerland
| | - Michel Neidhart
- Center for Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Steffen Gay
- Center for Experimental Rheumatology, Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Igor Novopashenny
- FB Mathematics and Computer Science, University of Bremen, Bremen, Germany
| | - Regine Wolters
- FB Mathematics and Computer Science, University of Bremen, Bremen, Germany
| | - Michelle Frank
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
| | | | - Thomas Felix Lüscher
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
| | - Willibald Maier
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
- * E-mail:
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Mahmoud KD, Holmes DR. Role and timing of coronary intervention in non-ST-elevation myocardial infarction. Interv Cardiol 2014. [DOI: 10.2217/ica.14.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abbasnezhad M, Soleimanpour H, Sasaie M, EJ Golzari S, Safari S, Soleimanpour M, Mehdizadeh Esfanjani R. Comparison of Prediction Between TIMI (Thrombolysis in Myocardial Infarction) Risk Score and Modified TIMI Risk Score in Discharged Patients From Emergency Department With Atypical Chest Pain. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e13938. [PMID: 24719735 PMCID: PMC3965868 DOI: 10.5812/ircmj.13938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/29/2013] [Accepted: 01/01/2014] [Indexed: 11/16/2022]
Abstract
Background: Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening. Objectives: In the current study, we evaluated the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department. Patients and Methods: In a prospective-analytic study, we collected data from 1020 patients with atypical chest pain enrolled to the study. All eligible patients were visited by the emergency medicine residents who were trained for this study. Based on the criteria in both systems, the emergency medicine attending decided on either discharging or hospitalizing patients. Patients were allocated into 2 equal groups randomly. In order to predict the opposing accidents in 30 days (coronary revascularization, myocardial infarction, and all-cause death) TIMI risk scores and Modified TIMI risk scores were assessed based on TIMI risk score (0 or 1) and Modified TIMI risk score (0 or 1). Results: No significant difference could be observed between both groups regarding demographic characteristics, ejection fraction, left ventricle hypertrophy, TRS criteria, risk factors and the history of coronary artery stenosis. None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events. Conclusions: The results obtained from this study support the idea that the TIMI and modified TIMI risk scores might be valuable tools that could be used to stratify the risk of patients with atypical chest pain in the emergency department.
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Affiliation(s)
- Mohsen Abbasnezhad
- Department of Cardiology, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Hassan Soleimanpour
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding Author: Hassan Soleimanpour, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel: +98-9141164134, Fax: +98-4113352078, E-mail:
| | - Mohamadreza Sasaie
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Samad EJ Golzari
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Saeid Safari
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, IR Iran
| | - Maryam Soleimanpour
- Gastroenterology Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Avoidable utilization of the chest pain observation unit: evaluation of very-low-risk patients. Crit Pathw Cardiol 2014; 12:59-64. [PMID: 23680810 DOI: 10.1097/hpc.0b013e31828dc764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Very-low-risk patients treated in a chest pain observation unit (CPOU) may threaten efficient care delivery. To optimize the efficiency of CPOU evaluations, it is necessary to quantify the avoidable CPOU utilization rate, examine physician variability, and determine patient and physician characteristics associated with avoidable CPOU utilization. METHODS Consecutive chest pain patients were evaluated in an Emergency Department-based CPOU. Patients were risk stratified based on the American College of Cardiology/American Heart Association framework, age, and electrocardiogram findings. Very-low-risk was defined as age <35, physician assessment of low-risk, and normal or nondiagnostic electrocardiogram. Patients identified as very-low-risk were considered avoidable CPOU evaluations. Individual physicians' avoidable CPOU utilization rates were calculated. Patients were followed for 30-day major adverse cardiac events, defined as the composite of death, acute myocardial infarction, and coronary revascularization. RESULTS Over 33 months, the registry included 1731 chest pain patients. The study definition of avoidable CPOU evaluations was met by 174 patients (10.1%, 95% confidence interval: 8.7-11.6%). The median rate of physician's avoidable CPOU utilization was 10% (interquartile range: 5.9-13.6%) and varied from 1.9% to 18.4%. None of the patients with an avoidable CPOU evaluation had a major adverse cardiac events within 30 days. Physician predictors of avoidable CPOU utilization included recent residency graduation (<5 years), part-time status, and moderate or high rates of CPOU use. CONCLUSIONS Approximately 10% of CPOU evaluations were avoidable. Wide variability exists among physicians regarding their individual rates of avoidable CPOU utilization. This variability could represent an opportunity to improve the efficiency of CPOU care delivery.
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A 2-Hour Accelerated Chest Pain Protocol to Assess Patients with Chest Pain Symptoms in an Accident and Emergency Department in Hong Kong. HONG KONG J EMERG ME 2014. [DOI: 10.1177/102490791402100105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The present study is a follow up analysis of ASPECT study. We aimed to prospectively validate a 2-hour accelerated chest pain protocol (ACPP) to assess patients presenting to emergency department with chest pain symptoms suggestive of acute coronary syndrome. Methods This observational study was carried out between June 2009 and July 2010. Patients were included if they were older than 18 years old and presented with at least 5 minutes duration of chest pain. The ACPP included modified Thrombolysis in Myocardial Infarction score, electrocardiograph and point-of-care troponin I at presentation and 2-hour after. Primary endpoint was major adverse cardiac event (MACE) at 45-day of initial hospital attendance. Results A total of 384 Chinese patients were recruited and completed 45-day follow up. Forty-five (11.7%) had 45-d MACE. The ACPP identified 124 (32.3%) low risk patients who could be discharged early. No MACE occurred within 45 days among these patients, giving a sensitivity of 100% (95% CI 90-100), a negative predictive value of 100% (96-100), and a specificity of 36.6% (31.5-42). Conclusions The ACPP is able to identify very low risk chest pain patients who might be suitable for early discharge without increasing risk of developing MACE. The observation period can be shortened to 2-hour of ED presentation. The variables are objective and easily available. This 2-hour Hong Kong Chest Pain Rule is applicable to Chinese population and has the potential to change the current practice in Emergency Departments in Hong Kong and China. (Hong Kong j.emerg.med. 2013;20: 261-269)
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Effectiveness of Using the Front Door Score to Enhance the Chest Pain Triage Accuracy of Emergency Nurse Triage Decisions. J Cardiovasc Nurs 2013; 28:E55-64. [DOI: 10.1097/jcn.0b013e318277c5ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Graham CA, Tsay SXH, Rotheray KR, Rainer TH. Validation of the TIMI risk score in Chinese patients presenting to the emergency department with chest pain. Int J Cardiol 2013; 168:597-8. [PMID: 23453446 DOI: 10.1016/j.ijcard.2013.01.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 01/18/2013] [Indexed: 11/15/2022]
Affiliation(s)
- Colin A Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong.
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Cardiac Risk Stratification Scoring Systems for Suspected Acute Coronary Syndromes in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-012-0004-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Holly J, Fuller M, Hamilton D, Mallin M, Black K, Robbins R, Davis V, Madsen T. Prospective evaluation of the use of the thrombolysis in myocardial infarction score as a risk stratification tool for chest pain patients admitted to an ED observation unit. Am J Emerg Med 2012; 31:185-9. [PMID: 22944539 DOI: 10.1016/j.ajem.2012.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 07/04/2012] [Accepted: 07/07/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Thrombolysis in Myocardial Infarction (TIMI) score has shown use in predicting 30-day and 1-year outcomes in emergency department (ED) patients with potential acute coronary syndrome. Few studies have evaluated the TIMI score in risk stratifying patients selected for the ED observation Unit (EDOU). Risk stratification of patients in this group could identify those at risk for significant cardiac events. Our goal was to evaluate TIMI use for risk stratification in this population and compare outcomes among differing scores. METHODS A prospective observational study with 30-day telephone follow-up for a 12 month period. Baseline data, outcomes related to EDOU stay, admission, and 30-day outcomes were recorded. TIMI scores were calculated for each patient placed in EDOU. TIMI score was not utilized in the decision to place patients in observation. RESULTS N = 552. Composite outcomes recorded were myocardial infarction, revascularization, or death either during the EDOU stay, inpatient admission, or the 30-day follow-up. Eighteen composite outcomes were recorded: stent (12 patients), coronary artery bypass graft (3 patients), myocardial infarction and stent (2 patients), and myocardial infarction, and coronary artery bypass graft (1 patient). Distribution by TIMI score was: 0 (102 patients), 1 (196), 2 (142), 3 (72), 4 (27), and 5 (5). Risk of composite outcome increased by score: 0 (1%), 1 (2.6%), 2 (2.1%), 3 (6.9%), 4 (11.1%), and 5 (20%). Those with an intermediate risk score (3-5) were also more likely to require admission (15.4% vs 9.8%, P = .048). CONCLUSION The TIMI risk score may serve as an effective risk stratification tool among chest pain patients selected for EDOU placement. Patients with intermediate-risk by TIMI may be considered for inpatient admission and/or more aggressive evaluation and therapy.
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Affiliation(s)
- Jessica Holly
- University of Utah School of Medicine, Department of Surgery, Division of Emergency Medicine, Salt Lake City, UT 84132, USA
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Scheuermeyer FX, Innes G, Grafstein E, Kiess M, Boychuk B, Yu E, Kalla D, Christenson J. Safety and Efficiency of a Chest Pain Diagnostic Algorithm With Selective Outpatient Stress Testing for Emergency Department Patients With Potential Ischemic Chest Pain. Ann Emerg Med 2012; 59:256-264.e3. [DOI: 10.1016/j.annemergmed.2011.10.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Revised: 09/02/2011] [Accepted: 10/07/2011] [Indexed: 11/28/2022]
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D'Ascenzo F, Biondi-Zoccai G, Moretti C, Bollati M, Omedè P, Sciuto F, Presutti DG, Modena MG, Gasparini M, Reed MJ, Sheiban I, Gaita F. TIMI, GRACE and alternative risk scores in Acute Coronary Syndromes: a meta-analysis of 40 derivation studies on 216,552 patients and of 42 validation studies on 31,625 patients. Contemp Clin Trials 2012; 33:507-14. [PMID: 22265976 DOI: 10.1016/j.cct.2012.01.001] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 12/20/2011] [Accepted: 01/03/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute coronary syndromes (ACS) represent a difficult challenge for physicians. Risk scores have become the cornerstone in clinical and interventional decision making. METHODS AND RESULTS PubMed was systematically searched for ACS risk score studies. They were divided into ACS studies (evaluating Unstable Angina; UA, Non ST Segment Elevation Myocardial Infarction; NSTEMI, and ST Segment Elevation Myocardial Infarction; STEMI), UA/NSTEMI studies or STEMI studies. The c-statistics of validation studies were pooled when appropriate with random-effect methods. 7 derivation studies with 25,525 ACS patients and 15 validation studies including 257,654 people were formally appraised. Pooled analysis of GRACE scores, both at short (0.82; 0.80-0.89 I.C 95%) and long term follow up (0.84; 0.82-0.87; I.C 95%) showed the best performance, with similar results to Simple Risk Index (SRI) derivation cohorts at short term. For NSTEMI/UA, 18 derivation studies with 56,560 patients and 18 validation cohorts with 56,673 patients were included. Pooled analysis of validations studies showed c-statistics of 0.54 (95% CI = 0.52-0.57) and 0.67 (95% CI = 0.62-0.71) for short and long term TIMI validation studies, and 0.83 (95% CI = 0.79-9.87) and 0.80 (95% CI = 0.74-0.89) for short and long term GRACE studies. For STEMI, 15 studies with 134,557 patients with derivation scores, and 17 validation studies with 187,619 patients showed a pooled c-statistic of 0.77 (95% CI = 0.71-0.83) and 0.77 (95% CI = 0.72-0.85) for TIMI at short and long term, and a pooled c-statistic of 0.82 (95% CI = 0.81-0.83) and 0.81 (95% CI = 0.80-0.82) for GRACE at short and long terms respectively. CONCLUSIONS TIMI and GRACE are the risk scores that up until now have been most extensively investigated, with GRACE performing better. There are other potentially useful ACS risk scores available however these have not undergone rigorous validation. This study suggests that these other scores may be potentially useful and should be further researched.
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Fabbri A, Ottani F, Marchesini G, Galvani M, Vandelli A. Predicting unfavorable outcome in subjects with diagnosis of chest pain of undifferentiated origin. Am J Emerg Med 2012; 30:61-7. [DOI: 10.1016/j.ajem.2010.09.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/10/2010] [Accepted: 09/14/2010] [Indexed: 11/12/2022] Open
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Goodacre SW, Bradburn M, Mohamed A, Gray A. Evaluation of Global Registry of Acute Cardiac Events and Thrombolysis in Myocardial Infarction scores in patients with suspected acute coronary syndrome. Am J Emerg Med 2012; 30:37-44. [DOI: 10.1016/j.ajem.2010.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 09/02/2010] [Accepted: 09/09/2010] [Indexed: 12/22/2022] Open
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The challenge of triaging chest pain patients: the bernese university hospital experience. Emerg Med Int 2011; 2012:975614. [PMID: 22114740 PMCID: PMC3205748 DOI: 10.1155/2012/975614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/15/2011] [Accepted: 07/29/2011] [Indexed: 01/12/2023] Open
Abstract
Accurate diagnosis of the causes of chest pain and dyspnea remain challenging. In this preliminary observational study with a 5-year follow-up, we attempted to find a simplified approach to selecting patients with chest pain needing immediate care based on the initial evaluation in ED. During a 24-month period were randomly selected 301 patients and a conditional inference tree (CIT) was used as the basis of the prognostic rule. Common diagnoses were musculoskeletal chest pain (27%), ACS (19%) and panic attack (12%). Using variables of ACS symptoms we estimated the likelihood of ACS based on a CIT to be high at 91% (32), low at 4% (198) and intermediate at 20.5–40% in (71) patients. Coronary catheterization was performed within 24 hours in 91% of the patients with ACS. A culprit lesion was found in 79%. Follow-up (median 4.2 years) information was available for 70% of the patients. Of the 164 patients without ACS who were followed up, 5 were treated with revascularization for stable angina pectoris, 2 were treated with revascularization for myocardial infarction, and 25 died. Although a simple triage decision tree could theoretically help to efficient select patients needing immediate care we need also to be vigilant for those presenting with atypical symptoms.
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Than M, Cullen L, Reid CM, Lim SH, Aldous S, Ardagh MW, Peacock WF, Parsonage WA, Ho HF, Ko HF, Kasliwal RR, Bansal M, Soerianata S, Hu D, Ding R, Hua Q, Seok-Min K, Sritara P, Sae-Lee R, Chiu TF, Tsai KC, Chu FY, Chen WK, Chang WH, Flaws DF, George PM, Richards AM. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet 2011; 377:1077-84. [PMID: 21435709 DOI: 10.1016/s0140-6736(11)60310-3] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Patients with chest pain contribute substantially to emergency department attendances, lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast process to identify patients presenting with chest pain who have a low short-term risk of a major adverse cardiac event is needed to facilitate early discharge. We aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome. METHODS This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min of chest pain. The ADP included use of a structured pre-test probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance). This trial is registered with the Australia-New Zealand Clinical Trials Registry, number ACTRN12609000283279. FINDINGS 3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11.8%) patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of 99.3% (95% CI 97.9-99.8), a negative predictive value of 99.1% (97.3-99.8), and a specificity of 11.0% (10.0-12.2). INTERPRETATION This novel ADP identifies patients at very low risk of a short-term major adverse cardiac event who might be suitable for early discharge. Such an approach could be used to decrease the overall observation periods and admissions for chest pain. The components needed for the implementation of this strategy are widely available. The ADP has the potential to affect health-service delivery worldwide. FUNDING Alere Medical (all countries), Queensland Emergency Medicine Research Foundation and National Health and Medical Research Council (Australia), Christchurch Cardio-Endocrine Research Group (New Zealand), Medquest Jaya Global (Indonesia), Science International (Hong Kong), Bio Laboratories Pte (Singapore), National Heart Foundation of New Zealand, and Progressive Group (Taiwan).
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Affiliation(s)
- Martin Than
- Christchurch Hospital, Christchurch, New Zealand.
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Bossaert L, O'Connor RE, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Hoek TLV, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e175-212. [PMID: 20959169 DOI: 10.1016/j.resuscitation.2010.09.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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O'Connor RE, Bossaert L, Arntz HR, Brooks SC, Diercks D, Feitosa-Filho G, Nolan JP, Vanden Hoek TL, Walters DL, Wong A, Welsford M, Woolfrey K. Part 9: Acute coronary syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010; 122:S422-65. [PMID: 20956257 DOI: 10.1161/circulationaha.110.985549] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
BACKGROUND Women with acute coronary syndromes have lower rates of cardiac catheterization (CC) than men. OBJECTIVE To determine whether sex⁄gender, age, risk level and patient preference influence physician decision making to refer patients for CC. METHODS Twelve clinical scenarios controlling for sex⁄gender, age (55 or 75 years of age), Thrombolysis in Myocardial Infarction risk score (low, moderate or high) and patient preference for CC (agreeable or refused⁄no preference expressed) were designed. Scenarios were administered to specialists across Canada using a web-based computerized survey instrument. Questions were standardized using a five-point Likert scale ranging from 1 (very unlikely to benefit from CC) to 5 (very likely to benefit from CC). Outcomes were assessed using a two-tailed mixed linear regression model. RESULTS Of 237 scenarios, physicians rated men as more likely to benefit from CC than women (mean [± SE] 4.44±0.07 versus 4.25±0.07, P=0.03), adjusted for age, risk and patient preference. Low-risk men were perceived to benefit more than low-risk women (4.20±0.13 versus 3.54±0.14, P<0.01), and low-risk younger patients were perceived to benefit more than low-risk older patients (4.52±0.17 versus 3.22±0.16, P<0.01). Regardless of risk, patients who agreed to CC were perceived as more likely to benefit from CC than patients who were disagreeable or made no comment at all (5.0±0.23, 3.67±0.21, 2.95±0.14, respectively, P<0.01). CONCLUSION Canadian specialists' decisions to refer patients for CC appear to be influenced by sex⁄gender, age and patient preference in clinical scenarios in which cardiac risk is held constant. Future investigation of possible age and sex⁄gender biases as proxies for risk is warranted.
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Hess EP, Perry JJ, Calder LA, Thiruganasambandamoorthy V, Body R, Jaffe A, Wells GA, Stiell IG. Prospective validation of a modified thrombolysis in myocardial infarction risk score in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med 2010; 17:368-75. [PMID: 20370775 DOI: 10.1111/j.1553-2712.2010.00696.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study attempted to prospectively validate a modified Thrombolysis In Myocardial Infarction (TIMI) risk score that classifies patients with either ST-segment deviation or cardiac troponin elevation as high risk. The objectives were to determine the ability of the modified score to risk-stratify emergency department (ED) patients with chest pain and to identify patients safe for early discharge. METHODS This was a prospective cohort study in an urban academic ED over a 9-month period. Patients over 24 years of age with a primary complaint of chest pain were enrolled. On-duty physicians completed standardized data collection forms prior to diagnostic testing. Cardiac troponin T-values of >99th percentile (> or =0.01 ng/mL) were considered elevated. The primary outcome was acute myocardial infarction (AMI), revascularization, or death within 30 days. The overall diagnostic accuracy of the risk scores was compared by generating receiver operating characteristic (ROC) curves and comparing the area under the curve. The performance of the risk scores at potential decision thresholds was assessed by calculating the sensitivity and specificity at each potential cut-point. RESULTS The study enrolled 1,017 patients with the following characteristics: mean (+/-SD) age 59.3 (+/-13.8) years, 60.6% male, 17.9% with a history of diabetes, and 22.4% with a history of myocardial infarction. A total of 117 (11.5%) experienced a cardiac event within 30 days (6.6% AMI, 8.9% revascularization, 0.2% death of cardiac or unknown cause). The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy (area under the ROC curve = 0.83 vs. 0.79; p = 0.030; absolute difference 0.037; 95% confidence interval [CI] = 0.004 to 0.071). The specificity of the modified score was lower at all cut-points of >0. Sensitivity and specificity at potential decision thresholds were: >0 = sensitivity 96.6%, specificity 23.7%; >1 = sensitivity 91.5%, specificity 54.2%; and >2 = sensitivity 80.3%, specificity 73.4%. The lowest cut-point (TIMI/modified TIMI >0) was the only cut-point to predict cardiac events with sufficient sensitivity to consider early discharge. The sensitivity and specificity of the modified and original TIMI risk scores at this cut-point were identical. CONCLUSIONS The modified TIMI risk score outperformed the original with regard to overall diagnostic accuracy. However, it had lower specificity at all cut-points of >0, suggesting suboptimal risk stratification in high-risk patients. It also lacked sufficient sensitivity and specificity to safely guide patient disposition. Both scores are insufficiently sensitive and specific to recommend as the sole means of determining disposition in ED chest pain patients.
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Affiliation(s)
- Erik P Hess
- Department of Emergency Medicine, Division of Emergency Medicine Research, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Weisenthal BM, Chang AM, Walsh KM, Collin MJ, Shofer FS, Hollander JE. Relation between thrombolysis in myocardial infarction risk score and one-year outcomes for patients presenting at the emergency department with potential acute coronary syndrome. Am J Cardiol 2010; 105:441-4. [PMID: 20152236 DOI: 10.1016/j.amjcard.2009.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 10/07/2009] [Accepted: 10/07/2009] [Indexed: 10/20/2022]
Abstract
The Thrombolysis in Myocardial Infarction (TIMI) score, derived from unstable angina/non-ST-segment elevation acute myocardial infarction patient population, predicts 14-day cardiovascular events. It has been validated in emergency department (ED) patients with potential acute coronary syndrome with respect to 30-day outcomes. Our objective was to determine whether the initial TIMI score could risk stratify ED patients with potential acute coronary syndrome with respect to the 1-year outcomes. This was a prospective cohort study of patients presenting to the ED with chest pain who underwent electrocardiography. Patients with ST-segment elevation myocardial infarction (acute myocardial infarction) were excluded. Follow-up was conducted by telephone and record review >1 year after the index visit. The main outcome was the 1-year mortality, nonfatal acute myocardial infarction, or revascularization stratified by the TIMI score. Of 2,819 patients, 253 (9%) met the composite outcome. The overall incidence of the composite 1-year outcome of death (n = 119), acute myocardial infarction (n = 96), and revascularization (n = 90) according to TIMI score was TIMI 0 (n = 1,162), 4%; TIMI 1 (n = 901), 8%; TIMI 2 (n = 495), 13%; TIMI 3 (n = 193), 23%; TIMI 4 (n = 60), 28%; and TIMI 5 to 7 (n = 8), 88% (p <0.001). In conclusion, in addition to risk stratifying ED patients with chest pain at the initial ED evaluation, the TIMI score can also predict the 1-year cardiovascular events in this patient population.
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Boxt LM, Lipton MJ. Can computed tomography improve outcomes in acute coronary syndrome? Br J Hosp Med (Lond) 2009; 70:459-63. [PMID: 19684536 DOI: 10.12968/hmed.2009.70.8.43539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Each year, six million patients in the USA visit the emergency department for acute chest pain. Many patients are hospitalized because immediate discharge of those suspected of acute coronary syndrome could be disastrous. This review looks at whether patient outcomes could be improved by coronary computed tomography angiography.
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Affiliation(s)
- Lawrence M Boxt
- Section of Cardiac CT and MR Imaging, Division of Cardiology, Montefiore Medical Center, Bronx, NY 10467, USA
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Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review. CAN J EMERG MED 2008; 10:373-82. [PMID: 18652730 DOI: 10.1017/s148180350001040x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting. METHODS We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 x 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form. RESULTS Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively. CONCLUSION Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice.
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Hess EP, Wells GA, Jaffe A, Stiell IG. A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology. BMC Emerg Med 2008; 8:3. [PMID: 18254973 PMCID: PMC2275746 DOI: 10.1186/1471-227x-8-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 02/06/2008] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge. METHODS/DESIGN The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions. DISCUSSION The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.
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Affiliation(s)
- Erik P Hess
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - George A Wells
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Allan Jaffe
- Department of Internal Medicine, Division of Cardiology, Mayo Clinic College of Medicine, Rochester, USA
| | - Ian G Stiell
- Department of Emergency Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
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Lyon R, Morris AC, Caesar D, Gray S, Gray A. Chest pain presenting to the Emergency Department--to stratify risk with GRACE or TIMI? Resuscitation 2007; 74:90-3. [PMID: 17360096 DOI: 10.1016/j.resuscitation.2006.11.023] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 11/18/2006] [Accepted: 11/29/2006] [Indexed: 10/23/2022]
Abstract
INTRODUCTION There is a need to stratify risk rapidly in patients presenting to the Emergency Department (ED) with undifferentiated chest pain. The Global Registry of Acute Coronary Events (GRACE) and the Thrombolysis in Myocardial Infarction (TIMI) scoring systems predict outcome of adverse coronary events in patients admitted to specialist cardiac units. This study evaluates the relationship between GRACE score and outcome in patients presenting to the ED with undifferentiated chest pain and establishes whether GRACE is preferential to TIMI in stratifying risk in patients in the ED setting. MATERIALS AND METHODS Descriptive study of a consecutive sample of 1000 ED patients with undifferentiated chest pain presenting to Edinburgh Royal Infirmary, Scotland. GRACE and TIMI scores were calculated for each patient and outcomes noted at 30 days. Outcomes included ST and non-ST myocardial infarction, cardiac arrest, revascularisation, unstable angina with myocardial damage and all cause mortality at 30 days. Score and outcome were compared using receiver operator characteristic curves (AUC-ROC). RESULTS The GRACE score stratifies risk accurately in patients presenting to the ED with undifferentiated chest pain (AUC-ROC 0.80 (95% CI 0.75-0.85), see Table 1). The TIMI score was found to be similarly accurate in stratifying risk in the study cohort with an AUC-ROC of 0.79 (95% CI 0.74-0.85). It was only possible to calculate a complete GRACE score in 76% (n=760) cases as not all the data variables were measured routinely in the ED. CONCLUSIONS GRACE and TIMI are both effective in accurately stratifying risk in patients presenting to the ED with undifferentiated chest pain. The GRACE score is more complex than the TIMI score and in the ED setting TIMI may be the preferred scoring method.
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Affiliation(s)
- Richard Lyon
- Department of Emergency Medicine, Royal Infirmary, Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, United Kingdom.
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