Safety and efficiency of emergency department assessment of chest discomfort

Prior electrocardiograms not useful for machine learning predictions of major adverse cardiac events in emergency department chest pain patients

At the emergency department (ED), it is important to quickly and accurately determine which patients are likely to have a major adverse cardiac event (MACE). Machine learning (ML) models can be used to aid physicians in detecting MACE, and improving the performance of such models is an active area of research. In this study, we sought to determine if ML models can be improved by including a prior electrocardiogram (ECG) from each patient. To that end, we trained several models to predict MACE within 30 days, both with and without prior ECGs, using data collected from 19,499 consecutive patients with chest pain, from five EDs in southern Sweden, between the years 2017 and 2018. Our results indicate no improvement in AUC from prior ECGs. This was consistent across models, both with and without additional clinical input variables, for different patient subgroups, and for different subsets of the outcome. While contradicting current best practices for manual ECG analysis, the results are positive in the sense that ML models with fewer inputs are more easily and widely applicable in practice.

Can ED chest pain patients with intermediate HEART scores be managed as outpatients?

PURPOSE

Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics.

METHODS

This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score.

RESULTS

There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8).

CONCLUSION

This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.

Suboptimal prehospital decision- making for referral to alternative levels of care - frequency, measurement, acceptance rate and room for improvement

Background

The emergency medical services (EMS) have undergone dramatic changes during the past few decades. Increased utilisation, changes in care-seeking behaviour and competence among EMS clinicians have given rise to a shift in EMS strategies in many countries. From transport to the emergency department to at the scene deciding on the most appropriate level of care and mode of transport. Among the non-conveyed patients some may suffer from “time-sensitive conditions” delaying diagnosis and treatment. Thus, four questions arise:

How often are time-sensitive cases referred to primary care or self-care advice?

How can we measure and define the level of inappropriate clinical decision-making?

What is acceptable?

How to increase patient safety?

Main text

To what extent time-sensitive cases are non-conveyed varies. About 5–25% of referred patients visit the emergency department within 72 hours, 5% are hospitalised, 1–3% are reported to have a time-sensitive condition and seven-day mortality rates range from 0.3 to 6%.

The level of inappropriate clinical decision-making can be measured using surrogate measures such as emergency department attendances, hospitalisation and short-term mortality. These measures do not reveal time-sensitive conditions. Defining a scoring system may be one alternative, where misclassifications of time-sensitive cases are rated based on how severely they affected patient outcome.

In terms of what is acceptable there is no general agreement. Although a zero-vision approach does not seem to be realistic unless under-triage is split into different levels of severity with zero-vision in the most severe categories.

There are several ways to reduce the risk of misclassifications. Implementation of support systems for decision-making using machine learning to improve the initial assessment is one approach. Using a trigger tool to identify adverse events is another.

Conclusion

A substantial number of patients are non-conveyed, including a small portion with time-sensitive conditions. This poses a threat to patient safety. No general agreement on how to define and measure the extent of such EMS referrals and no agreement of what is acceptable exists, but we conclude an overall zero-vision is not realistic. Developing specific tools supporting decision making regarding EMS referral may be one way to reduce misclassification rates.

Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity

BACKGROUND

Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life.

METHODS

A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points.

RESULTS

Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up.

CONCLUSIONS

Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.

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

Background

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

Methods

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

Results

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

Conclusion

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

Value of Repeated Troponin Measurements to Improve the Safety of the HEART Score for Chest Pain Patients at the Emergency Department

OBJECTIVE

The HEART score is a clinical decision support tool for physicians to stratify the risk of major adverse cardiac events (MACE) in patients presenting with chest pain at the emergency department. The score includes 5 elements, including troponin level. Our aim was to compare safety and efficiency of the HEART scores calculated by using the first representative troponin (ie, based on time since symptom onset) compared to the original HEART score, where calculation was based on the first available troponin measurement, irrespective of duration of symptoms.

METHODS

We performed a secondary analysis on patients from the HEART-impact trial (2013-2014, the Netherlands). Two HEART scores were calculated for all patients: a HEART score with a T (troponin) element score based on the first available troponin (HEART-first) and 1 with a T element score based on the first representative troponin (ie, at least 3 hours after symptom onset; HEART-representative). We compared all patients' scores and risk categories between HEART-first and HEART-representative. Furthermore, we compared safety (proportion of patients with MACE receiving a low score) and efficiency (proportion of patients with a low score) between HEART-first and HEART-representative.

RESULTS

We included 1222 patients. In 882 (72%) patients, the first troponin was representative, resulting in the same HEART-first and HEART-representative score. In the remaining 340 patients the use of HEART-representative led to a different score than HEART-first in 43 patients (3.5%). Out of the 222 patients with MACE, 11 patients (5.0%) received a low score by using HEART-first compared with 10 patients (4.5%) when using HEART-representative (P = 0.83). The number of patients with a low score was similar (P = 0.93) when using the HEART-first (464/1222; 38%) or HEART-representative score (462/1222; 38%).

CONCLUSIONS

Using a representative troponin measurement changed the value of the HEART score in only 3.5% of patients and had no impact on safety and efficiency of the HEART score. These results suggest there is no need to wait for a representative troponin measurement and should encourage physicians to adhere to the original HEART score guidelines.

Evaluation of TP-E Interval and TP-E/QT Ratio in Panic Disorder

Background and Objectives: The autonomic nervous system (ANS) is involved in panic disorders. ANS dysfunction has been shown to be associated with ventricular arrhythmia and increased heterogeneity of ventricular repolarization. However, there remains limited evidence of the relationship between panic disorders and ventricular depolarization markers, including the Tp-e interval and Tp-e/QT ratio. This study aimed to evaluate ventricular repolarization parameters in patients with panic disorder. Materials and Methods: In total, 40 patients with panic disorder, diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, were included in the study group. The control group comprised of 50 age- and sex-matched healthy individuals. A standard 12 lead electrocardiogram was recorded on all participants, and heart rate, QT interval, QRS duration, Tp-e interval, and Tp-e/QT ratio were measured. Results: QRS durations and QT intervals were similar in the study and control groups. Compared to the control group, QTd, Tp-e, and cTp-e intervals as well as Tp-e/QT and Tp-e/QTc ratios were significantly increased in patients with panic disorder (p < 0.05 for all). In the study group, the Severity Measure for Panic Disorder-Adult score had a significant positive correlation with the Tp-e interval (r = 0.369, p < 0001), cTp-e interval (r = 0.531, p < 0.001), Tp-e/QT ratio (r = 0.358, p = 0.001), and Tp-e/QTc ratio (r = 0.351, p = 0.001). Conclusion: These findings indicate that panic disorders are associated with increased ventricular repolarization heterogeneity, which may be attributed to ANS dysregulation.

Comparison of usual care and the HEART score for effectively and safely discharging patients with low-risk chest pain in the emergency department: would the score always help?

Background

Triage decisions for chest pain patients receiving usual care are based on a dynamic and comprehensive strategy performed in the physician's mind. It remains controversial whether simple, structured risk tools can surpass real, complex judgments.

Hypothesis

The potentially used History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score would help identify low‐risk patients for discharge.

Methods

Patients with acute, non‐traumatic chest pain managed according to usual care were consecutively enrolled in a tertiary university hospital in China from August 24, 2015 to September 30, 2017. Major adverse cardiac events (MACE) included death, acute myocardial infarction, revascularization, and significant coronary stenosis (>50%) within 30 days. We compared the efficacy and safety of usual care and the potentially used HEART score in this population.

Results

Of 2185 patients analyzed, 926 (42.4%) patients were directly discharged by usual care, whereas HEART≤3 would have identified 524 (24.0%) patients as low‐risk (P < .001). The MACE rate in discharged patients was 2.2% (20/926) and would have been 5.2% (27/524) in those with HEART≤3 (P = .002). For discharged patients, the MACE rates in HEART≤3 vs HEART>3 groups were not significantly different (1.5% vs 2.7%, P = .225). Negative predictive value (NPV) was higher with usual care than with the HEART score (P = .003), but sensitivity was similar. For 340 patients with serial troponins, usual care was superior to the potentially used HEART score in regard to efficacy.

Conclusions

At this institution, usual care identified many more patients for discharge than the HEART score would have without apparently different outcomes in discharged patients with lower vs higher HEART scores. The HEART score would not appear to provide helpful risk stratification.

Evaluating possible acute coronary syndrome in primary care: the value of signs, symptoms, and plasma heart-type fatty acid-binding protein (H-FABP). A diagnostic study

Background

Additional diagnostic means could be of added value when evaluating possible acute coronary syndrome (ACS) in primary care.

Aim

To determine whether heart-type fatty acid-binding protein (H-FABP)-based point-of-care (POC) biomarker testing, embedded in a clinical decision rule (CDR), is helpful to the GP when evaluating possible ACS.

Design & setting

A prospective, non-randomised, double-blinded, diagnostic derivation study was undertaken, with a delayed-type cross-sectional diagnostic model among GPs in the Netherlands and Belgium.

Method

Signs and symptoms predicting acute myocardial infarction (AMI) or ACS were identified using both logistic regression analysis, and classification and regression trees (CART). Diagnostic values of the POC H-FABP test (cut-off value 4 ng/ml) alone and as part of a CDR were determined.

Results

A total of 303 participants (48.8% male) with chest pain or discomfort who had consulted a GP were enrolled. ACS was found in 32 (10.6%) of these 303 patients. For ACS, sensitivity and negative predictive value (NPV) of the POC H-FABP test was 25.8% (95% confidence interval [CI] = 12.5 to 44.9) and 91.6% (95% CI = 87.6% to 94.5%), respectively. The area under the receiver operating curve of the optimal CDR was 0.78 for ACS.

Conclusion

Sensitivity of the current H-FABP POC test (cut-off value 4 ng/ml) as a stand-alone test is poor, either owing to limitations of the marker or of the test device. Usability of a CDR derived from these results is doubtful: the number of ACS cases missed by the GP is reduced but, as a consequence, disproportionally more ACS-negative patients are referred.

Incidence of panic disorder in patients with non-cardiac chest pain and panic attacks

This study documented the 6-month incidence of panic disorder and its predictors in emergency department patients with panic attacks and non-cardiac chest pain. The assessment included a validated structured interview to identify panic attacks and questionnaires measuring the potential predictors of panic disorder. Presence of panic disorder was assessed 6 months later. The incidence of panic disorder was 10.1 percent ( n = 14/138). Anxiety sensitivity was the only significant predictor of the incidence of panic disorder (odds ratio = 1.06; 95% confidence interval = 1.01–1.12). Patients with panic attacks and non-cardiac chest pain are at an elevated risk for panic disorder. This vulnerability appears to increase with anxiety sensitivity.

Comparison of nine coronary risk scores in evaluating patients presenting to hospital with undifferentiated chest pain

INTRODUCTION

We compared performance of nine risk scores for coronary heart disease (CHD) among patients presenting to an emergency department (ED) with undifferentiated chest pain of possible coronary origin.

METHODS

A retrospective study was undertaken of adult patients presenting with chest pain to atertiary hospital ED with no electrocardiographs or troponin results diagnostic of ischemic chest pain (ICP) or acute coronary syndrome at ED presentation, and no clearly evident noncoronary diagnosis. Risk scores were applied using cut-points distinguishing low- from high-risk patients according to discharge diagnosis of noncardiac chest pain (NCCP) or ICP, respectively. A lower odds ratio (OR) for ICP denoted lower risk for ICP. Score performance was compared using area under receiver-operator characteristic curves (AUC) and predictive values.

RESULTS

A total of 401 patients were studied, of whom 123 (30.7%) had ICP as final diagnosis. Among the nine risk scores, those with greatest ability to detect low-risk patients were The North American Chest Pain Rule (NACPR) score (OR=0.35, 95% CI=0.27-0.46); History, ECG, Age, Risk Factors, and Troponin (HEART) score (OR=0.43; 95% CI=0.35-0.52); and Thrombolysis in Myocardial Infarction (TIMI) score (OR=0.49; 95% CI=0.41-0.58). Discrimination between patients with NCCP and those with ICP was greatest for HEART score (AUC=0.82; 95% CI=0.78-0.86) and lowest for Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT) score (AUC=0.63; 95% CI=0.58-0.69). In excluding ICP, ADAPT had negative predictive value (NPV) 100% (miss rate 0%) but classified only 1.7% of patients as low risk, compared to NACPR with NPV 98% (miss rate 2%), classifying 10.2% as low risk, and HEART with NPV 94% (miss rate 6%), classifying 32.4% as low risk.

CONCLUSION

The NACPR risk score maximized yield of low-risk patients with lowest miss rate for ICP, while HEART score classified highest proportion of low-risk patients but with a higher miss rate.

Evaluation and management of patients with acute chest pain in China (EMPACT): protocol for a prospective, multicentre registry study

INTRODUCTION

Acute chest pain represents a major healthcare burden in emergency departments (ED) throughout the world. Among these patients, rapidly determining whether an acute coronary syndrome (ACS) is evolving remains difficult. In China, there are limited data correlating the baseline characteristics, evaluation and management of ED patients with acute chest pain and ACS-related symptoms with clinical outcomes. Nor has there been an evaluation of outcomes at different levels of hospitals. The Evaluation and Management of Patients with Acute ChesT pain in China (EMPACT) study will address this evidence gap through a regional representative prospective registry.

METHODS AND ANALYSIS

Twenty-two public hospitals with ED in Shandong province have been selected based on a stratified random sampling approach. A total of 10 000 patients with acute chest pain or suspected ACS presenting to the ED will be consecutively enrolled from January 2016 to September 2017. Episodes of care will be evaluated for key performance measures such as the time to first ECG, receipt of troponin testing, receipt of reperfusion therapy for ST segment elevation ACS and provision of angiography for troponin-positive patients. All patients will be assessed for the composite endpoint of adjudicated major adverse cardiac events in 30 days after presentation, including death from all causes, non-fatal myocardial infarction, urgent revascularisation, stroke, cardiac arrest and cardiogenic shock. The secondary outcomes include revisit to ED and rehospitalisation within 30 days.

ETHICS AND DISSEMINATION

Ethics approval was obtained at all participating centres. The registry is the first attempt to comprehensively evaluate the current emergency care of acute chest pain from a regional representative sample in China. Findings will allow new opportunities to facilitate the clinical quality improvements and ultimately reduce the mortality in patients with acute chest pain and suspected ACS.

TRIAL REGISTRATION NUMBER

NCT02536677; Pre-results.

Do Patients with Chest Pain Benefit from Installing Triage System in Emergency Department?

INTRODUCTION

Chest pain, which can be cardiac or non-cardiac and either benign or life-threatening, needs appropriate diagnosis and treatment in emergency department (ED).

OBJECTIVE

The aim of this study was to compare delivery time of primary care for patients with chest pain before and after applying triage system in ED.

METHODS

Medical records were reviewed of thirty patients (group one) with chief complaint of chest pain who referred to ED between April and July 2008 (before installing triage system) and thirty-five patients (group two) with the same chief complaint who referred between August and September 2009 (after installing triage system). Time between patients' arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and electrocardiogram performance were compared between the two groups.

RESULTS

Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p>0.05). Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post triage installing period than previously (p<0.001). Door to first visit by physician was not statistically different in the two study periods (p=0.421).

CONCLUSION

It is likely that patients with chest pain who referred to ED benefit from installing triage system in terms of performing some nursing care including ECG performance, starting cardiac monitoring, and IV insertion.

The prevalence of non-cardiac chest pain (NCCP) using emergency department (ED) data: a Northern Ireland based study

Background

The aim of this study was to assess the frequency of chest pain presentations and the subsequent non-cardiac chest pain diagnoses in an emergency department (ED) over a 3 year period.

Methods

Administrative data on ED attendances to an urban general hospital in Northern Ireland between March 2013 and March 2016 were used. Data were coded and analysed to estimate frequencies of ‘chest pain’ presentation and the subsequent diagnoses for each year.

Results

Both chest pain presentations and chest pain presentations with a subsequent diagnosis of unknown cause increased each year. In total, 58.7% of all chest presentations across 3 years resulted in a non-cardiac diagnosis of either ‘anxiety’, ‘panic’ or ‘chest pain of unknown cause’.

Discussion

There is a significant amount of patients in the ED leaving with a non-cardiac diagnosis, following an initial presentation with chest pain.

Conclusion

Given the link between non-cardiac chest pain and frequent use of services, the degree of repeat attendance should be investigated.

A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events

BACKGROUND

A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction.

OBJECTIVES

The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm).

METHODS

This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician's assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause.

RESULTS

In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10.

CONCLUSIONS

A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.

Identifying Low-risk Patients for Early Discharge From Emergency Department Without Using Subjective Descriptions of Chest Pain: Insights From Providing Rapid Out of Hospital Acute Cardiovascular Treatment (PROACT) 3 and 4 Trials

BACKGROUND

Several accelerated diagnostic protocols (ADPs) have been developed to allow emergency department (ED) physicians to identify appropriate patients for safe early discharge after presentation with symptom of chest pain. Most ADPs require chest pain to be described and modify the algorithm based on the subjective chest pain characteristics. We investigated the performance of three established major ADPs simplified by eliminating the need for chest pain as a descriptor.

METHODS

We pooled patients from PROACT-3 and -4 trials, in which patients presenting to emergency medical services with chest pain or dyspnea were enrolled. The simplified Vancouver Chest Pain Rule (sVCPR), the simplified Emergency Department Assessment of Chest Pain Score (sEDACS) ADP and the Accelerated Diagnostic protocol to Assess Patients with chest pain using contemporary troponins as the only biomarker (ADAPT-ADP) were compared using the sensitivity, specificity, and positive and negative predictive values (NPV). The primary outcome of interest was 30-day major adverse cardiac events (MACE); the diagnosis of acute coronary syndrome (ACS) occurring within 30 days after ED presentation was also explored.

RESULTS

A total of 1,081 patients were included (median age = 67 years, 53% male, median GRACE score = 113) of which 222 ACS diagnoses and 150 cardiac events occurred within 30 days after index ED presentation. The sVCPR, sEDACS ≥ 3, and ADAPT-ADP, respectively, identified 9.7, 13.3, and 4.1% of patients as low risk with a sensitivity and NPV of 100% for the primary outcome of 30-day MACE. The sEDACS-ADP identified 24.2% of patients as low risk with a cut-point score of 4 (sensitivity of 98.0% and NPV of 98.8%). The sVCPR, sEDACS ≥ 3, and ADAPT-ADP, respectively, had NPVs of 98.1, 95.8, and 93.3% in identifying patients at higher risk of ACS diagnosis within 30 days after index ED visit.

CONCLUSION

The diagnostic protocols performed well without their chest pain characteristics component. Further studies are suggested to explore the performance of ADPs when these simplified ADPs are combined with high-sensitive troponin assays.

A closer look at the relationships between panic attacks, emergency department visits and non-cardiac chest pain

This study examined the prevalence of emergency department visits prompted by panic attacks in patients with non-cardiac chest pain. A validated structured telephone interview was used to assess panic attacks and their association with the emergency department consultation in 1327 emergency department patients with non-cardiac chest pain. Patients reported at least one panic attack in the past 6 months in 34.5 per cent (95% confidence interval: 32.0%–37.1%) of cases, and 77.1 per cent (95% confidence interval: 73.0%–80.7%) of patients who reported panic attacks had visited the emergency department with non-cardiac chest pain following a panic attack. These results indicate that panic attacks may explain a significant proportion of emergency department visits for non-cardiac chest pain.

Does Concordance with Guideline Triage Recommendations Affect Clinical Care of Patients with Possible Acute Coronary Syndrome?

Background. The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. Methods. This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias. Results. Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63—1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69—0.96). Conclusions. This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.

Predictors of Adverse Outcomes of Patients with Chest Pain and Primary Diagnosis of Non-Cardiac Pain at the Time of Discharge from Emergency Department: A 30-Days Prospective Study

Background

Chest pain is a common symptom for referring patients to emergency departments (ED). Among those referred, some are admitted to hospitals with a definite or tentative diagnosis of acute coronary syndrome and some are discharged with primary diagnosis of non-cardiac chest pain. This study aimed at investigating 30 days' adverse outcomes of patients discharged from ED of a major heart center in Iran.

Methods

Out of 1638 chest pain admissions to the centre during 2010–2011, 962 patients (mean age= 50.9±15.9 years) who were admitted to Afshar Heart Center's ED with chest pain as their chief complaint, and discharged with primary diagnosis of non-cardiac chest pain, were followed for any adverse cardiac events 30 days post discharge. The adverse events were: unstable angina, non-ST-elevated myocardial infarction (NSTEMI), ST elevated myocardial infarction (STEMI), coronary revascularization (percutaneous angioplasty, coronary artery bypass grafting) and death.

Results

Adverse cardiac events, including acute coronary syndrome (ACS), revascularization and death were observed in 30 patients (3.1%) including: acute MI n=5 (0.5%, sudden cardiac death inn=1 (0.1%, coronary revascularization in n=8 (0.8%) and hospitalization due to unstable angina/NSTEMI in n=16 (1–7%). Adverse events were seen more frequently in patients with history of hypertension, dyslipidemia and previous coronary artery disease. In univariate analysis, the chance of postdischarge adverse cardiac events was higher in patients with hypertension (OR=9.36, CI=3.24–27.03), previous coronary artery disease (OR= 3.8, CI=1.78–8.0), dyslipidemia (OR=3.5, CI=1.7–7.38) and discharge against medical advice (OR=2.85, CI= 1.37–5.91).

Conclusion

The extent of adverse cardiac events in patients with a primary diagnosis of non-cardiac chest pain within 30 days of discharge was significant, mandating nation-wide registries to provide better care for these patients.

Efficiency and safety of coronary CT angiography compared to standard care in the evaluation of patients with acute chest pain: a Canadian study

The optimal assessment of patients with chest pain and possible acute coronary syndrome (ACS) remains a diagnostic dilemma for emergency physicians. Cardiac computed tomographic angiography (CCTA) may identify patients who can be safely discharged home from the emergency department (ED). The objective of the study was to compare the efficiency and safety of CCTA to standard care in patients presenting to the ED with low- to intermediate-risk chest pain. This was a single-center before-after study enrolling ED patients with chest pain and low to intermediate risk of ACS, before and after implementing a cardiac CT-based management protocol. The primary outcome was efficiency (time to diagnosis). Secondary outcomes included safety (30-day incidence of major adverse cardiovascular events (MACE)) and length of stay in the ED. We enrolled 258 patients: 130 in the standard care group and 128 in the cardiac CT-based management group. The cardiac CT group had a shorter time to diagnosis of 7.1 h (IQR 5.8-14.0) compared to 532.9 h (IQR 312.8-960.5) for the standard care group (p < 0.0001) but had a longer length of stay in the ED of 7.9 h (IQR 6.5-10.8) versus 5.5 h (IQR 3.9-7.7) (p < 0.0001). The MACE rate was 1.6 % in the standard care group and 0 % in the cardiac CT group. In conclusion, a cardiac CT-based management strategy to rule out ACS in ED patients with low- to intermediate-risk chest pain was safe and led to a shorter time to diagnosis but increased length of stay in the ED.

Clinical assessment of patients with chest pain; a systematic review of predictive tools

Background

The clinical assessment of patients with chest pain of recent onset remains difficult. This study presents a critical review of clinical predictive tools for the assessment of patients with chest pain.

Methods

Systematic review of observational studies and estimation of probabilities of coronary artery disease (CAD) in patients with chest pain. Searches were conducted in PubMed, Embase, Scopus, and Web of Science to identify studies reporting tools, with at least three variables from clinical history, physical examination or ECG, produced with multivariate analysis, to estimate probabilities of CAD in patients with chest pain of recent onset, published from inception of the database to the 31^st July 2015. The references of previous relevant reviews were hand searched. The methodological quality was assessed with standard criteria. Since the incidence of CAD has changed in the past few decades, the date of publication was acknowledged to be relevant in order to use the tool in clinical practice, and more recent papers were considered more relevant. Probabilities of CAD according to the studies of highest quality were estimated and the evidence provided was graded.

Results

Twelve papers were included out of the 19126 references initially identified. The methodological quality of all of them was high. The clinical characteristics of the chest pain, age, past medical history of cardiovascular disease, gender, and abnormalities in the ECG were the predictors of CAD most commonly reported across the studies. The most recent papers, with highest methodological quality, and most practical for use in clinical settings, reported prediction or exclusion of CAD with area under the curve 0.90 in Primary Care, 0.91 in Emergency department, and 0.79 in Cardiology. These papers provide evidence of high level (1B) and the recommendation to use their results in the management of patients with chest pain is strong (A).

Conclusions

The risk of CAD can be estimated on clinical grounds in patients with chest pain in different clinical settings with high accuracy. The estimation of probabilities of CAD presented in these studies could be used for a better management of patients with chest pain and also in the development of future predictive tools.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0196-4) contains supplementary material, which is available to authorized users.

A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study

STUDY OBJECTIVE

The high volume of patients treated in an emergency department (ED) for atrial fibrillation is predicted to increase significantly in the next few decades. Currently, 11% of these patients die within a year. We sought to derive and validate a complex model and a simplified model that predicts mortality in ED patients with atrial fibrillation.

METHODS

This population-based, retrospective cohort study included 3,510 adult patients with a primary diagnosis of atrial fibrillation who were treated at 24 hospital EDs in Ontario, Canada, between April 2008 and March 2009. The main outcome was 30-day all-cause mortality.

RESULTS

In the derivation cohort (n=2,343; mean age 68.8 years), 2.6% of patients died within 30 days of the ED visit versus 2.7% in the validation cohort (n=1,167; mean age 68.3 years). Variables associated with mortality in the complex model included age, presenting pulse rate and systolic blood pressure, presence of chest pain, 2 laboratory results (positive troponin result and creatinine level greater than 200 μmol [2.26 mg/dL]), 4 comorbidities (smoking, chronic obstructive pulmonary disease, cancer, and dementia), an increased bleeding risk, and a second acute ED diagnosis (in addition to atrial fibrillation). Observed 30-day mortality in the 5 risk strata that were defined by the predicted probability of death were 0.44%, 0.41%, 0.23%, 1.61%, and 10.3%. The c statistics were 0.88 and 0.87 in the derivation and validation cohorts, respectively. The a priori-selected 6-variable model, TrOPs-BAC, included a positive Troponin result, Other acute ED diagnosis, Pulmonary disease (chronic obstructive pulmonary disease), Bleeding risk, Aged 75 years or older, and Congestive heart failure. The c statistic for the simplified model was 0.81 in both the derivation and validation cohorts.

CONCLUSION

Using a population-based sample, we derived and validated both a complex and a simplified instrument that predicts mortality after an emergency visit for atrial fibrillation. These may aid clinicians in identifying high-risk patients for hospitalization while safely discharging more patients home.

The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers

OBJECTIVE

High-sensitivity troponin T (hs-TnT) assays detect myocardial injury sooner, possibly improving throughput times for emergency department (ED) assessment of suspected acute myocardial infarction (AMI). This study evaluates the influence of hs-TnT implementation on ED length of stay (LOS), consultations and admissions, as well as ED revisits with cardiology admissions for patients undergoing testing for suspected AMI.

METHODS

This control pre-post design analysis included patients evaluated using hs-TnT or conventional troponin T. Data were collected from 3 ED databases for patients who had a troponin assay for suspected AMI for the periods February 12, 2011-April 22, 2011 (Ctrl); November 20, 2011-January 28, 2012 (Pre); and February 12, 2012-April 21, 2012 (Post). The primary outcome was ED LOS; secondary outcomes included the proportions of patients who received ED cardiology consultations, patients who were admitted to hospital, and discharged patients who revisited the ED within 30 days.

RESULTS

Data were analyzed from 6650 (Ctrl), 6866 (Pre), and 5754 (Post) patients. Median ED LOS decreased following hs-TnT implementation (6.60 hours in Ctrl and Pre vs 6.10 hours in Post, P < .001). There was no change in cardiology consultations or admissions following hs-TnT implementation. Fewer ED revisits occurred within 30 days in Post (16.0% Ctrl, 16.5% Pre vs 14.9% Post; P < .01). These results were preserved after adjusting for age and Canadian Triage Acuity Score.

CONCLUSIONS

This hs-TnT implementation strategy, using an equivalent cutoff for the conventional troponin T and hs-TnT assays, decreased ED LOS for patients with suspected AMI and did not increase cardiology resource utilization or ED revisits.

Alignment of site versus adjudication committee–based diagnosis with patient outcomes: Insights from the Providing Rapid Out of Hospital Acute Cardiovascular Treatment 3 trial

Background:

Adjudication by an adjudication committee in clinical trials plays an important role in the assessment of outcomes. Controversy exists regarding the utility of adjudication committee versus site-based assessments and their relationship to subsequent clinical events.

Methods:

This study is a secondary analysis of the Providing Rapid Out of Hospital Acute Cardiovascular Treatment-3 trial, which randomized patients with chest pain or shortness of breath for biomarker testing in the ambulance. The emergency department physician diagnosis at the time of emergency department disposition was compared with an adjudicated diagnosis assigned by an adjudication committee. The level of agreement between emergency department and adjudication committee diagnosis was evaluated using kappa coefficient and compared to clinical outcomes (30-day re-hospitalization, 30-day and 1-year mortality).

Results:

Of the 477 patients, 49.3% were male with a median age of 70 years; hospital admission rate was 31.2%. The emergency department physicians and the adjudication committee disagreed in 55 cases (11.5%) with a kappa of 0.71 (95% confidence interval: 0.64, 0.78). The 30-day re-hospitalization, 30-day mortality, and 1-year mortality were 22%, 1.9%, and 9.4%, respectively. Although there were similar rates of re-hospitalization irrespective of adjudication, in cases of disagreement compared to agreement between adjudication committee and emergency department diagnosis, there was a higher 30-day (7.3% vs 1.2%, p = 0.002) and 1-year mortality (27.3% vs 7.1%, p < 0.001).

Conclusion:

Despite substantial agreement between the diagnosis of emergency department physicians and adjudication committee, in the subgroup of patients where there was disagreement, there was significantly worse short-term and long-term mortality.

Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial

Introduction:

Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP).

Methods:

Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations.

Results:

Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ2= 6.69,p&lt; 0.001) with a relative risk of 1.29 (95% confidence interval 1.18–1.40), and the results remained significant after a “worst case” sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary.

Conclusion:

When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.

Application of Lean principles to improve early cardiac care in the emergency department

Objective:

To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED).

Methods:

Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study.

Results:

The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p&lt; 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p= 0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (pvalues &lt; 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources.

Conclusions:

The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED.

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Objectives:

Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing.

Methods:

This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000–2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results.

Results:

In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4–100.0) and 23.4% specific (95% CI 20.6–26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is &lt; 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule.

Conclusion:

The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation.

The value of signs, symptoms and plasma heart-type fatty acid-binding protein (H-FABP) in evaluating patients presenting with symptoms possibly matching acute coronary syndrome: background and methods of a diagnostic study in primary care

Background

Chest complaints presented to a general practitioner (GP) are frequently caused by diseases which have advantageous outcomes. However, in some cases, acute coronary syndrome (ACS) is present (1.5-22% of cases). The patient’s signs, symptoms and electrocardiography results are insufficient diagnostic tools to distinguish mild disease from ACS. Therefore, most patients presenting chest complaints are referred to secondary care facilities where ACS is then ruled out in a majority of patients (78%). Recently, a point of care test for heart-type fatty acid-binding protein (H-FABP) using a low cut-off value between positive and negative of 4 ng/ml has become available. We aim to study the role of this point of care device in triage of patients presenting chest complaints possibly due to ACS, in primary care. Our research protocol is presented in this article. Results are expected in 2015.

Methods/Design

Participating GPs will register signs and symptoms in all patients presenting chest complaints possibly due to ACS. Point of care H-FABP testing will also be performed. Our study will be a derivation study to identify signs and symptoms that, combined with point of care H-FABP testing, can be part of an algorithm to either confirm or rule out ACS. The diagnostic value for ACS of this algorithm in general practice will be determined.

Discussion

A safe diagnostic elimination of ACS by application of the algorithm can be of significant clinical relevance. Improved triage and thus reduction of the number of patients with chest complaints without underlying ACS, that are referred to secondary care facilities, could lead to a substantial cost reduction.

Trial registration

ClinicalTrials.gov, NCT01826994, accepted April 8^th 2013.

Sensitivity, specificity, and sex differences in symptoms reported on the 13-item acute coronary syndrome checklist

Background

Clinical symptoms are part of the risk stratification approaches used in the emergency department (ED) to evaluate patients with suspected acute coronary syndromes (ACS). The objective of this study was to determine the sensitivity, specificity, and predictive value of 13 symptoms for a discharge diagnosis of ACS in women and men.

Methods and Results

The sample included 736 patients admitted to 4 EDs with symptoms suggestive of ACS. Symptoms were assessed with the 13‐item validated ACS Symptom Checklist. Mixed‐effects logistic regression models were used to estimate sensitivity, specificity, and predictive value of each symptom for a diagnosis of ACS, adjusting for age, obesity, diabetes, and functional status. Patients were predominantly male (63%) and Caucasian (70.5%), with a mean age of 59.7±14.2 years. Chest pressure, chest discomfort, and chest pain demonstrated the highest sensitivity for ACS in both women (66%, 66%, and 67%) and men (63%, 69%, and 72%). Six symptoms were specific for a non‐ACS diagnosis in both women and men. The predictive value of shoulder (odds ratio [OR]=2.53; 95% CI=1.29 to 4.96) and arm pain (OR 2.15; 95% CI=1.10 to 4.20) in women was nearly twice that of men (OR=1.11; 95% CI=0.67 to 1.85 and OR=1.21; 95% CI=0.74 to 1.99). Shortness of breath (OR=0.49; 95% CI=0.30 to 0.79) predicted a non‐ACS diagnosis in men.

Conclusions

There were more similarities than differences in symptom predictors of ACS for women and men.

Ultrasound Detection of Myocardial Ischemic Memory Using an E-Selectin Targeting Peptide Amenable to Human Application

Vascular endothelial leukocyte adhesion molecules, such as E-selectin, are acutely upregulated in myocardial ischemia/reperfusion and are thus "ischemic memory" biomarkers for recent cardiac ischemia. We sought to develop an ultrasound molecular imaging agent composed of microbubbles (MBs) targeted to E-selectin to enable the differential diagnosis of myocardial ischemia in patients presenting with chest pain of unclear etiology. Biodegradable polymer MBs were prepared bearing a peptide with specific human E-selectin affinity (MB_ESEL). Control MBs had scrambled peptide (MB_CTL) or nonspecific IgG (MB_IgG). MB_ESEL adhesion to activated rat endothelial cells (ECs) was confirmed in vitro in a flow system and in vivo with intravital microscopy of rat cremaster microcirculation. Ultrasound molecular imaging of recent myocardial ischemia was performed in rats 4 hours after transient (15 minutes) coronary occlusion. MB_ESEL adhesion was higher to inflamed versus normal ECs in vitro; there was no difference in MB_CTL or MB_IgG adhesion to inflamed versus normal ECs. There was greater adhesion of MB_ESEL to inflamed versus noninflamed microcirculation and minimal adhesion of MB_CTL or MB_IgG under any condition. Ultrasound imaging after injection of MB_SEL demonstrated persistent contrast enhancement of the previously ischemic region. Videointensity in postischemic myocardium after MB_ESEL was higher than that in the nonischemic bed (11.6 ± 2.7 dB vs 3.6 ± 0.8 dB, p < .02) and higher than that after MB_CTL (4.0 ± 1.0 dB, p < .03) or MB_IgG (1.7 ± 0.1 dB, p < .03). MBs targeted to E-selectin via a short synthetic peptide with human E-selectin binding affinity enables echocardiographic detection of recent ischemia, setting the stage for clinical myocardial ischemic memory imaging to identify acute coronary syndromes.

A comparative analysis of risk stratification tools for emergency department patients with chest pain

Background

Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS).

Methods

This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC).

Results

Two hundred eighty-one patients were studied; the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi² (3) = 67.21, N = 276, p < 0.0001].

Conclusion

The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.

Low-risk chest pain patients younger than 40 years do not benefit from admission and stress testing

BACKGROUND

A number of studies have suggested clinical decision rules for patients age <40 who are at low risk for acute coronary syndrome (ACS) and may be safe for discharge from the emergency department. Despite this, many such patients continue to be admitted for observation in low-risk observation units. We hypothesized that patients age <40 without coronary artery disease, with a nonischemic electrocardiogram (ECG), and normal initial troponin I (TnI) who are admitted to a CPU are at very low risk (<1%) for ACS or 30-day major adverse cardiac event (MACE) and would not benefit from observation care.

METHODS

This was a prospective, observational study of consecutive patients admitted to the CPU in a large-volume academic urban emergency department. Eligibility criteria included age >18 but <40, American Heart Association low-to-intermediate risk, nonischemic ECGs, and normal initial TnI. Standard descriptive statistics were used for demographics, cardiac comorbidities, and risk scores. Our primary outcomes were CPU ACS rate and 30-day MACE. MACE was defined as death, nonfatal AMI, revascularization, or out of hospital cardiac arrest. A sample size of at least 400 was chosen to have 1% precision about an expected outcome rate of 0.3% (based on prior CPU data of patients of all ages). Confidence intervals (CIs) were calculated using the refined Wilson simple asymptotic method with continuity correction. All patients were called at 30 days. All charts on index visit and any subsequent visit within 30 days were reviewed using standardized chart abstractions forms by 2 trained abstractors blinded to the hypothesis of the study. A Social Security Death Index search was performed on all patients.

RESULTS

Three hundred eighty-four patients accounting for 403 CPU admissions were enrolled over a 28-month period. Mean age was 34.3 ± 4.5; 42% were women; and 89%, 8%, 2%, and 1% had Thrombolysis in Myocardial Infarction scores of 0, 1, 2, and 3, respectively. No patient had an abnormal TnI. The ACS rate was 0 (95% CI, 0-0.8%). The 30-day MACE rate was 0 (95% CI, 0-0.8%). Forty-two percentage of these patients received stress testing but 0 (95% CI, 0-1.8%) were positive.

CONCLUSIONS

Patients age <40 with a normal ECG and normal first biomarker have <1% risk of ACS or 30-day MACE, such that admission and stress testing are of no benefit.

A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department

INTRODUCTION

Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain.

METHODS AND ANALYSIS

The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument.

ETHICS AND DISSEMINATION

This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.

Evaluation and outcomes of patients admitted to a tertiary medical assessment unit with acute chest pain of possible coronary origin

OBJECTIVES

The study aims to (i) profile clinical characteristics, risk estimates of acute coronary syndrome (ACS), use and yield of non-invasive cardiac testing, discharge diagnosis and 30-day outcomes among patients admitted with acute chest pain of possible coronary origin; and (ii) construct a risk stratification algorithm that informs management decisions.

METHODS

This is a retrospective cohort study of 130 consecutive patients admitted to a tertiary hospital medical assessment unit between 24 January and 22 March 2012. Estimates of ACS risk were based on Australian guidelines and Thrombolysis in Myocardial Infarction (TIMI) scores.

RESULTS

Patients were of mean age 61 years, 45% had known coronary artery disease (CAD), 58% presented with typical ischaemic pain, 82% had intermediate to high ACS risk and 61% underwent testing. Myocardial ischaemia was cardiologist-confirmed discharge diagnosis in 29% of patients, and was associated with known CAD, typical pain, multiple risk factors and high TIMI risk scores (P < 0.001 for all associations). Of 98 non-invasive investigations, 9% (95% CI, 5-17%) were positive for myocardial ischaemia. Major adverse event rate at 30 days was 0.8% (95% CI, <0.1-6%). An algorithm was constructed that integrates known CAD, ACS risk and TIMI scores in identifying low-risk patients capable of rapid discharge from EDs without further investigation, and classifying the remainder into risk groups that informs choice of investigations and need for telemetry.

CONCLUSIONS

In patients with indeterminate chest pain, clinical features and risk scores identify most with myocardial ischaemia. An algorithm is presented that might inform triaging, early discharge, choice of testing and need for telemetry.

Validation of the Vancouver Chest Pain Rule: a prospective cohort study

OBJECTIVES

The objective was to validate the Vancouver Chest Pain Rule in an emergency department (ED) setting to identify very-low-risk patients with acute chest pain.

METHODS

A prospective cohort study was conducted on consecutive patients 25 years of age and older presenting to the ED with a chief complaint of acute chest pain during January 2009 to July 2009. According to the Vancouver Chest Pain Rule, cardiac history, chest pain characteristics, physical and electrocardiogram (ECG) findings, and cardiac biomarker measurement (creatine kinase-myocardial band isoenzyme [CK-MB]) were used to identify patients with very low risk for developing acute coronary syndrome (ACS) in 30 days. The primary outcome was defined as developing ACS (myocardial infarction or non-ST-elevation myocardial infarction [MI]/unstable angina) within 30 days of ED presentation, and all diagnoses were made using predefined explicit criteria. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

RESULTS

Of 593 patients who were eligible for evaluation, 39 (6.6%) developed MI and 43 (7.3%) developed unstable angina. Among all patients, 292 (49.2%) patients could have been assigned to the very-low-risk group and discharged after a brief ED assessment according to the Vancouver Chest Pain Rule. Among these patients, four (1.4%) developed ACS within 30 days. Sensitivity of the rule was 95.1% (95% confidence interval [CI]=88.0% to 98.7%), specificity was 56.3% (95% CI=52.0% to 60.7%), positive prediction value was 25.9% (95% CI=21.0% to 31.0%), and negative prediction value was 98.6% (95% CI=96.5% to 99.6%).

CONCLUSIONS

This study showed a lower sensitivity and higher specificity when applying the Vancouver Chest Pain Rule to this population as compared to the original study.

Imaging strategies for acute chest pain in the emergency department

OBJECTIVE

Echocardiography, radionuclide myocardial perfusion imaging (MPI), and coronary CT angiography (CTA) are the three main imaging techniques used in the emergency department for the diagnosis of acute coronary syndrome (ACS). The purpose of this article is to quantitatively examine existing evidence about the diagnostic performance of these imaging tests in this setting.

CONCLUSION

Our systematic search of the medical literature showed no significant difference between the modalities for the detection of ACS in the emergency department. There was a slight, positive trend favoring coronary CTA. Given the absence of large differences in diagnostic performance, practical aspects such as local practice, expertise, medical facilities, and individual patient characteristics may be more important.

Structured classification for ED presenting complaints - from free text field-based approach to ICPC-2 ED application

BACKGROUND

Although there is a major need to record and analyse presenting complaints in emergency departments (EDs), no international standard exists. The aim of the present study was to produce structured complaint classification suitable for ED use and to implement it in practice. The structured classification evolved from a study of free text fields and ICPC-2 classification.

METHODS

Presenting complaints in a free text field of ED admissions during a one-year period (n=40610) were analyzed and summarized to 70 presenting complaint groups. The results were compared to ICPC-2 based complaints collected in another ED. An expert panel reviewed the results and produced an ED application of ICPC-2 classification. This study implemented the new classification into an ED.

RESULTS

The presenting complaints summarized from free text fields and those from ICPC-2 categories were remarkably similar. However, the ICPC-2 classification was too broad for ED; an adapted version was needed. The newly developed classification includes 89 presenting complaints and ED staff found it easy to use.

CONCLUSIONS

ICPC-2 classification can be adapted for ED use. The authors suggest a list of 89 presenting complaints for use in EDs adult patients.

Differentiating ischemic from non-ischemic chest pain using white blood cell-surface inflammatory and coagulation markers

Chest pain is one of the most common complaints seen in emergency departments (ED), up to 5-8 % of all ED visits. About 50-60 % of chest pain patients presenting to the ED are hospitalized. Seventy percentage of those patients not discharged from the ED are subsequently shown to not have acute cardiac disease. It has been estimated that emergency physician miss 2-6 % of acute coronary syndrome (ACS) that present to ED. While admitting a non-ACS patient is a financial burden on the medical system, releasing to home an undiagnosed ACS patient has life-threatening consequences. This study used flow cytometry to evaluate a panel of mononuclear cells, neutrophils, cytokines and fibrinolytic activation markers in patients presenting in ED with acute chest pain. The goal was to add diagnostic tools to the differentiation between true ischemic cardiac and non-ischemic chest pain in the process of triage. The study population consisted of 74 consecutive patients presenting with acute chest pain to the emergency department of Ziv Medical Center and were admitted to Intensive Cardiac Care Unit or Internal Wards of our hospital during the period September 2009 to February 2010. ACS has been clearly associated with a decrease in CD89+/CD62L+ population, an increase in percentage of cytotoxic T-cell subset, and an increase in platelet marker. Differences in thrombin receptor surface expression were also noted. The combination of multiple biomarkers may help to enhance diagnostic accuracy.