Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room

Designing an ECG curriculum for residents: Evidence-based approaches to improving resident ECG interpretation skills

Residents enter their training with variable comfort and competency in electrocardiogram (ECG) interpretation. Accurately interpreting an ECG is a fundamental skill in medicine and resident physicians would benefit from a longitudinal, dedicated ECG curriculum as part of their training to enhance interpretation skills and improve patient outcomes. Educators currently employ a wide array of methodologies to teach their trainees proper ECG interpretation skills, with no single modality established as the gold-standard for teaching this crucial skill. We present evidence-based guidance on how educators may develop and implement an effective ECG interpretation curriculum as part of residency training.

Comparing the utility of clinical risk scores and integrated clinical judgement in patients with suspected acute coronary syndrome

AIMS

The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician.

METHODS AND RESULTS

Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively.

CONCLUSION

The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT00470587.

Telehealth Rapid Access Chest Pain Clinic: Initial Experience During COVID-19 Pandemic

Objectives: Rapid Access Chest Pain Clinics (RACPCs) provide safe and efficient follow-up for outpatients presenting with new-onset chest pain. RACPC delivery by telehealth has not been reported. We sought to evaluate a telehealth RACPC established during the coronavirus disease 2019 (COVID-19) pandemic. There was a need to reduce the frequency of additional testing arranged by the RACPC during this time, and the safety of this approach was also explored. Methods: This was a prospective evaluation of a cohort of RACPC patients reviewed by telehealth during the COVID-19 pandemic compared with a historical control group of face-to-face consultations. The main outcomes included emergency department re-presentation at 30 days and 12 months, major adverse cardiovascular events at 12 months, and patient satisfaction scores. Results: One hundred forty patients seen in the telehealth clinic were compared with 1,479 in-person RACPC controls. Baseline demographics were similar; however, telehealth patients were less likely to have a normal prereferral electrocardiogram than RACPC controls (81.4% vs. 88.1%, p = 0.03). Additional testing was ordered less often for telehealth patients (35.0% vs. 80.7%, p < 0.001). Rates of adverse cardiovascular events were low in both groups. One hundred twenty (85.7%) patients reported being satisfied or highly satisfied with the telehealth clinic service. Conclusions: In the setting of COVID-19, a telehealth RACPC model with reduced use of additional testing facilitated social distancing and achieved clinical outcomes equivalent to a face-to-face RACPC control. Telehealth may have an ongoing role beyond the pandemic, supporting specialist chest pain assessment for rural and remote communities. Pending further study, it may be safe to reduce the frequency of additional testing following RACPC review.

Implementation of a longitudinal, near-peer ECG didactic curriculum in an internal medicine residency program and impact on ECG interpretation skills

BACKGROUND

To determine the impact of a longitudinal, near-peer, dedicated ECG didactic curriculum on internal medicine resident ability to accurately interpret ECGs.

METHODS

This study employs a prospective cohort design. Internal medicine residents at University at Buffalo participated in monthly ECG didactic sessions over a 7-month period. Residents were invited to complete pre- and post-curriculum questionnaires. Responses were anonymous and participation voluntary. Data collected included basic demographics, career interest, exposure to clinical cardiology, and number of sessions attended. Residents were asked to interpret sixteen unique ECGs, divided evenly among eight common rhythms into both questionnaires. Pre- and post-curriculum cohorts were compared using t-tests and chi-square analyses. Associations between attendance, comfort level in interpretation, and number of correct interpretations were analyzed using Pearson correlations. Multivariate linear regression determined the strongest predictor of the number of correct ECG interpretations.

RESULTS

The post-curriculum cohort correctly interpreted a significantly greater percentage of ECGs compared to pre-curriculum cohort (74.5% vs. 60.9%, p < .001). Didactic attendance was significantly associated with comfort level in interpreting ECGs (r = .328, p = .018) and trended towards an increased number of correct interpretations (r = .248, p = .077). Residents who attended three or more sessions demonstrated increased ECG interpretation skills compared to those who attended two or fewer sessions (80.0% vs. 71.1%, p = .048). Number of clinical cardiology rotations attended was significantly associated with correct interpretations (r = .310, p < .001) and was the strongest predictor of accurately interpreting ECGs (β = 0.29, p = .037).

CONCLUSIONS

Participation in a longitudinal, near-peer ECG didactic curriculum improved resident ability to interpret ECGs. A curriculum which contains both didactic sessions and clinical exposure may offer the greatest benefit in improving ECG interpretation skills.

A comprehensive framework to estimate the frequency, duration, and risk factors for diagnostic delays using bootstrapping-based simulation methods

BACKGROUND

The incidence of diagnostic delays is unknown for many diseases and specific healthcare settings. Many existing methods to identify diagnostic delays are resource intensive or difficult to apply to different diseases or settings. Administrative and other real-world data sources may offer the ability to better identify and study diagnostic delays for a range of diseases.

METHODS

We propose a comprehensive framework to estimate the frequency of missed diagnostic opportunities for a given disease using real-world longitudinal data sources. We provide a conceptual model of the disease-diagnostic, data-generating process. We then propose a bootstrapping method to estimate measures of the frequency of missed diagnostic opportunities and duration of delays. This approach identifies diagnostic opportunities based on signs and symptoms occurring prior to an initial diagnosis, while accounting for expected patterns of healthcare that may appear as coincidental symptoms. Three different bootstrapping algorithms are described along with estimation procedures to implement the resampling. Finally, we apply our approach to the diseases of tuberculosis, acute myocardial infarction, and stroke to estimate the frequency and duration of diagnostic delays for these diseases.

RESULTS

Using the IBM MarketScan Research databases from 2001 to 2017, we identified 2,073 cases of tuberculosis, 359,625 cases of AMI, and 367,768 cases of stroke. Depending on the simulation approach that was used, we estimated that 6.9-8.3% of patients with stroke, 16.0-21.3% of patients with AMI and 63.9-82.3% of patients with tuberculosis experienced a missed diagnostic opportunity. Similarly, we estimated that, on average, diagnostic delays lasted 6.7-7.6 days for stroke, 6.7-8.2 days for AMI, and 34.3-44.5 days for tuberculosis. Estimates for each of these measures was consistent with prior literature; however, specific estimates varied across the different simulation algorithms considered.

CONCLUSIONS

Our approach can be easily applied to study diagnostic delays using longitudinal administrative data sources. Moreover, this general approach can be customized to fit a range of diseases to account for specific clinical characteristics of a given disease. We summarize how the choice of simulation algorithm may impact the resulting estimates and provide guidance on the statistical considerations for applying our approach to future studies.

Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease

Importance

The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis).

Objective

To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher.

Design, Setting, and Participants

This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022.

Interventions/Exposures

Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm.

Main Outcomes and Measures

Cardiac death or MI at 30 days determined by expert adjudicators.

Results

During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04).

Conclusions and Relevance

Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.

Racial Disparities in Hospitalization Among Patients Who Receive a Diagnosis of Acute Coronary Syndrome in the Emergency Department

Background Timely hospitalization of patients who are diagnosed with an acute coronary syndrome (ACS) at the emergency department (ED) is a crucial step to lower the risk of ACS mortality. We examined whether there are racial and ethnic differences in the risk of being discharged home among patients who received a diagnostic code of ACS at the ED and whether having health insurance plays a role. Methods and Results We examined 51 022 910 discharge records of ED visits in Florida, New York, and Utah in the years 2008, 2011, 2014, and 2016/2017 using state-specific data from the Healthcare Cost and Utilization Project. We identified ED admissions for acute myocardial infarction or unstable angina using the International Classification of Diseases, Ninth Revision (ICD-9)/International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes. We used generalized estimating equation models to compare the risk of being discharged home across racial and ethnic groups. We used Poisson marginal structural models to estimate the mediating role of health insurance status. The proportion discharged home with a diagnostic code of ACS was 12% among Black patients, 6% among White patients, 9% among Hispanic patients, and 9% among Asian/Pacific Islander patients. The incidence risk ratio for being discharged home was 1.26 (95% CI, 1.18-1.34) in Black patients, 1.23 (95% CI, 1.15-1.32) in Hispanic patients, and 1.11 (95% CI, 0.93-1.31) in Asian/Pacific Islander patients compared with White patients. Race and ethnicity were marginally associated with discharge home via pathways not mediated by health insurance. Conclusions Racial and ethnic disparities exist in the hospitalization of patients who received a diagnostic code of ACS in the ED. Possible causes need to be investigated.

Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?

BACKGROUND

Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted. The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD).

METHODS

A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments. Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated.

RESULTS

Among 4,550 patients with HEART Pathway assessments, 24.8% (1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12).

CONCLUSION

MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.

Factors associated with late presentation to the emergency department in patients complaining of chest pain

OBJECTIVE

We investigated which factors predict late presentation (LP) to the emergency department (ED) in patients with non-traumatic chest pain (CP).

METHODS

All CP cases attended at a single ED (2008-2017) were included. LP was considered if time from CP onset to ED arrival was>6 h. We analyzed associations between 42 patient/CP-related characteristics and LP in the whole cohort and in patients with CP due to acute coronary syndrome (ACS).

RESULTS

The cohort included 25,693 cases (LP=50.6%; ACS=19.0%). Twenty factors were associated with LP, and 8 were also found in patients with ACS: CP of short-duration, aggravated by exertion or breathing/movement, undulating or recurrent CP increased the risk of LP, whereas CP accompanied by diaphoresis, irradiated to the throat, and chronic treatment with nitrates decreased the risk of LP. Exertional and recurrent CP were associated with both, LP and ACS.

CONCLUSION

Some characteristics, mainly CP-related, may lead to LP to the ED. CP aggravated by exercise and recurrent CP were associated with both LP and a final diagnosis of ACS.

PRACTICE IMPLICATIONS

Patient educational initiatives should consider these two features as potential warnings for ACS and thereby encourage patients to seek early medical consultation.

Utilizing Supplemental Online Modules for Physician Assistant Student Electrocardiogram Interpretation Training

PURPOSE

The literature suggests that graduating medical and physician assistant (PA) students lack competency in electrocardiogram (ECG) interpretation. This project aimed to determine whether use of perceptual adaptive learning modules (PALMs) would improve PA students' ECG interpretation, alter self-perceptions of their ECG education, or both.

METHODS

PALMs were incorporated into the PA curriculum after lecture-based ECG learning. Students' pretest, posttest, and delayed-posttest scores were then compared. Students' ability to correctly interpret ECGs (accuracy) and the percentage of ECGs accurately interpreted within 15 seconds or less (fluency) also were evaluated. Finally, students' perceptions of PALMs and overall ECG training were assessed.

RESULTS

PALM training improved ECG interpretation accuracy and fluency (p < .0001), as well as delayed-posttest accuracy and fluency (p < .0001). The majority of student respondents felt supplemental training enhanced their learning.

CONCLUSION

These perception results combined with data on ECG interpretation improvement supports continued use of supplemental PALMs in ECG interpretation training.

Coronary CT angiography for improved assessment of patients with acute chest pain and low-range positive high-sensitivity troponins: study protocol for a prospective, observational, multicentre study (COURSE trial)

INTRODUCTION

Current evaluation of patients suspected of a non-ST-elevation acute coronary syndrome (NSTE-ACS) involves the use of algorithms that incorporate clinical information, electrocardiogram (ECG) and high-sensitivity cardiac troponins (hs-troponins). While primarily designed to rule out NSTE-ACS safely, these algorithms can also be used for rule in of NSTE-ACS in some patients. Still, in a substantial number of patients, these algorithms do not provide a conclusive work-up. These patients often present with an atypical clinical profile and low-range positive hs-troponin values without a characteristic rise or fall pattern. They represent a heterogeneous group of patients with various underlying conditions; only a fraction (30%-40%) will eventually be diagnosed with a myocardial infarction. Uncertainty exists about the optimal diagnostic strategy and their management depends on the clinical perspective of the treating physician ranging from direct discharge to admission for invasive coronary angiography. Coronary CT angiography (CCTA) is a non-invasive test that has been shown to be safe, fast and reliable in the evaluation of coronary artery disease. In this study, we will determine the usefulness of CCTA in patients with acute chest pain and low-range positive hs-troponin values.

METHODS AND ANALYSIS

A prospective, double-blind, observational, multicentre study conducted in the Netherlands. Patients aged 30-80 years presenting to the emergency department with acute chest pain and a suspicion of NSTE-ACS, a normal or non-diagnostic ECG and low-range positive hs-troponins will be scheduled to undergo CCTA. The primary outcome is the diagnostic accuracy of CCTA for the diagnosis of NSTE-ACS at discharge, in terms of sensitivity and negative predictive value.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Ethics Committee of Erasmus Medical Center in Rotterdam, the Netherlands (registration number MEC-2017-506). Written informed consent to participate will be obtained from all participants. This study's findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT03129659).

Early Noninvasive Cardiac Testing After Emergency Department Evaluation for Suspected Acute Coronary Syndrome

IMPORTANCE

Professional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI).

OBJECTIVE

To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge.

EXPOSURES

Noninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome.

MAIN OUTCOMES AND MEASURES

The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge.

RESULTS

A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin.

CONCLUSIONS AND RELEVANCE

Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.

Outcomes of an Emergency Department Observation Unit-Based Pathway for the Treatment of Uncomplicated Vaso-occlusive Events in Sickle Cell Disease

STUDY OBJECTIVE

This was a prospective, pre-post, 13-year observational study documenting the multiyear implementation of an observation unit sickle cell pathway for patients with uncomplicated vaso-occlusive events.

METHODS

The sickle cell pathway begins with rapid triage to identify patients with uncomplicated vaso-occlusive events for immediate transfer to the observation unit and initiation of patient-controlled analgesia followed by repeated evaluations of pain and identification of other complications. Data were abstracted from the electronic medical record or observation unit database. The sickle cell pathway was initiated in April 2006. Major revisions of it were carried out in June 2009 (physician evaluation occurs in sickle cell pathway and only patient-controlled analgesia administration of medications) and October 2010 (multidisciplinary management and individual dosing).

RESULTS

Annual ED visits ranged between 287 and 528. The preimplementation hospital admission rate was 33% (123/368), 3-day return rate 16% (60/368), and 30-day return rate 67% (248/368). Refinements to the sickle cell pathway have resulted in a decrease in admission rate to 20% (258/1276); 3-day return rate, to 3.6% (46/1,276); and 30-day return rate, to 41% (525/1,276) for the past 3 years.

CONCLUSION

The use of a sickle cell pathway for the treatment of uncomplicated vaso-occlusive events has been effective in providing rapid treatment and reducing hospital admissions. However, it was not only the intervention and its refinement that made the sickle cell pathway successful. With the Consolidated Framework for Implementation Research, it was discerned that outer setting factors of organizational commitment to the care of patients with SCD, inner setting factors of learning climate and leadership engagement, individuals, and process contributed to the success of the sickle cell pathway.

Role of cardiac nuclear stress perfusion exam after computed tomographic coronary angiogram for evaluation of obstructive coronary artery disease in patients with chest pain

Background

Clinical workup for chest pain varies among institutions. Acute coronary syndrome (ACS) is the primary diagnosis to rule out in the differential diagnosis, due to its associated mortality and morbidity. Although studies have demonstrated efficacy of coronary computed tomographic angiography (CCTA) in diagnosis obstructive coronary artery disease (CAD), there is limited evidence in the clinical value of performing cardiac nuclear stress perfusion imaging [myocardial perfusion imaging (MPI)] exam in patients with chest pain after undergoing CCTA. We aim to evaluate clinical value of follow-up nuclear cardiac MPI in patients with chest pain who have undergone recent CCTA.

Methods

A total of 1,000 patients were evaluated in this IRB approved retrospective study who presented with symptoms of ACS. Patients who had elevated troponin or abnormal electrocardiogram (ECG) findings at initial presentation or prior to cardiac nuclear MPI were excluded from the study. All patients who underwent 64- or 320-detector row ECG-gated CCTA as well as a follow-up nuclear MPI. Patients who had diagnostics studies limited by artifact [e.g., suboptimal intravenous (IV) contrast bolus in CCTA, motion artifact on CCTA or MPI, etc.] were excluded.

Results

One hundred patients met the inclusion criteria. Patient demographics include average age 64.3 [32–89] years, 59 male, 41 females. Ninety-five/100 patients had at least one vessel with 50–70% coronary artery diameter stenosis measured on CCTA. There were no focal perfusion abnormalities identified on cardiac nuclear MPI in patients with less than 70% stenosis diagnosed on CCTA. Five percent of patients were identified with coronary arterial narrowing greater than 70% on CCTA and all 5 of these patients have evidence of abnormal cardiac nuclear stress test (perfusion abnormalities, chest pain, abnormal ECG).

Conclusions

In low-to-intermediate risk patients with chest pain and evidence of non-critical coronary artery stenosis (i.e., less than 70% stenosis) diagnosed on CCTA, a follow-up cardiac nuclear perfusion imaging is of limited value.

External validation of an emergency department triage algorithm for chest pain patients

BACKGROUND

We aimed to externally validate an emergency department triage algorithm including five hierarchical clinical variables developed to identify chest pain patients at low risk of having an acute coronary syndrome justifying delayed rather than immediate evaluation.

METHODS

In a single-centre cohort enrolling 29,269 consecutive patients presenting with chest pain, the performance of the algorithm was compared against the emergency department discharge diagnosis. In an international multicentre study enrolling 4069 patients, central adjudication by two independent cardiologists using all data derived from cardiac work-up including follow-up served as the reference. Triage towards 'low-risk' required absence of all five clinical 'high-risk' variables: history of coronary artery disease, diabetes, pressure-like chest pain, retrosternal chest pain and age above 40 years. Safety (sensitivity and negative predictive value (NPV)) and efficacy (percentage of patients classified as low risk) was tested in this initial proposal (Model A) and in two additional models: omitting age criteria (Model B) and allowing up to one (any) of the five high-risk variables (Model C).

RESULTS

The prevalence of acute coronary syndrome was 9.4% in the single-centre and 28.4% in the multicentre study. The triage algorithm had very high sensitivity/NPV in both cohorts (99.4%/99.1% and 99.9%/99.1%, respectively), but very low efficacy (6.2% and 2.7%, respectively). Model B resulted in sensitivity/NPV of 97.5%/98.3% and 96.1%/89.4%, while efficacy increased to 14.2% and 10.4%, respectively. Model C resulted in sensitivity/NPV of 96.7%/98.6% and 95.2%/91.3%, with a further increase in efficacy to 23.1% and 15.5%, respectively.

CONCLUSION

A triage algorithm for the identification of low-risk chest pain patients exclusively based on simple clinical variables provided reasonable performance characteristics possibly justifying delayed rather than immediate evaluation in the emergency department.

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Feasibility and Reliability of Rapid Diagnosis of Myocardial Infarction

BACKGROUND

Prevailing hospital practice dictates a protracted phase of observation for patients with chest pain to establish or exclude the diagnosis of myocardial infarction. Early diagnosis of acute myocardial infarction may improve patient care and reduce both complications and hospital costs. A study was performed to investigate the feasibility of early diagnosis of myocardial infarction within the first 9 hours of the hospital stay.

METHODS

The records of all patients admitted with chest pain within one calendar year were analyzed. The timing of creatine kinase-MB (CK-MB) quantification was determined with reference to the initial phlebotomy (time 0). An enzymatic diagnosis of myocardial infarction was assigned if any determination of CK-MB exceeded the upper limit of normal, and the diagnosis of each patient at or before 9 hours (early diagnosis) was compared to the ultimate diagnosis at 14 to 24 hours (final diagnosis) beyond initial assessment.

RESULTS

Of the 528 included patients, 523 patients (99.1%) had identical early and final diagnostic outcomes; 5 patients (0.9%) had conflicting results. An early diagnosis of myocardial infarction was assigned to 195 of the 528 patients (36.9%). Of these, 190 achieved the diagnosis within 9 hours (sensitivity 97.4%). The negative predictive value was 98.5%.

CONCLUSION

Standard CK-MB mass measurements within 9 hours of arrival provided an accurate clinical assessment in > 99% of the cases. The high sensitivity and negative predictive values suggest that early diagnosis of myocardial infarction is feasible and reliable.

Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30 Days in Patients With Acute Chest Pain

BACKGROUND

The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results.

OBJECTIVE

The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days.

METHODS

This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE.

RESULTS

Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors.

CONCLUSIONS

No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Multicentre cross-sectional observational registry to monitor the safety of early discharge after rule-out of acute myocardial infarction by copeptin and troponin: the Pro-Core registry

OBJECTIVES

There is sparse information on the safety of early primary discharge from the emergency department (ED) after rule-out of myocardial infarction in suspected acute coronary syndrome (ACS). This prospective registry aimed to confirm randomised study results in patients at low-to-intermediate risk, with a broader spectrum of symptoms, across different institutional standards and with a range of local troponin assays including high-sensitivity cTn (hs-cTn), cardiac troponin (cTn) and point-of-care troponin (POC Tn).

DESIGN

Prospective, multicentre European registry.

SETTING

18 emergency departments in nine European countries (Germany, Austria, Switzerland, France, Spain, UK, Turkey, Lithuania and Hungary) PARTICIPANTS: The final study cohort consisted of 2294 patients (57.2% males, median age 57 years) with suspected ACS.

INTERVENTIONS

Using the new dual markers strategy, 1477 patients were eligible for direct discharge, which was realised in 974 (42.5%) of patients.

MAIN OUTCOME MEASURES

The primary endpoint was all-cause mortality at 30 days.

RESULTS

Compared with conventional workup after dual marker measurement, the median length of ED stay was 60 min shorter (228 min, 95% CI: 219 to 239 min vs 288 min, 95% CI: 279 to 300 min) in the primary dual marker strategy (DMS) discharge group. All-cause mortality was 0.1% (95% CI: 0% to 0.6%) in the primary DMS discharge group versus 1.1% (95% CI: 0.6% to 1.8%) in the conventional workup group after dual marker measurement. Conventional workup instead of discharge despite negative DMS biomarkers was observed in 503 patients (21.9%) and associated with higher prevalence of ACS (17.1% vs 0.9%, p<0.001), cardiac diagnoses (55.2% vs 23.5%, p<0.001) and risk factors (p<0.01), but with a similar all-cause mortality of 0.2% (95% CI: 0% to 1.1%) versus primary DMS discharge (p=0.64).

CONCLUSIONS

Copeptin on top of cardiac troponin supports safe discharge in patients with chest pain or other symptoms suggestive of ACS under routine conditions with the use of a broad spectrum of local standard POC, conventional and high-sensitivity troponin assays.

TRIAL REGISTRATION NUMBER

NCT02490969.

Diagnostic and Prognostic Role of the Modified Diamond-Forrester Model in Combination With Coronary Calcium Score in Acute Chest Pain Patients

BACKGROUND

The aim of this study was to evaluate whether pretest probability (PTP) assessment using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS) can safely rule out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients.

METHODS

We retrospectively evaluated consecutive patients, age ≥18 years, with no known CAD, negative initial electrocardiogram, and troponin level. All patients had coronary computed tomographic angiography (CCTA) with CCS, and our final cohort consisted of 1988 patients. Obstructive CAD was defined as luminal narrowing of ≥50% in 1 or more vessels by CCTA. Patients were classified according to PTP as low (<10%), intermediate (10%-90%), or high (>90%).

RESULTS

The DFM classified 293 (14.7%), 1445 (72.7%), and 250 (12.6%) of patients as low, intermediate, and high risk, respectively, with corresponding 30-day MACE rates of 0.0%, 2.35%, and 14.8%. For patients with intermediate PTP and CCS ≤10, the negative predictive value was 99.2% (95% confidence interval: 98.7-99.8) for 30-day MACE while it was 92.62% (95% confidence interval: 87.9-97.3) for patients with high PTP. Among patients with a high PTP and CCS of zero, the prevalence of 30-day MACE and obstructive CAD remained high (7.07% and 10.1%, respectively).

CONCLUSIONS

In acute chest pain patients without evidence of ischemia on initial electrocardiogram and cardiac troponin, low PTP by DFM or the combination of intermediate PTP and CCS ≤10 had excellent negative predictive values to rule out 30-day MACE. CCS is not sufficient to exclude obstructive CAD and 30-day MACE in patients with high PTP.

Characteristics and Outcomes of Patients Hospitalized With Suspected Acute Coronary Syndrome in Whom the Diagnosis is not Confirmed

Patients admitted with suspected acute coronary syndrome (ACS) in whom the diagnosis is not confirmed are poorly characterized. In a contemporary registry of consecutive patients hospitalized with suspected ACS as the primary diagnosis, we assessed characteristics on admission and in-hospital and 6-month mortality of patients discharged with other diagnoses and compared this subgroup with true ACS patients. Of 2557 patients included, 9.0% were discharged with a non-ACS diagnosis such as nonspecific chest pain, myopericarditis, stress cardiomyopathy, hemodynamic disturbances, heart failure, myocardial, pulmonary or valvular disease, or others. Compared with true ACS patients, those with other diagnoses were younger, more often female, and had less cardiovascular risk factors. Both groups had comparable rates of nonchest pain presentation and similar hemodynamic characteristics on admission. Non-ACS patients presented less often with Q waves or with ST-segment or T-wave changes and had a lower Global Registry of Acute Coronary Events score than true ACS patients. In-hospital (4.3 vs 4.0%, respectively, p = 0.834) and 6-month (5.4 vs 8.0%, respectively, p = 0.163) mortality rates were comparable in both groups. However, if patients in the non-ACS group were divided into subgroups with nonspecific chest pain (6.2% of total) or other diagnoses (2.8% of total), major differences in in-hospital (0.0 vs 13.9%, respectively, p < 0.001) and 6-month (0.7 vs 15.7%, respectively, p < 0.001) mortality rates would become apparent and remain after multivariable adjustment. In conclusion, in a non-negligible proportion of patients hospitalized with suspected ACS, this diagnosis is not confirmed. Prognosis of these patients follows a bimodal pattern, being excellent in those with nonspecific chest pain but worse than that of true ACS patients in the rest. Efforts are necessary to ensure prompt identification and early risk stratification of these patients allowing appropriate management decisions.

Unrecognized Cardiovascular Emergencies Among Medicare Patients

IMPORTANCE

The Institute of Medicine described diagnostic error as the next frontier in patient safety and highlighted a critical need for better measurement tools.

OBJECTIVES

To estimate the proportions of emergency department (ED) visits attributable to symptoms of imminent ruptured abdominal aortic aneurysm (AAA), acute myocardial infarction (AMI), stroke, aortic dissection, and subarachnoid hemorrhage (SAH) that end in discharge without diagnosis; to evaluate longitudinal trends; and to identify patient characteristics independently associated with missed diagnostic opportunities.

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective cohort study of all Medicare claims for 2006 to 2014. The setting was hospital EDs in the United States. Participants included all fee-for-service Medicare patients admitted to the hospital during 2007 to 2014 for the conditions of interest. Hospice enrollees and patients with recent skilled nursing facility stays were excluded.

MAIN OUTCOMES AND MEASURES

The proportion of potential diagnostic opportunities missed in the ED was estimated using the difference between observed and expected ED discharges within 45 days of the index hospital admissions as the numerator, basing expected discharges on ED use by the same patients in earlier months. The denominator was estimated as the number of recognized emergencies (index hospital admissions) plus unrecognized emergencies (excess discharges).

RESULTS

There were 1 561 940 patients, including 17 963 hospitalized for ruptured AAA, 304 980 for AMI, 1 181 648 for stroke, 19 675 for aortic dissection, and 37 674 for SAH. The mean (SD) age was 77.9 (10.3) years; 8.9% were younger than 65 years, and 54.1% were female. The proportions of diagnostic opportunities missed in the ED were as follows: ruptured AAA (3.4%; 95% CI, 2.9%-4.0%), AMI (2.3%; 95% CI, 2.1%-2.4%), stroke (4.1%; 95% CI, 4.0%-4.2%), aortic dissection (4.5%; 95% CI, 3.9%-5.1%), and SAH (3.5%; 95% CI, 3.1%-3.9%). Longitudinal trends were either nonsignificant (AMI and aortic dissection) or increasing (ruptured AAA, stroke, and SAH). Patient characteristics associated with unrecognized emergencies included age younger than 65 years, dual eligibility for Medicare and Medicaid coverage, female sex, and each of the following chronic conditions: end-stage renal disease, dementia, depression, diabetes, cerebrovascular disease, hypertension, coronary artery disease, and chronic obstructive pulmonary disease.

CONCLUSIONS AND RELEVANCE

Among Medicare patients, opportunities to diagnose ruptured AAA, AMI, stroke, aortic dissection, and SAH are missed in less than 1 in 20 ED presentations. Further improvement may prove difficult.

Cardiac CT in the Emergency Department: Contrasting Evidence from Registries and Randomized Controlled Trials

PURPOSE OF REVIEW

To compare outcomes between registries and randomized controlled trials of coronary computed tomographic angiography (CCTA)-based versus standard of care approaches to the initial evaluation of patients with acute chest pain.

RECENT FINDINGS

Randomized trials have demonstrated CCTA to be a safe and efficient tool for triage of low- to intermediate-risk patients presenting to the emergency department with chest pain. Recent studies demonstrate heterogeneous result using different standard of care approaches for evaluation of hard endpoints in comparison with standard evaluation. Also, there has been continued concern for increase in subsequent testing after coronary CTA. Although CCTA improves detection of coronary artery disease, it is uncertain if it will bring improvement of long-term health outcomes at this point of time. Careful analysis of the previous results and further investigation will be required to validate evaluation of hard endpoints.

Proposed In-Training Electrocardiogram Interpretation Competencies for Undergraduate and Postgraduate Trainees

Despite its importance in everyday clinical practice, the ability of physicians to interpret electrocardiograms (ECGs) is highly variable. ECG patterns are often misdiagnosed, and electrocardiographic emergencies are frequently missed, leading to adverse patient outcomes. Currently, many medical education programs lack an organized curriculum and competency assessment to ensure trainees master this essential skill. ECG patterns that were previously mentioned in literature were organized into groups from A to D based on their clinical importance and distributed among levels of training. Incremental versions of this organization were circulated among members of the International Society of Electrocardiology and the International Society of Holter and Noninvasive Electrocardiology until complete consensus was reached. We present reasonably attainable ECG interpretation competencies for undergraduate and postgraduate trainees. Previous literature suggests that methods of teaching ECG interpretation are less important and can be selected based on the available resources of each education program and student preference. The evidence clearly favors summative trainee evaluation methods, which would facilitate learning and ensure that appropriate competencies are acquired. Resources should be allocated to ensure that every trainee reaches their training milestones and should ensure that no electrocardiographic emergency (class A condition) is ever missed. We hope that these guidelines will inform medical education programs and encourage them to allocate sufficient resources and develop organized curricula. Assessments must be in place to ensure trainees acquire the level-appropriate ECG interpretation skills that are required for safe clinical practice.

The Value of Point-Of-Care Fatty Acid Binding Protein in Patients with Chest Pain in Determining Myocardial Infarction in the Emergency Setting

Introduction

Detecting patients in the early hours of acute myocardial infarction is still a challenge for emergency physicians. Fatty acid binding protein (FABP) was thought to be released into the intravascular space earlier than cardiac troponins. The aim of this study was to determine the diagnostic value of point-of-care FABP test either in diagnosing or excluding myocardial infarction during the initial admission of patients presenting with typical chest pain to the emergency department.

Methods

This study was performed in a tertiary care emergency department. Patients with typical chest pain were included into the study. Point-of-care FABP was studied during the initial admission and two hours after admission. Patients were diagnosed as myocardial infarction or not ultimately by ECG and troponin levels.

Results

A total of 224 patients were included into the study, 73 of them (32.6%) were diagnosed as acute myocardial infarction. FABP had a sensitivity and specificity of 41.0% (95%CI 29.7 to 53.2) and 100% (95%CI 97.6 to 100) and myoglobin had a sensitivity and specificity of 57.5% (95%CI 45.4 to 69.0) and 90.7% (95%CI 85.0 to 95.0) during the initial admission. Cardiac troponin T had a sensitivity of 45.2% (95%CI 33.7 to 57.2) and specificity of 100% (95%CI 97.0 to 100) during the initial admission. Two hours after admission, FABP had a sensitivity of 56.0% (95%CI 40.0 to 71.0) and specificity of 99.0% (95%CI 96.4 to 100) respectively.

Conclusions

Point-of-care FABP is good at diagnosing acute myocardial infarction in patients presenting with chest pain. However, FABP was found to be not better than either myoglobin or cardiac troponin T in excluding acute myocardial infarction in patients presenting with chest pain.

Patient with Chest Pain of Obscure Origin: Can AMI be Recognised Early at AED? - A Review of Diagnostic Methods and a Suggested Protocol for the Local A&E Department

Chest pain is a common presentation to Accident and Emergency departments (AED). There are many causes ranging from the most trivial, an example of which is costochondritis to the life-threatening examples such as acute myocardial infarction (AMI). It is not uncommon for acute myocardial infarction to present as atypical chest pain or discomfort, or non-diagnostic electrocardiogram (ECG). The various common diagnostic methods for AMI in patients with atypical chest pain are reviewed and a suggested protocol for managing patient with chest pain of obscure origin at AED is presented. The recent introduction of rapid bedside troponin assay is likely to bring a major impact on the management of atypical chest pain in future.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical update. Computed Tomography — an Emerging Tool for Triple Rule-Out in the Emergency Department. A Review

New imaging tools have been developed in recent years to rapidly and accurately diagnose life-threatening diseases associated with high mortality rates, such as acute coronary syndromes, acute aortic dissection, or pulmonary embolism. The concept of using computed tomographic (CT) assessment in emergency settings is based on the possibility of excluding multiple acute pathologies within one scan. It can be used for patients complaining of acute chest pain of unclear etiology with the possible association of acute coronary dissection or pulmonary embolism, but only a low to moderate risk of developing an acute coronary syndrome. One of the benefits of this protocol is the possibility of decreasing the number of patients who are hospitalized for further investigations. The technique also allows the rapid triage of patients and the safe discharge of those who show negative results. The aim of this review is to summarize the current medical literature regarding the potential use of CT for the triple rule-out (TRO) of coronary etiologies.

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early death after discharge from emergency departments: analysis of national US insurance claims data

OBJECTIVE

 To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients.

DESIGN

 Retrospective cohort study.

SETTING

 Claims data from the US Medicare program, covering visits to an emergency department, 2007-12.

PARTICIPANTS

 Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded.

MAIN OUTCOME MEASURE

 Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients.

RESULTS

 Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7).

CONCLUSIONS

 Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.

Admissions after discharge from an emergency department for chest symptoms

BACKGROUND

Often patients who present to the emergency department (ED) with chest symptoms return to the hospital within 30 days with the same or closely related symptoms and are admitted, raising questions about quality of care, timeliness of diagnosis, and patient safety. This study examined the frequency of and patient characteristics associated with subsequent inpatient admissions for related symptoms after discharge from an ED for chest symptoms.

METHODS

We used data from the 2012 and 2013 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) and State Emergency Department Databases (SEDD) from eight states to identify over 1.8 million ED discharges for chest symptoms.

RESULTS

Approximately 3% of ED discharges experienced potentially related subsequent admissions within 30 days - 0.2% for acute myocardial infarction (AMI), 1.7% for other cardiovascular conditions, 0.5% for respiratory conditions, and 0.6% for mental disorders. Logistic regression results showed higher odds of subsequent admission for older patients and those residing in low-income areas, and lower odds for females and non White racial/ethnic groups. Privately insured patients had lower odds of subsequent admission than did those who were uninsured or covered by other programs.

CONCLUSIONS

Because we included multiple diagnostic categories of subsequent admissions, our results show a more complete picture of patients presenting to the ED with chest symptoms compared with previous studies. In particular, we show a lower rate of subsequent admission for AMI versus other diagnoses. ED physicians and administrators can use the results to identify characteristics associated with increased odds of subsequent admission to target at-risk populations.

The Role of Nurses in a Chest Pain Unit

The chest pain unit (CPU) provides a service for patients at moderate-to-low risk for acute coronary syndrome (ACS). Although the number of CPUs has continued to grow worldwide, little has been written on the specific role and contribution of nursing in CPUs. The stay of patients in the CPU can be divided into six stages: triage, diagnosis, treatment, observation/monitoring, discharge, and follow-up. CPU nurses are in a unique position to promote evidence-based practice during all of these stages. Deeper insight into the unique role of nurses in CPUs will promote understanding of what type of knowledge, skills, and attitudes are required to provide the services that will contribute to improved quality of care for chest pain patients.

Associations of volume and other hospital characteristics on mortality within 30 days of acute myocardial infarction in South Korea

OBJECTIVE

The mortality for acute myocardial infarction (AMI) has declined worldwide. However, improvements in care for AMI in South Korea have lagged slightly behind those in other countries. Therefore, it is important to investigate how factors such as hospital volume, structural characteristics of hospital and hospital staffing level affect 30-day mortality due to AMI in South Korea.

SETTING

We used health insurance claim data from 114 hospitals to analyse 30-day mortality for AMI.

PARTICIPANTS

These data consisted of 19,638 hospitalisations during 2010-2013.

INTERVENTIONS

No interventions were made.

OUTCOME MEASURE

Multilevel models were analysed to examine the association between the 30-day mortality and inpatient and hospital level variables.

RESULTS

In the 30 days after hospitalisation, 10.5% of patients with AMI died. Hospitalisation cases at hospitals with a higher AMI volume had generally inverse associations with 30-day mortality (1st quartile=ref; 2nd quartile=OR 0.811, 95% CI 0.658 to 0.998, 3rd quartile=OR 0.648, 95% CI 0.500 to 0.840, 4th quartile=OR 0.807, 95% CI 0.573 to 1.138). In addition, hospitals with a greater proportion of specialists were associated with better outcomes (above median=OR 0.789, 95% CI 0.663 to 0.940).

CONCLUSIONS

Health policymakers need to include volume and staffing when defining the framework for treatment of AMI in South Korean hospitals. Otherwise, they must consider increasing the proportion of specialists or regulating the hiring of emergency medicine specialists. In conclusion, they must make an effort to reduce 30-day mortality following AMI based on such considerations.

Cardiac CT angiography for evaluation of acute chest pain

Chest pain is the second most common emergency department (ED) presentation in the United States. Cardiac computed tomography angiography (CCTA) now plays an important role in the evaluation of patients with suspected acute coronary syndrome in the ED setting. In this article, we review the available techniques focused on the use of CCTA to evaluate patients fosr coronary atherosclerosis for timely triage of acute chest pain.

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 physicians' acute coronary syndrome testing threshold and diagnostic performance: acute coronary syndrome critical pathway with return visit feedback

OBJECTIVES

Emergency physician threshold to test for acute coronary syndrome (ACS) is directly related to ACS diagnosis rate and inversely related to ACS missed diagnosis rate. Feedback to emergency physicians of information on their prior patients whose ACS diagnosis was not identified may improve physician diagnostic performance.

METHODS

A critical pathway for evaluation of patients for ACS was modified to include feedback to physicians on their cases who had a return visit and did not have their ACS diagnosis identified at their prior emergency department visit. Feedback included case-specific details, discussion of the case at the monthly Morbidity and Mortality conference, and a yearly a report to each physician comparing their performance to their peers (ACS evaluation rate, ACS diagnosis rate, and ACS missed diagnosis rate). Cases were identified, and physician-specific performance was calculated from a computerized encounter database at 2 community teaching hospitals.

RESULTS

During the study period, 29 emergency physicians evaluated 295,758 patients and identified 6472 ACS cases. During the study, the yearly ACS evaluation rate for individual physician ranged from 19% to 70% (average 40.3%; 95% confidence interval [CI], 39.5%-41.1%), the yearly ACS diagnosis rate for individual physician ranged from 1.1% to 4.2% (average 1.7%; 95% CI, 1.65%-1.75%), and the yearly missed ACS diagnosis rate for individual physician ranged from 0% to 17% (average 2.8%; 95% CI, 2.3%-3.3%). Individual physician ACS evaluation rate was directly related to physician ACS diagnosis rate (r 0.76, P = 0.00012) and was inversely related to that physician missed ACS rate (r 0.45, P = 0.001). During the study, implementation of the critical pathway increased the ACS evaluation rate from 30% to 48% and decreased the ACS missed diagnosis rate from 1.5% to 0.3%.

CONCLUSIONS

Emergency physicians with lower threshold for ACS evaluation more frequently diagnose patients with ACS and less frequently miss the diagnosis of ACS. Feedback to emergency physicians of information on their patient's return visits and their own diagnostic performance may improve outcome for patients with ACS.

Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department

In the assessment of chest pain patients with suspected acute coronary syndrome (ACS) in the emergency department (ED), physicians rely on global diagnostic impressions (‘gestalt’). The aim of this study was to determine the diagnostic value of the ED physician’s overall assessment of ACS likelihood, and the values of the main diagnostic modalities underlying this assessment, namely the chest pain history, the ECG and the initial troponin result. 1,151 consecutive ED chest pain patients were prospectively included. The ED physician’s interpretation of the chest pain history, the ECG, and the global likelihood of ACS were recorded on special forms. The discharge diagnoses were retrieved from the medical records. A chart review was carried out to determine whether patients with a non-ACS diagnosis at the index visit had ACS or suffered cardiac death within 30 days. The gestalt was better than its components both at ruling in (“Obvious ACS”, LR 29) and at ruling out (“No Suspicion of ACS”, LR 0.01) ACS. In the “Strong suspicion of ACS” group, 60% of the patients did not have ACS. A positive TnT (LR 24.9) and an ischemic ECG (LR 8.3) were strong predictors of ACS and seemed superior to pain history for ruling in ACS. In patients with a normal TnT and non-ischemic ECG, chest pain history typical of AMI was not a significant predictor of AMI (LR 1.9) while pain history typical of unstable angina (UA) was a moderate predictor of UA (LR 4.7). Clinical gestalt was better than its components both at ruling in and at ruling out ACS, but overestimated the likelihood of ACS when cases were assessed as strong suspicion of ACS. Among the components of the gestalt, TnT and ECG were superior to the chest pain history for ruling in ACS, while pain history was superior for ruling out ACS.