Predicting acute coronary syndrome in males and females with chest pain who call an emergency medical communication centre

Development of an Initial Screening Scale to Detect Patients With Chest Pain From Acute Coronary Syndrome in the Emergency Department

BACKGROUND

Identifying patients with chest pain potentially due to acute coronary syndrome (ACS) early is crucial for triage nurses. They need a reliable, validated screening tool.

AIMS

This study aims to develop an initial screening scale to detect ACS in patients presenting with chest pain in the emergency department.

METHODS

We analyzed electronic medical records of 3131 chest pain patients from 103,041 emergency department visits between January 2018 and December 2019. ACS diagnosis was confirmed by cardiologists through clinical symptoms, electrocardiograms, and cardiac enzyme levels. The study proceeded in four stages: (1) identifying potential ACS predictors through a literature review, (2) validating these predictors with experts, (3) comparing data between ACS and non-ACS patients and (4) developing a screening scale based on identified predictors. Statistical methods included univariate analysis and binary logistic regression. The scale's accuracy was assessed using ROC curve analysis and compared to existing tools.

RESULTS

Eight significant ACS predictors were identified: male sex, age over 49 for males and over 65 for females, typical symptoms, initial pain scale score of 6 or higher, pain duration of at least 10 min, history of ACS, hypertension, and dyslipidemia. Each predictor was scored, with typical symptoms and severe pain receiving higher scores, totaling up to 10 points. A score of 6 or more indicated high ACS risk, demonstrating accuracy comparable to the HEART and TIMI score systems.

CONCLUSION

This study developed a new ACS screening scale for use by triage nurses in emergency departments. This scale can facilitate early detection and intervention for patients at high risk of ACS.

Diagnostic accuracy of signs and symptoms in acute coronary syndrome and acute myocardial infarction

BACKGROUND

Acute coronary syndrome (ACS) and acute myocardial infarction (AMI) account for a large portion of cardiovascular deaths. Signs and symptoms for these syndromes, such as chest pain, are non-specific and can be caused by a variety of non-cardiac conditions, especially in low-prevalence settings such as general practice. The diagnostic value of these signs and symptoms can be assessed using diagnostic meta-analyses, but the last one dates from 2012.

METHODS

We performed a diagnostic meta-analysis in accordance with PRISMA guidelines. We searched PubMed, Embase and CENTRAL from 2006 to 2024. We included studies that assessed the diagnostic accuracy of thirteen different signs and symptoms. We divided patients into two subgroups (AMI and ACS) on which analysis was performed independently.

RESULTS

We selected 24 articles for inclusion. Our analysis indicates that signs and symptoms have a limited role in the diagnosis of AMI or ACS. The most useful (highest diagnostic odds ratios, DOR) in the diagnosis of AMI were pain radiating to both arms (DOR 2.95 (95%CI 1.57-5.06)), absence of chest wall tenderness (DOR 3.51 (95%CI 1.64-6.61)), pain radiating to the right arm (DOR 5.17 (95%CI 1.77-11.9)) and sweating (DOR 5.75 (95%CI 2.51-11.4)). For ACS these were pain radiating to the right arm (DOR 3.9 (95%CI 0.7-12.6)) and absence of chest wall tenderness (DOR 7.73 (95%CI 2.19-19.8)).

CONCLUSION

We report the accuracy of thirteen signs and symptoms in the diagnosis of AMI and ACS. These can be useful to calibrate general practitioners' diagnostic assessment of chest pain in primary care settings.

Qualité en régulation médicale : critères et évaluation

Les Samu Centre 15 sont soumis à une politique de qualité qui répond à une approche transversale prenant en considération le patient, le professionnel et l’établissement de santé. La démarche qualité assure à chaque patient de pouvoir accéder à une plateforme de communication en tout point du territoire et d’obtenir pour toutes demandes de soins urgents ou non programmés une réponse juste et adaptée. Pour les professionnels des Samu Centres 15, la qualité en régulation appelle à améliorer puis sécuriser les pratiques dans un contexte de sollicitation constamment croissante depuis ces dernières années. Il s’agit également de garantir des conditions de travail optimales pour les intervenants et de contribuer ainsi à une réponse de qualité. Cette démarche s’intègre également dans la certification par la Haute Autorité de santé des établissements de santé et rentre dans le concept d’hôpitaux « magnétiques » pour allier résultats sanitaires performants et conditions de travail bienveillantes pour les soignants. La stratégie d’amélioration continue de la qualité doit s’appuyer sur des travaux de recherche appliquée à la régulation médicale qu’il convient de développer. S’inspirer des méthodes utilisées dans d’autres systèmes de traitement des appels d’urgence et intégrer de nouveaux outils au sein des Samu Centres 15 pourraient contribuer à atteindre cet objectif de qualité.

Le numéro commun santé : enjeux et impacts

Les questions relatives aux numéros d’urgence concernent en premier lieu nos concitoyens. Elles relèvent également d’enjeux de société au travers de l’impératif de maintien du fonctionnement du système dans son ensemble. Souvent réduites aux désaccords entre professionnels de l’urgence, il apparaît nécessaire de considérer les constats portés sur le territoire national et d’objectiver les impératifs opérationnels afin d’œuvrer à la mise en place d’un système lisible, simplifié et efficient. La singularité et la complexité des demandes de soins urgents, non programmés, relève d’une prise en charge spécifique. L’instauration d’un numéro commun santé, articulé et interopéré avec les services de secours et de sécurité, répond à un modèle organisationnel cible en lien avec la réalité du besoin en France, principalement constitué par la demande sanitaire. Ainsi, le service d’accès aux soins (SAS), désormais inscrit dans la loi, constitue un objectif central d’amélioration de la prise en charge des patients en situation d’urgence ou nécessitant des soins non programmés ambulatoires. Il répond à la volonté de convergence des professionnels de santé de la ville et de l’hôpital dans un objectif d’efficience grâce à l’adaptation de la réponse sanitaire au besoin de soins réels du patient. Accéder au SAS par le numéro commun santé contribue à la mise en œuvre globale d’un dispositif pertinent au regard des contraintes opérationnelles et médicoéconomiques actuelles.

Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for patients with chest pain: a systematic literature review

OBJECTIVE

To systematically appraise the available evidence to determine the accuracy of decision aids for emergency medical services (EMS) telephone triage of patients with chest pain suspected to be caused by acute coronary syndrome (ACS) or life-threatening conditions.

DESIGN

Systematic review.

DATA SOURCES

Electronic searches were performed in Embase 1974, Medline 1946 and CINAHL 1937 databases from 3 March 2020 to 4 March 2020.

ELIGIBILITY CRITERIA

The review included all types of original studies that included adult patients (>18 years) who called EMS with a primary complaint of chest pain and evaluated dispatch triage priority by telephone. Outcomes of interest were a final diagnosis of ACS, acute myocardial infarction or other life-threatening conditions.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted data on study design, population, study period, outcome and all data for assessment of accuracy, including cross-tabulation of triage priority against the outcomes of interest. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 assessment tool.

RESULTS

Searches identified 553 papers, of which 3 were eligible for inclusion. Those reports described the evaluation of three different prediction models with variation in the variables used to detect ACS. The overall results showed that dispatch triage tools have good sensitivity to detect ACS and life-threatening conditions, even though they are used to triage signs and symptoms rather than diagnosing the patients. On the other hand, prediction models were built to detect ACS and life-threatening conditions, and therefore, prediction models showed better sensitivity and negative predictive value than dispatch triage tools.

CONCLUSION

We have identified three prediction models for telephone triage of patients with chest pain. While they have been found to have greater accuracy than standard EMS dispatch systems, prospective external validation is essential before clinical use is considered.

PROSPERO REGISTRATION NUMBER

This systematic review was pre-registered on the International prospective register of systematic reviews (PROSPERO) database (reference CRD42020171184).

Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study

OBJECTIVES

To describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions.

DESIGN

Prospective observational cohort study.

SETTING

Two centre study in a Swedish county emergency medical services (EMS) organisation.

PARTICIPANTS

Unselected inclusion of 2917 patients with chest pain contacting the EMS due to chest pain during 2018.

PRIMARY OUTCOME MEASURES

Low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge.

RESULTS

Of included EMS missions, 68% concerned patients with a low-risk condition without medical need of acute hospital treatment in hindsight. Sixteen per cent concerned patients with a high-risk condition in need of rapid transport to hospital care. Numerous variables with significant association with low-risk or high-risk conditions were found. In total high-risk and low-risk prediction models shared six predictive variables of which ST-depression on ECG and age were most important. Previously known risk factors such as history of acute coronary syndrome, diabetes and hypertension had no predictive value in the multivariate analyses. Some aspects of the symptoms such as pain intensity, pain in the right arm and paleness did on the other hand appear to be helpful. The area under the curve (AUC) for prediction of low-risk candidates was 0.786 and for high-risk candidates 0.796. The addition of troponin in a subset increased the AUC to >0.8 for both.

CONCLUSIONS

A majority of patients with chest pain cared for by the EMS suffer from a low-risk condition and have no prognostic reason for acute hospital care given their diagnosis on hospital discharge. A smaller proportion has a high-risk condition and is in need of prompt specialist care. Building models with good accuracy for prehospital identification of these groups is possible. The use of risk stratification models could make a more personalised care possible with increased patient safety.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.