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Khalil MH, Sekma A, Yaakoubi H, Bel Haj Ali K, Msolli MA, Beltaief K, Grissa MH, Boubaker H, Sassi M, Chouchene H, Hassen Y, Ben Soltane H, Mezgar Z, Boukef R, Bouida W, Nouira S. 30 day predicted outcome in undifferentiated chest pain: multicenter validation of the HEART score in Tunisian population. BMC Cardiovasc Disord 2021; 21:555. [PMID: 34798811 PMCID: PMC8603499 DOI: 10.1186/s12872-021-02381-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 11/02/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physcian effectively progrnosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. However, most validation studies of HEART score were not performed in populations different from those included in the original one. OBJECTIVE To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain. METHODS Our prospective, multicenter study enrolled adult patients presenting with chest pain at chest pain units. Patients over 30 years of age with a primary complaint of chest pain were enrolled. HEART score was calculated for every patient. The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. The discriminative power of HEART score was evaluated by the area under the ROC curve. A calibration analysis of the HEART score in this population was performed using Hosmer-Lemeshow goodness of test. RESULTS We enrolled 3880 patients (age 56.3; 59.5% males). The application of HEART score showed that most patients were in intermediate risk category (55.3%). Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group. The area under receiver operating characteristic curve was 0.87 (95% CI 0.85-0.88). HEART score was not well calibrated (χ2 statistic = 12.34; p = 0.03). CONCLUSION HEART score showed a good discrimination performance in predicting MACE occurrence at 30 days for Tunisian patients with undifferentiated acute chest pain. Heart score was not well calibrated in our population.
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Affiliation(s)
- Mohamed Hassene Khalil
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia. .,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia.
| | - Adel Sekma
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Hajer Yaakoubi
- Emergency Department, Sahloul University Hospital, 4011, Sousse, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Khaoula Bel Haj Ali
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Mohamed Amine Msolli
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Kaouthar Beltaief
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Mohamed Habib Grissa
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Hamdi Boubaker
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Mohamed Sassi
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Hamadi Chouchene
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Youssef Hassen
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Houda Ben Soltane
- Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia.,Emergency Department, Farhat Hached University Hospital, 4031, Sousse, Tunisia
| | - Zied Mezgar
- Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia.,Emergency Department, Farhat Hached University Hospital, 4031, Sousse, Tunisia
| | - Riadh Boukef
- Emergency Department, Sahloul University Hospital, 4011, Sousse, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Wahid Bouida
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
| | - Semir Nouira
- Emergency Department and Laboratory Research (LR12SP18), Fattouma Bourguiba University Hospital, 5000, Monastir, Tunisia.,Research Laboratory LR12SP18, University of Monastir, 5019, Monastir, Tunisia
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Shoaib A, Rashid M, Berry C, Curzen N, Kontopantelis E, Timmis A, Ahmad A, Kinnaird T, Mamas MA. Clinical Characteristics, Management Strategies, and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Patients With and Without Prior Coronary Artery Bypass Grafting. J Am Heart Assoc 2021; 10:e018823. [PMID: 34612049 PMCID: PMC8751868 DOI: 10.1161/jaha.120.018823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background There are limited data on the management strategies, temporal trends and clinical outcomes of patients who present with non–ST‐segment–elevation myocardial infarction and have a prior history of CABG. Methods and Results We identified 287 658 patients with non–ST‐segment–elevation myocardial infarction between 2010 and 2017 in the United Kingdom Myocardial Infarction National Audit Project database. Clinical and outcome data were analyzed by dividing into 2 groups by prior history of coronary artery bypass grafting (CABG): group 1, no prior CABG (n=262 362); and group 2, prior CABG (n=25 296). Patients in group 2 were older, had higher GRACE (Global Registry of Acute Coronary Events) risk scores and burden of comorbid illnesses. More patients underwent coronary angiography (69% versus 63%) and revascularization (53% versus 40%) in group 1 compared with group 2. Adjusted odds of receiving inpatient coronary angiogram (odds ratio [OR], 0.91; 95% CI, 0.88–0.95; P<0.001) and revascularization (OR, 0.73; 95% CI, 0.70–0.76; P<0.001) were lower in group 2 compared with group 1. Following multivariable logistic regression analyses, the OR of in‐hospital major adverse cardiovascular events (composite of inpatient death and reinfarction; OR, 0.97; 95% CI, 0.90–1.04; P=0.44), all‐cause mortality (OR, 0.96; 95% CI, 0.88–1.04; P=0.31), reinfarction (OR, 1.02; 95% CI, 0.89–1.17; P=0.78), and major bleeding (OR, 1.01; 95% CI, 0.90–1.11; P=0.98) were similar across groups. Lower adjusted risk of inpatient mortality (OR, 0.67; 95% CI, 0.46–0.98; P=0.04) but similar risk of bleeding (OR,1.07; CI, 0.79–1.44; P=0.68) and reinfarction (OR, 1.13; 95% CI, 0.81–1.57; P=0.47) were observed in group 2 patients who underwent percutaneous coronary intervention compared with those managed medically. Conclusions In this national cohort, patients with non–ST‐segment–elevation myocardial infarction with prior CABG had a higher risk profile, but similar risk‐adjusted in‐hospital adverse outcomes compared with patients without prior CABG. Patients with prior CABG who received percutaneous coronary intervention had lower in‐hospital mortality compared with those who received medical management.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences University of Glasgow UK
| | - Nick Curzen
- Cardiothoracic Department University Hospital Southampton & Faculty of MedicineUniversity of Southampton UK
| | | | - Adam Timmis
- Barts & the London School of Medicine and Dentistry Queen Mary University London London UK
| | - Ayesha Ahmad
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
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Ke J, Chen Y, Wang X, Wu Z, Chen F. Indirect comparison of TIMI, HEART and GRACE for predicting major cardiovascular events in patients admitted to the emergency department with acute chest pain: a systematic review and meta-analysis. BMJ Open 2021; 11:e048356. [PMID: 34408048 PMCID: PMC8375746 DOI: 10.1136/bmjopen-2020-048356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The study aimed to compare the predictive values of the thrombolysis in myocardial infarction (TIMI); History, Electrocardiography, Age, Risk factors and Troponin (HEART) and Global Registry in Acute Coronary Events (GRACE) scoring systems for major adverse cardiovascular events (MACEs) in acute chest pain (ACP) patients admitted to the emergency department (ED). METHODS We systematically searched PubMed, Embase and the Cochrane Library from their inception to June 2020; we compared the following parameters: sensitivity, specificity, positive and negative likelihood ratios (PLR and NLR), diagnostic OR (DOR) and area under the receiver operating characteristic curves (AUC). RESULTS The pooled sensitivity and specificity for TIMI, HEART and GRACE were 0.95 and 0.36, 0.96 and 0.50, and 0.78 and 0.56, respectively. The pooled PLR and NLR for TIMI, HEART and GRACE were 1.49 and 0.13, 1.94 and 0.08, and 1.77 and 0.40, respectively. The pooled DOR for TIMI, HEART and GRACE was 9.18, 17.92 and 4.00, respectively. The AUC for TIMI, HEART and GRACE was 0.80, 0.80 and 0.70, respectively. Finally, the results of indirect comparison suggested the superiority of values of TIMI and HEART to those of GRACE for predicting MACEs, while there were no significant differences between TIMI and HEART for predicting MACEs. CONCLUSIONS TIMI and HEART were superior to GRACE for predicting MACE risk in ACP patients admitted to the ED.
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Affiliation(s)
- Jun Ke
- Department of Emergency, Fujian Provincial Hospital, Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fuzhou, China
| | - Yiwei Chen
- Shanghai Synyi Medical Technology Co., Ltd, Shanghai, China
| | - Xiaoping Wang
- Department of Emergency, Fujian Provincial Hospital, Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, China
- Fujian Provincial Institute of Emergency Medicine, Fuzhou, China
| | - Zhiyong Wu
- Department of Cardiology, Fujian Provincial Hospital, Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, Fujian, China
| | - Feng Chen
- Department of Emergency, Fujian Provincial Hospital, Fuzhou, Fujian, China
- Provincial College of Clinical Medicine, Fujian Medical University, Fuzhou, China
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Ruangsomboon O, Thirawattanasoot N, Chakorn T, Limsuwat C, Monsomboon A, Praphruetkit N, Surabenjawong U, Riyapan S, Nakornchai T. The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients. Int J Cardiol 2020; 322:23-28. [PMID: 32882291 DOI: 10.1016/j.ijcard.2020.08.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/12/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients. METHODS A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures. RESULTS Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2-97.6%) and 97.2% (95%CI 93.2-98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8-85.2%) and 53.9% (95%CI 46.2-61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68-0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge. CONCLUSION The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.
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Affiliation(s)
- Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand.
| | - Netiporn Thirawattanasoot
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Chok Limsuwat
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Apichaya Monsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Nattakarn Praphruetkit
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Usapan Surabenjawong
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Tanyaporn Nakornchai
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
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Zheng W, Wang G, Ma J, Wu S, Zhang H, Zheng J, Xu F, Wang J, Chen Y. Evaluation and comparison of six GRACE models for the stratification of undifferentiated chest pain in the emergency department. BMC Cardiovasc Disord 2020; 20:199. [PMID: 32334528 PMCID: PMC7183650 DOI: 10.1186/s12872-020-01476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 04/12/2020] [Indexed: 02/07/2023] Open
Abstract
Background The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), while in hospital (IH), within 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). We aimed to perform the first comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACEs) in patients with acute chest pain in the emergency department (ED). Methods Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 from the EDs of two public hospitals in China. The 30-day MACEs included death, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest and cardiogenic shock. The correlation, calibration, discrimination, reclassification and diagnostic accuracy at certain cutoff values of six GRACE models were evaluated. Comparisons with the History, ECG, Age, Risk Factors, and Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores were conducted. Results A total of 2886 patients were analyzed, with 590 (20.4%) patients experiencing outcomes. The GRACE (IHDthMI), GRACE (IH6mDthMI), GRACE (IHDth), GRACE (IH6mDth), GRACE (OH6mDth) and GRACE (OH6mDthMI) showed positive linear correlations with the actual MACE rates (r ≥ 0.568, P < 0.001). All these models had good calibration (Hosmer-Lemeshow test, P ≥ 0.073) except GRACE (IHDthMI) (P < 0.001). The corresponding C-statistics were 0.83(0.81,0.84), 0.82(0.81,0.83), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71), respectively, first two of which were comparable to HEART (0.82, 0.80–0.83) and superior to TIMI (0.71, 0.69–0.73). With a sensitivity ≥95%, GRACE (IHDthMI) ≤81 and GRACE (IH6mDthMI) ≤79 identified 868(30%) and 821(28%) patients as low risk, respectively, which were significantly better than other GRACEs and HEART ≤3(22%). With a specificity ≥95%, GRACE (IHDthMI) > 186 and GRACE (IH6mDthMI) > 161 could recognize 12% and 11% patients as high risk, which were greater than other GRACEs, HEART ≥8(9%) and TIMI ≥5(8%). Conclusions In this Chinese setting, certain strengths of GRACE models beyond HEART and TIMI scores were still noteworthy for stratifying chest pain patients. The validation and reasonable application of appropriate GRACE models in the evaluation of undifferentiated chest pain should be recommended.
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Affiliation(s)
- Wen Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Guangmei Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jingjing Ma
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Shuo Wu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - He Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiali Wang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China.,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China.,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China.,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, No.107, Wen Hua Xi Road, Jinan, 250012, Shandong, China. .,Clinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China. .,Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Qilu Hospital of Shandong University, Jinan, China. .,The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China.
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Wu CC, Hsu WD, Wang YC, Kung WM, Tzeng IS, Huang CW, Huang CY, Li YC. An Innovative Scoring System for Predicting Major Adverse Cardiac Events in Patients With Chest Pain Based on Machine Learning. IEEE Access 2020. [DOI: 10.1109/access.2020.3004405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Laureano-phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H. HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2019; 74:187-203. [DOI: 10.1016/j.annemergmed.2018.12.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 11/12/2018] [Accepted: 12/05/2018] [Indexed: 01/26/2023]
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Innes GD. Can a HEART Pathway Improve Safety and Diagnostic Efficiency for Patients With Chest Pain? Ann Emerg Med 2019; 74:181-184. [DOI: 10.1016/j.annemergmed.2019.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Indexed: 11/30/2022]
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Innocenti F, Luzzi M, Donnini C, Zanobetti M, Tassinari I, Caldi F, Pini R. Does an imaging stress-test adds information to prognostic scores in patients with chest pain in the emergency department? Intern Emerg Med 2019; 14:119-125. [PMID: 29845517 DOI: 10.1007/s11739-018-1882-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/18/2018] [Indexed: 11/26/2022]
Abstract
We evaluated the ability of a stress-test (Str-T) to improve the risk stratification based on prognostic scores in patients presenting to the ED with chest pain. Between 2008, June and 2013, December, 1082 patients with chest pain were evaluated with an imaging Str-T. With a retrospective analysis, patients were stratified according to: (1) Florence Prediction Rule as low (0-1, LR-FPR), intermediate (2-4, IR-FPR), high risk (5-6, HR-FPR), respectively, 26, 50 and 24% of patients; (2) HEART score as LR-HEART, (0-3) and HR-HEART (≥4), respectively, 36 and 64%; (3) likelihood of CAD according to NICE guidelines, 10-29% LR-NICE, 30-60% IR-NICE and > 60% HR-NICE, respectively, 12, 18 and 70%. Scores' diagnostic performance was calculated with Str-T as reference. One-month follow-up by a phone call was performed, to investigate the occurrence of new cardiovascular events. In LR and HR patients, FPR and NICE score showed sensitivity 66 vs 93%, specificity 59 vs 19% (both p < 0.001), Positive Predictive Value (PPV) 36 vs 31%, Negative Predictive Value (NPV) 83 vs 87%. Among LR-HEART patients, Str-T was positive for inducible ischemia in 53 (14%) patients and 12 (4%) of them underwent a percutaneous coronary revascularization. The Str-T was negative for inducible ischemia in 760 (70%) patients, positive in 272 (25%), inconclusive in 50 (5%); among patients in the LR and IR subgroups, incidence of CAD (1.3 and 1.6%) and the cumulative incidence of significant events at 1-month follow-up (both 1%) was very low Str-T improved prognostic scores' diagnostic performance in LR- and HR-subgroups.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
| | - Margherita Luzzi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Chiara Donnini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Maurizio Zanobetti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Irene Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Francesca Caldi
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy
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Wamala H, Aggarwal L, Bernard A, Scott IA. Comparison of nine coronary risk scores in evaluating patients presenting to hospital with undifferentiated chest pain. Int J Gen Med 2018; 11:473-481. [PMID: 30588062 PMCID: PMC6296689 DOI: 10.2147/ijgm.s183583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Henry Wamala
- Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Leena Aggarwal
- Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Anne Bernard
- Queensland Facility for Advanced Bioinformatics, University of Queensland, Brisbane, QLD, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD, Australia, .,Southside School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia,
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Tomaszewski CA, Nestler D, Shah KH, Sudhir A, Brown MD, Brown MD, Wolf SJ, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Harrison NE, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Nazarian DJ, Proehl JA, Promes SB, Shah KH, Shih RD, Silvers SM, Smith MD, Thiessen ME, Tomaszewski CA, Valente JH, Wall SP, Cantrill SV, Hirshon JM, Schulz T, Whitson RR. Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes. Ann Emerg Med 2018; 72:e65-e106. [DOI: 10.1016/j.annemergmed.2018.07.045] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Moumneh T, Richard-Jourjon V, Friou E, Prunier F, Soulie-Chavignon C, Choukroun J, Mazet-Guilaumé B, Riou J, Penaloza A, Roy PM. Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients. Intern Emerg Med 2018; 13:1111-1119. [PMID: 29500619 DOI: 10.1007/s11739-018-1803-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 02/25/2018] [Indexed: 01/19/2023]
Abstract
In patients consulting in the Emergency Department for chest pain, a HEART score ≤ 3 has been shown to rule out an acute coronary syndrome (ACS) with a low risk of major adverse cardiac event (MACE) occurrence. A negative CARE rule (≤ 1) that stands for the first four elements of the HEART score may have similar rule-out reliability without troponin assay requirement. We aim to prospectively assess the performance of the CARE rule and of the HEART score to predict MACE in a chest pain population. Prospective two-center non-interventional study. Patients admitted to the ED for non-traumatic chest pain were included, and followed-up at 6 weeks. The main study endpoint was the 6-week rate of MACE (myocardial infarction, coronary angioplasty, coronary bypass, and sudden unexplained death). 641 patients were included, of whom 9.5% presented a MACE at 6 weeks. The CARE rule was negative for 31.2% of patients, and none presented a MACE during follow-up [0, 95% confidence interval: (0.0-1.9)]. The HEART score was ≤ 3 for 63.0% of patients, and none presented a MACE during follow-up [0% (0.0-0.9)]. With an incidence below 2% in the negative group, the CARE rule seemed able to safely rule out a MACE without any biological test for one-third of patients with chest pain and the HEART score for another third with a single troponin assay.
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Affiliation(s)
- Thomas Moumneh
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France.
| | | | - Emilie Friou
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | - Fabrice Prunier
- Institut MITOVASC, Service de Cardiologie, CHU d'Angers, Université d'Angers, Angers, France
| | - Caroline Soulie-Chavignon
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | | | - Betty Mazet-Guilaumé
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
| | - Jérémie Riou
- Unité de Formation-Recherche Santé, Université d'Angers, MINT INSERM, UMR 6021, Angers, France
| | - Andréa Penaloza
- Service de Médecine d'Urgence, Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Pierre-Marie Roy
- Institut MITOVASC, Département de Médecine d'Urgence, CHU d'Angers, Université d'Angers, Angers, France
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13
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Streitz MJ, Oliver JJ, Hyams JM, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain. Intern Emerg Med 2018; 13:727-748. [PMID: 28895038 DOI: 10.1007/s11739-017-1743-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/19/2017] [Indexed: 01/16/2023]
Abstract
Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient's electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0-10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838-0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification.
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Affiliation(s)
- Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA.
| | - Joshua James Oliver
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | | | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
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14
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Schriger DL, Menchine M, Wiechmann W, Carmelli G. Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study. Ann Emerg Med 2018; 72:511-22. [PMID: 29685372 DOI: 10.1016/j.annemergmed.2018.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 09/06/2017] [Accepted: 02/28/2018] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low-risk chest pain. METHODS We created a Web-based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin-level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3-item Fear of Malpractice scale. RESULTS Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety-five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms "very low risk" and "low risk" only when their probability estimates were less than 1%. CONCLUSION The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.
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15
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Greenslade JH, Chung K, Parsonage WA, Hawkins T, Than M, Pickering JW, Cullen L. Modification of the Thrombolysis in Myocardial Infarction risk score for patients presenting with chest pain to the emergency department. Emerg Med Australas 2017; 30:47-54. [PMID: 29232768 DOI: 10.1111/1742-6723.12913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 10/31/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To develop a modified Thrombolysis in Myocardial Infarction (TIMI) score to effectively risk stratify patients presenting to the ED with chest pain. METHODS A prospective observational study was conducted at two metropolitan EDs. Data were obtained during patient interview. The primary outcome was major adverse cardiovascular events (MACE) within 30 days of presentation. Two separate modifications of the TIMI score were developed. These scores were compared to the original TIMI in terms of the area under the receiver operating characteristic curve and diagnostic accuracy statistics (sensitivity, specificity, positive and negative predictive values). RESULTS Of 1760 patients, 364 (20.7%) experienced 30 day MACE. The first modified TIMI score was a simplified TIMI (s-TIMI) including four variables: age ≥65 years, three or more risk factors, high-sensitivity troponin (hs-cTnI) and electrocardiogram changes. The second score included the same four variables plus two Global Registry of Acute Coronary Events (GRACE) variables (systolic blood pressure and estimated glomerular filtration rate). This score was termed the GRACE TIMI (g-TIMI). s-TIMI had a lower sensitivity compared to the original TIMI score (93.41 and 96.98%), but higher specificity (45.49 and 24.50%). The g-TIMI had a sensitivity of 98.90% and specificity of 14.90%. CONCLUSIONS Attempts to modify the TIMI score yielded two scores with added predictive utility in comparison to the original TIMI model. The addition of GRACE variables (g-TIMI) increased sensitivity for MACE, but decreased the specificity of the model. The s-TIMI score yielded good specificity but had sensitivity that would not be acceptable by emergency physicians. The s-TIMI may be useful as part of an accelerated chest pain protocol.
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Affiliation(s)
- Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Kimberly Chung
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - William A Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Tracey Hawkins
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Martin Than
- Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - John W Pickering
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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16
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Bouriche F, Yvorra S, Hassan A, Paganelli F, Bonello L, Luigi S, Attia F. [Management of NSTEMI in a hospital without interventional cardiology and without use of GRACE score: Does the clinician appreciation match the GRACE score calculated retrospectively for the coronarography delay?]. Ann Cardiol Angeiol (Paris) 2017; 66:288-294. [PMID: 29029775 DOI: 10.1016/j.ancard.2017.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The management of non-ST segment elevation acute coronary syndromes (NSTEACS) remains an issue for mobidity, mortality, and an economic stake. The first aim of the study was to evaluate the additional value of the GRACE score for the compliance with the recommended times to coronary angiography in an hospital without interventional cardiology. We also analysed the in-hospital and 6-month mortality and the predictive factors of compliance for the coronarography delays. METHODS Retrospective monocenter cross-sectional study including consecutive patients with chest pain suggestive of a NSTEACS during 1 year. Data of the delay to coronarography were collected and GRACE score was calculated a posteriori. RESULTS The time to perform coronary angiography was non-compliant in 49% of cases (27 patients out of 55). The calculation of the GRACE score would have allowed correcting the delay for two patients of our cohort. Clinical appreciation, troponin elevation, ECG modifications were associated with the delay compliance. Age <75 years predisposed to recommended delays. Renal failure and history of coronaropathy were significantly associated with non compliant delays. A non-compliant delay was significantly associated with higher mortality. CONCLUSION In our experience, the knowledge of the GRACE score had little impact on the timing of coronary angiography. However, as a predictor of mid and long term mortality, GRACE score remains SCA ST+ useful to intensify surveillance of high-risk patients.
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Affiliation(s)
- F Bouriche
- Centre hospitalier de Martigues, 3, boulevard des Rayettes, 13500 Martigues, France.
| | - S Yvorra
- Centre hospitalier de Martigues, 3, boulevard des Rayettes, 13500 Martigues, France
| | - A Hassan
- Centre hospitalier de Martigues, 3, boulevard des Rayettes, 13500 Martigues, France
| | - F Paganelli
- Centre hospitalo-universitaire Nord, chemin des Bourrely, 13015 Marseille, France
| | - L Bonello
- Centre hospitalo-universitaire Nord, chemin des Bourrely, 13015 Marseille, France
| | - S Luigi
- Centre hospitalier de Martigues, 3, boulevard des Rayettes, 13500 Martigues, France
| | - F Attia
- Centre hospitalier de Martigues, 3, boulevard des Rayettes, 13500 Martigues, France
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17
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Mehmood T, Al Shehrani MS, Ahmad M. Acute coronary syndrome risk prediction of rapid emergency medicine scoring system in acute chest pain. An observational study of patients presenting with chest pain in the emergency department in Central Saudi Arabia. Saudi Med J 2017; 38:900-904. [PMID: 28889147 PMCID: PMC5654023 DOI: 10.15537/smj.2017.9.20809] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess the diagnostic validity of the rapid emergency medical score (REMS) for the risk stratification of acute coronary syndrome (ACS) from non-cardiogenic chest pain. Methods: An observational cross-sectional study was carried out among patients presenting with chest pain to the Emergency Department of Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia, for 6 months from January to June 2016. All patients, included through non-probability convenience sampling, were assessed using standard protocols for the physiological parameters of the REMS, and ACS was confirmed through electrocardiography, cardiac enzyme testing, and angiography (if needed). Data were analyzed using Statistical Package for Social Sciences software version 15 (SPSS Inc, Chicago, IL, USA). The validity of REMS was determined using a cutoff value of 17. Results: In total, 176 (70.4%) of patients were men with a mean age of 49±8.5 years. The mean REM score of the patients was 9.3±4.5, and a sensitivity of 81.6%, specificity of 90.05%, positive predictive value of 66.67%, and a negative predictive value of 95.26% were obtained. Conclusion: Rapid emergency medical score is a simple and fairly valid tool that may be used for diagnosis of ACS with limited resources in emergency medicine.
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Affiliation(s)
- Tahir Mehmood
- Department of Emergency, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia. E-mail:.
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18
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Sprockel Díaz JJ, Mantilla Durán HJ, Cruz Daza LC, Barón RA, Diaztagle JJ. Aplicación de las escalas de estratificación del riesgo en el diagnóstico de los síndromes coronarios agudos. Revista Colombiana de Cardiología 2017; 24:480-487. [DOI: 10.1016/j.rccar.2016.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Long B, Oliver J, Streitz M, Koyfman A. An end-user's guide to the HEART score and pathway. Am J Emerg Med 2017; 35:1350-1355. [DOI: 10.1016/j.ajem.2017.03.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/17/2017] [Accepted: 03/19/2017] [Indexed: 01/23/2023] Open
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Smulowitz PB, Dizitzer Y, Tadiri S, Thibodeau L, Jagminas L, Novack V. Impact of implementation of the HEART pathway using an electronic clinical decision support tool in a community hospital setting. Am J Emerg Med 2017; 36:408-413. [PMID: 28869099 DOI: 10.1016/j.ajem.2017.08.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/17/2017] [Accepted: 08/20/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Peter B Smulowitz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
| | - Yotam Dizitzer
- Clinical Research Center, Soroka University Medical Center, Beer Sheba, Israel
| | - Sarah Tadiri
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, United States
| | - Lara Thibodeau
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, United States
| | - Liudvikas Jagminas
- Department of Emergency Medicine, Beth Israel Deaconess Hospital, Plymouth, United States
| | - Victor Novack
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Internal Medicine, Be'er Sheva, Israel
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Sakamoto JT, Liu N, Koh ZX, Guo D, Heldeweg MLA, Ng JCJ, Ong MEH. Integrating heart rate variability, vital signs, electrocardiogram, and troponin to triage chest pain patients in the ED. Am J Emerg Med 2018; 36:185-92. [PMID: 28743479 DOI: 10.1016/j.ajem.2017.07.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Current triage methods for chest pain patients typically utilize symptoms, electrocardiogram (ECG), and vital sign data, requiring interpretation by dedicated triage clinicians. In contrast, we aimed to create a quickly obtainable model integrating the objective parameters of heart rate variability (HRV), troponin, ECG, and vital signs to improve accuracy and efficiency of triage for chest pain patients in the emergency department (ED). METHODS Adult patients presenting to the ED with chest pain from September 2010 to July 2015 were conveniently recruited. The primary outcome was a composite of revascularization, death, cardiac arrest, cardiogenic shock, or lethal arrhythmia within 72-h of presentation to the ED. To create the chest pain triage (CPT) model, logistic regression was done where potential covariates comprised of vital signs, ECG parameters, troponin, and HRV measures. Current triage methods at our institution and modified early warning score (MEWS) were used as comparators. RESULTS A total of 797 patients were included for final analysis of which 146 patients (18.3%) met the primary outcome. Patients were an average age of 60years old, 68% male, and 56% triaged to the most acute category. The model consisted of five parameters: pain score, ST-elevation, ST-depression, detrended fluctuation analysis (DFA) α1, and troponin. CPT model>0.09, CPT model>0.15, current triage methods, and MEWS≥2 had sensitivities of 86%, 74%, 75%, and 23%, respectively, and specificities of 45%, 71%, 48%, and 78%, respectively. CONCLUSION The CPT model may improve current clinical triage protocols for chest pain patients in the ED.
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Chew DP, Scott IA, Cullen L, French JK, Briffa TG, Tideman PA, Woodruffe S, Kerr A, Branagan M, Aylward PE. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2017; 25:895-951. [PMID: 27465769 DOI: 10.1016/j.hlc.2016.06.789] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. MAIN RECOMMENDATIONS This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.
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Affiliation(s)
- Derek P Chew
- Department of Cardiology, Flinders University, Adelaide, SA
| | - Ian A Scott
- Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, QLD
| | - Louise Cullen
- Australian Centre for Health Services Innovation, Brisbane, QLD
| | - John K French
- Coronary Care and Cardiovascular Research, Liverpool Hospital, Sydney, NSW
| | - Tom G Briffa
- School of Population Health, University of Western Australia, Perth, WA
| | - Philip A Tideman
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, SA
| | - Stephen Woodruffe
- Ipswich Cardiac Rehabilitation and Heart Failure Service, Ipswich Hospital, Ipswich, QLD
| | - Alistair Kerr
- Cardiomyopathy Association of Australia, Melbourne, VIC
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Yiadom MYAB, Liu X, McWade CM, Liu D, Storrow AB. Acute Coronary Syndrome Screening and Diagnostic Practice Variation. Acad Emerg Med 2017; 24:701-709. [DOI: 10.1111/acem.13184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/16/2023]
Affiliation(s)
| | - Xulei Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Conor M. McWade
- Schools of Medicine and Public Health; Vanderbilt University; Nashville TN
| | - Dandan Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
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Santi L, Farina G, Gramenzi A, Trevisani F, Baccini M, Bernardi M, Cavazza M. The HEART score with high-sensitive troponin T at presentation: ruling out patients with chest pain in the emergency room. Intern Emerg Med 2017; 12:357-364. [PMID: 27178708 DOI: 10.1007/s11739-016-1461-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 05/06/2016] [Indexed: 02/07/2023]
Abstract
The HEART score is a simple scoring system, ranging from 0 to 10, specifically developed for risk stratification of patients with undifferentiated chest pain. It has been validated for the conventional troponin, but not for high-sensitive troponin. We assess a modified version of the HEART score using a single high-sensitivity troponin T dosage at presentation, regardless of symptom duration, and with different ECG criteria to evaluate if the patients with a low HEART score could be safely discharged early. The secondary aim was to confirm a statistically significant difference in each HEART score group (low 0-3, intermediate 4-6, high 7-10) in the occurrence of major adverse cardiac events at 30 and 180 days. We retrospectively analyzed the HEART score of 1597 consecutive patients admitted to the Emergency Department of our Hospital for chest pain between January 1 and June 30, 2014. Of these, 190 did not meet the inclusion criteria and 29 were lost to follow-up. None of the 512 (37.2 %) patients with a low HEART score had an event within 180 days. The difference between the cumulative incidences of events in the three HEART score groups was statistically significant (P < 0.0001). We demonstrate that it might be possible to safely discharge Emergency Department chest pain patients with a low modified HEART score after an initial determination of high-sensitive troponin T, without a prolonged observation period or an additional cardiac testing.
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Affiliation(s)
- Luca Santi
- Department of Emergency, Medicina d'Urgenza e Pronto Soccorso, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy.
| | - Gabriele Farina
- Department of Emergency, Medicina d'Urgenza e Pronto Soccorso, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Annagiulia Gramenzi
- Department of Clinical and Surgical Sciences, Semeiotica Medica, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Franco Trevisani
- Department of Clinical and Surgical Sciences, Semeiotica Medica, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Margherita Baccini
- Department of Clinical and Surgical Sciences, Endocrinologia, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Mauro Bernardi
- Department of Clinical and Surgical Sciences, Semeiotica Medica, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Mario Cavazza
- Department of Emergency, Medicina d'Urgenza e Pronto Soccorso, Policlinico S. Orsola-Malpighi, Bologna, Italy
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Abstract
BACKGROUND Patients with chest pain comprise a large proportion of emergency presentations and place a major burden on healthcare resources. Therefore, efforts to safely and rapidly identify those with and without acute myocardial infarction (AMI) are needed. The challenge for clinicians is to accurately identify patients with acute coronary syndromes, while balancing the need to safely and rapidly reassure and discharge those without serious conditions. CONTENT This review summarizes the evidence to date on optimum accelerated strategies for the rule-in and rule-out of AMI, using strategies focused on optimum use of troponin results. Evidence based on both sensitive and highly sensitive troponin assay results is presented. The use of novel biomarkers is also addressed and the combination of biomarkers with other clinical information in accelerated diagnostic strategies is discussed. SUMMARY The majority of patients, who are not at risk of myocardial infarction or other serious harm, may be suitable for discharge directly from the emergency setting using approaches focused on troponin algorithms and accelerated diagnostic protocols. Evidence about the clinical and health economic impact of use of such strategies is needed, as they may have major benefits for both patients and healthcare providers.
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Affiliation(s)
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Simon Mahler
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Richard Body
- Central Manchester University Hospitals NHS Foundation Trust, UK
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Wang H, Watson K, Robinson RD, Domanski KH, Umejiego J, Hamblin L, Overstreet SE, Akin AM, Hoang S, Shrivastav M, Collyer M, Krech RN, Schrader CD, Zenarosa NR. Chest Pain Risk Scores Can Reduce Emergent Cardiac Imaging Test Needs With Low Major Adverse Cardiac Events Occurrence in an Emergency Department Observation Unit. Crit Pathw Cardiol 2016; 15:145-151. [PMID: 27846006 DOI: 10.1097/hpc.0000000000000090] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare and evaluate the performance of the HEART, Global Registry of Acute Coronary Events (GRACE), and Thrombolysis in Myocardial Infarction (TIMI) scores to predict major adverse cardiac event (MACE) rates after index placement in an emergency department observation unit (EDOU) and to determine the need for observation unit initiation of emergent cardiac imaging tests, that is, noninvasive cardiac stress tests and invasive coronary angiography. METHODS A prospective observational single center study was conducted from January 2014 through June 2015. EDOU chest pain patients were included. HEART, GRACE, and TIMI scores were categorized as low (HEART ≤ 3, GRACE ≤ 108, and TIMI ≤1) versus elevated based on thresholds suggested in prior studies. Patients were followed for 6 months postdischarge. The results of emergent cardiac imaging tests, EDOU length of stay (LOS), and MACE occurrences were compared. Student t test was used to compare groups with continuous data, and χ testing was used for categorical data analysis. RESULTS Of 986 patients, emergent cardiac imaging tests were performed on 62%. A majority of patients were scored as low risk by all tools (85% by HEART, 81% by GRACE, and 80% by TIMI, P < 0.05). The low-risk patients had few abnormal cardiac imaging test results as compared with patients scored as intermediate to high risk (1% vs. 11% in HEART, 1% vs. 9% in TIMI, and 2% vs. 4% in GRACE, P < 0.05). The average LOS was 33 hours for patients with emergent cardiac imaging tests performed and 25 hours for patients without (P < 0.05). MACE occurrence rate demonstrated no significant difference regardless of whether tests were performed emergently (0.31% vs. 0.97% in HEART, 0.27% vs. 0.95% in TIMI, and 0% vs. 0.81% in GRACE, P > 0.05). CONCLUSIONS Chest pain risk stratification via clinical decision tool scores can minimize the need for emergent cardiac imaging tests with less than 1% MACE occurrence, especially when the HEART score is used.
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Affiliation(s)
- Hao Wang
- From the *Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX; †Department of Emergency Medicine, Parkland Health and Hospital System, Dallas, TX; ‡Division of Emergency and Disaster Global Health, Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX; §Department of Emergency Medicine, Texas Health Huguley Hospital, Burleson, TX; ¶Texas College of Osteopathic Medicine, UNT Health Science Center, Fort Worth, TX; and ‖Research Institute, John Peter Smith Health Network, Fort Worth, TX
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Chen XH, Jiang HL, Li YM, Chan CPY, Mo JR, Tian CW, Lin PY, Graham CA, Rainer TH. Prognostic values of 4 risk scores in Chinese patients with chest pain: Prospective 2-centre cohort study. Medicine (Baltimore) 2016; 95:e4778. [PMID: 28033243 PMCID: PMC5207539 DOI: 10.1097/md.0000000000004778] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Four risk scores for stratifying patients with chest pain presenting to emergency departments (EDs) (namely Thrombolysis in myocardial infarction [TIMI], Global registry for acute coronary events [GRACE], Banach and HEART) have been developed in Western settings but have never been compared and validated in Chinese patients. We aimed to find out to the number of MACE within 7 days, 30 days, and 6 months after initial ED presentation, and also to compare the prognostic performance of these scores in Chinese patients with suspected cardiac chest pain (CCP) to predict 7-day, 30-day, and 6-month major adverse cardiac events (MACE).A prospective 2-center observational cohort study of consecutive patients presenting with chest pain to the EDs of 2 university hospitals in Guangdong and Hong Kong from 17 March 2012 to 14 August 2013 was conducted. Patients aged ≥18 years with suspected CCP but without ST-segment elevation myocardial infarction (STEMI) were recruited.Of 833 enrolled patients (mean age 65.1 years, SD14.5; 55.6% males), 121 (14.5%) experienced MACE within 6 months (4.8% with safety outcomes and 10.3% with effectiveness outcomes). The HEART score had the largest area under the receiver operating characteristic (ROC) curve for predicting MACE at 7-day, 30-day, and 6-month follow-up [area under curve (AUC) = 0.731, 0.726, and 0.747, respectively. The HEART score also had the largest AUC for predicting effectiveness outcome (AUC = 0.715, 0.704, and 0.721, respectively). However, there was no significant difference in AUC between HEART and TIMI scores. Banach had the largest AUC for predicting safety outcome (AUC = 0.856, 0.837, and 0.850, respectively).The HEART score performed better than the GRACE and Banach scores to predict total MACE and effectiveness outcome in Chinese patients with suspected CCP, whereas the Banach score best predicted safety outcomes.
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Affiliation(s)
- Xiao-Hui Chen
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Hui-Lin Jiang
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Yun-Mei Li
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Cangel Pui Yee Chan
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China
| | - Jun-Rong Mo
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Chao-Wei Tian
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Pei-Yi Lin
- Emergency Department, The 2nd Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Colin A. Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China
| | - Timothy H. Rainer
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong, China
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Sakamoto JT, Liu N, Koh ZX, Fung NXJ, Heldeweg MLA, Ng JCJ, Ong MEH. Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department. Int J Cardiol 2016; 221:759-64. [DOI: 10.1016/j.ijcard.2016.07.147] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 07/09/2016] [Indexed: 02/07/2023]
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Lu Y, Li Y, Yao R, Li Y, Li L, Zhao L, Zhang Y. Clinical effect of ticagrelor administered in acute coronary syndrome patients following percutaneous coronary intervention. Exp Ther Med 2016; 11:2177-2184. [PMID: 27284299 PMCID: PMC4887760 DOI: 10.3892/etm.2016.3224] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/25/2016] [Indexed: 12/25/2022] Open
Abstract
The aim of the present study was to retrospectively analyze the clinical effect and safety of ticagrelor administration in acute coronary syndrome (ACS) patients following percutaneous coronary intervention (PCI). In total, 203 patients were enrolled, who were confirmed with ACS between March 2013 and May 2013, and had successfully undergone PCI. The patients were randomly divided into two groups, including the clopidogrel (group A, n=108) and ticagrelor groups (group B, n=95). Patients in group A were treated with a 600 mg loading dose of clopidogrel followed by 75 mg/day clopidogrel plus 100 mg/day aspirin. Patients in group B received a 180 mg loading dose of ticagrelor followed by 90 mg ticagrelor twice daily plus 100 mg/day aspirin. Light transmission aggregometry was performed to measure the platelet aggregation rate prior to and following 4 weeks of anti-platelet drug treatment. In addition, the rate of cardiovascular events and the adverse drug reactions were recorded within a 1-year treatment period. Compared with the clopidogrel group, the rate of recurrent angina in the ticagrelor group was significantly lower (P=0.05). However, the rate of dyspnea in the ticagrelor group was significantly higher when compared with that in the clopidogrel group (P=0.03). After 4 weeks of treatment, the reduction in the platelet aggregation rate was significantly different between the two groups (P<0.05). Therefore, ticagrelor, which is a novel antiplatelet aggregation drug, may reduce the rate of the adverse cardiovascular events in ACS patients following PCI, but a higher incidence of side-effects, such as dyspnea, may be observed.
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Affiliation(s)
- Yanjiao Lu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Yanshen Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Rui Yao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Yapeng Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Ling Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Luosha Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Yanzhou Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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Peschanski N, Wain-hobson J, Chouihed T, Quibel T, Lenourry V, Ray P. Prise en charge en urgence des syndromes coronariens aigus non-ST+en 2015. Ann Fr Med Urgence 2015; 5:320-328. [DOI: 10.1007/s13341-015-0583-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Marques T, Henriques J, de Carvalho P, Paredes S, Rocha T, Morais J. Personalization Based on Grouping Strategies for Short-Term Cardiovascular Event Risk Assessment. Cardiovasc Eng Technol 2015; 6:392-9. [PMID: 26577370 DOI: 10.1007/s13239-015-0228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
Abstract
Cardiovascular diseases are the main cause of death in Europe, representing 47% of all deaths. This could be avoided, if each patient underwent the most adequate treatment. For this to happen, it is important to determine the patient's risk of having a cardiovascular event. This is known as risk assessment, and can be done using risk scores. However, there are several risk scores with similar performances, which makes it difficult to choose the most adequate one. We propose to overcome this by combining risk scores using personalization based on groups, where new patients are assigned to the most similar group and consequently to the most adequate risk score. This eliminates the need to choose a specific tool, and improves the overall performance (when compared with the performance of individual tools). This strategy was validated using the Santa Cruz Dataset. The results obtained were able to maintain the highest sensitivity while improving the specificity in 13% when compared with the highest values achieved by the selected individual risk scores (GRACE, TIMI, PURSUIT).
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Abstract
Chest pain is one of the most common presenting complaints in the emergency department, though only a small minority of patients are subsequently diagnosed with acute coronary syndrome (ACS). However, missing the diagnosis has potential for significant morbidity and mortality. ACS presentations can be atypical, and their workups are often prolonged and costly. In order to risk-stratify patients and better direct the workup and care given, many decision aids have been developed. While each may have merit in certain clinical settings, the most useful aid in the emergency department is one that finds all cases of ACS while also identifying a substantial subset of patients at low risk who can be discharged without stress testing or coronary angiography. This review describes several of the chest pain decision aids developed and studied through the recent past, starting with the thrombolysis in myocardial infarction (TIMI) risk score and Global Registry of Acute Coronary Events (GRACE) scores, which were developed as prognostic aids for patients already diagnosed with ACS, then subsequently validated in the undifferentiated chest pain population. Asia-Pacific Evaluation of Chest Pain Trial (ASPECT); Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins (ADAPT); North American Chest Pain Rule (NACPR); and History, Electrocardiogram, Age, Risk factors, Troponin (HEART) score have been developed exclusively for use in the undifferentiated chest pain population as well, with improved performance compared to their predecessors. This review describes the relative merits and limitations of these decision aids so that providers can determine which tool fits the needs of their clinical practice setting.
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Affiliation(s)
- William Alley
- Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Boubaker H, Beltaief K, Grissa MH, Kerkeni W, Dridi Z, Msolli MA, Chouchène H, Belaïd A, Chouchène H, Sassi M, Bouida W, Boukef R, Methemmem M, Marghli S, Nouira S. Inaccuracy of Thrombolysis in Myocardial Infarction and Global Registry in Acute Coronary Events scores in predicting outcome in ED patients with potential ischemic chest pain. Am J Emerg Med 2015; 33:1209-12. [DOI: 10.1016/j.ajem.2015.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/23/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022] Open
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Affiliation(s)
- Clare L Atzema
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (C.L.A., M.J.S.); Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (C.L.A., M.J.S.); and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (C.L.A., M.J.S.).
| | - Michael J Schull
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (C.L.A., M.J.S.); Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada (C.L.A., M.J.S.); and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (C.L.A., M.J.S.)
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Scheuermeyer FX, Wong H, Yu E, Boychuk B, Innes G, Grafstein E, Gin K, Christenson J. Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain. CAN J EMERG MED 2015; 16:106-19. [DOI: 10.2310/8000.2013.130938] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjectives: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 < 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.
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Taylor BT, Mancini M. Discrepancy between clinician and research assistant in TIMI score calculation (TRIAGED CPU). West J Emerg Med 2014; 16:24-33. [PMID: 25671004 PMCID: PMC4307721 DOI: 10.5811/westjem.2014.9.21685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/28/2014] [Accepted: 09/04/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Several studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify emergency department (ED) patients with potential acute coronary syndromes (ACS). Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED providers functioning in their normal work capacity. We assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators. Methods This was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. We examined provider type, patient gender, and TIMI elements for their effects on TIMI risk score discrepancy. Results Of the 501 adult patients enrolled in the study, 29.3% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. In our low-risk population the majority of TIMI risk score differences were small; however, 12% of TIMI risk scores differed by two or more points. Conclusion TIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider.
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Affiliation(s)
- Brian T Taylor
- Lakeland HealthCare, Department of Emergency Medicine, St. Joseph MI, Department of Emergency Medicine, Saint Joseph, Michigan
| | - Michelino Mancini
- Lakeland HealthCare, Department of Emergency Medicine, St. Joseph MI, Department of Emergency Medicine, Saint Joseph, Michigan
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64:e139-e228. [PMID: 25260718 DOI: 10.1016/j.jacc.2014.09.017] [Citation(s) in RCA: 2052] [Impact Index Per Article: 205.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e344-426. [PMID: 25249585 DOI: 10.1161/cir.0000000000000134] [Citation(s) in RCA: 628] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Liu N, Koh ZX, Goh J, Lin Z, Haaland B, Ting BP, Ong MEH. Prediction of adverse cardiac events in emergency department patients with chest pain using machine learning for variable selection. BMC Med Inform Decis Mak 2014; 14:75. [PMID: 25150702 PMCID: PMC4150554 DOI: 10.1186/1472-6947-14-75] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 08/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The key aim of triage in chest pain patients is to identify those with high risk of adverse cardiac events as they require intensive monitoring and early intervention. In this study, we aim to discover the most relevant variables for risk prediction of major adverse cardiac events (MACE) using clinical signs and heart rate variability. METHODS A total of 702 chest pain patients at the Emergency Department (ED) of a tertiary hospital in Singapore were included in this study. The recruited patients were at least 30 years of age and who presented to the ED with a primary complaint of non-traumatic chest pain. The primary outcome was a composite of MACE such as death and cardiac arrest within 72 h of arrival at the ED. For each patient, eight clinical signs such as blood pressure and temperature were measured, and a 5-min ECG was recorded to derive heart rate variability parameters. A random forest-based novel method was developed to select the most relevant variables. A geometric distance-based machine learning scoring system was then implemented to derive a risk score from 0 to 100. RESULTS Out of 702 patients, 29 (4.1%) met the primary outcome. We selected the 3 most relevant variables for predicting MACE, which were systolic blood pressure, the mean RR interval and the mean instantaneous heart rate. The scoring system with these 3 variables produced an area under the curve (AUC) of 0.812, and a cutoff score of 43 gave a sensitivity of 82.8% and specificity of 63.4%, while the scoring system with all the 23 variables had an AUC of 0.736, and a cutoff score of 49 gave a sensitivity of 72.4% and specificity of 63.0%. Conventional thrombolysis in myocardial infarction score and the modified early warning score achieved AUC values of 0.637 and 0.622, respectively. CONCLUSIONS It is observed that a few predictors outperformed the whole set of variables in predicting MACE within 72 h. We conclude that more predictors do not necessarily guarantee better prediction results. Furthermore, machine learning-based variable selection seems promising in discovering a few relevant and significant measures as predictors.
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Affiliation(s)
| | | | | | | | | | | | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore 169608, Singapore.
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Abbasnezhad M, Soleimanpour H, Sasaie M, EJ Golzari S, Safari S, Soleimanpour M, Mehdizadeh Esfanjani R. Comparison of Prediction Between TIMI (Thrombolysis in Myocardial Infarction) Risk Score and Modified TIMI Risk Score in Discharged Patients From Emergency Department With Atypical Chest Pain. Iran Red Crescent Med J 2014; 16:e13938. [PMID: 24719735 PMCID: PMC3965868 DOI: 10.5812/ircmj.13938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/29/2013] [Accepted: 01/01/2014] [Indexed: 11/16/2022]
Abstract
Background: Chest pain is one of the most common causes of the admission to the emergency departments. It, however, can be due to numerous diseases some of which are life threatening. Objectives: In the current study, we evaluated the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) and Modified TIMI risk scores to stratify the risk for patients with atypical chest pain being discharged from the emergency department. Patients and Methods: In a prospective-analytic study, we collected data from 1020 patients with atypical chest pain enrolled to the study. All eligible patients were visited by the emergency medicine residents who were trained for this study. Based on the criteria in both systems, the emergency medicine attending decided on either discharging or hospitalizing patients. Patients were allocated into 2 equal groups randomly. In order to predict the opposing accidents in 30 days (coronary revascularization, myocardial infarction, and all-cause death) TIMI risk scores and Modified TIMI risk scores were assessed based on TIMI risk score (0 or 1) and Modified TIMI risk score (0 or 1). Results: No significant difference could be observed between both groups regarding demographic characteristics, ejection fraction, left ventricle hypertrophy, TRS criteria, risk factors and the history of coronary artery stenosis. None of the atypical chest pain patients discharged based on TIMI and modified TIMI risk scores experienced any adverse events. Conclusions: The results obtained from this study support the idea that the TIMI and modified TIMI risk scores might be valuable tools that could be used to stratify the risk of patients with atypical chest pain in the emergency department.
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Affiliation(s)
- Mohsen Abbasnezhad
- Department of Cardiology, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Hassan Soleimanpour
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding Author: Hassan Soleimanpour, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel: +98-9141164134, Fax: +98-4113352078, E-mail:
| | - Mohamadreza Sasaie
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Samad EJ Golzari
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Saeid Safari
- Department of Anesthesiology and Critical Care, Iran University of Medical Sciences, Tehran, IR Iran
| | - Maryam Soleimanpour
- Gastroenterology Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Haaf P, Zellweger C, Reichlin T, Zbinden A, Wildi K, Mosimann T, Twerenbold R, Reiter M, Balmelli C, Freidank H, Gimenez MR, Peter F, Freese M, Stelzig C, Hartmann B, Dinter C, Osswald S, Mueller C. Utility of C-terminal Proendothelin in the Early Diagnosis and Risk Stratification of Patients With Suspected Acute Myocardial Infarction. Can J Cardiol 2014; 30:195-203. [DOI: 10.1016/j.cjca.2013.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 11/20/2013] [Accepted: 11/20/2013] [Indexed: 10/26/2022] Open
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Mahler SA, Burke GL, Goff DC Jr, Hiestand BC, Nicks BA, Hoekstra JW, Case LD, Miller CD. Avoidable utilization of the chest pain observation unit: evaluation of very-low-risk patients. Crit Pathw Cardiol 2013; 12:59-64. [PMID: 23680810 DOI: 10.1097/HPC.0b013e31828dc764] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Very-low-risk patients treated in a chest pain observation unit (CPOU) may threaten efficient care delivery. To optimize the efficiency of CPOU evaluations, it is necessary to quantify the avoidable CPOU utilization rate, examine physician variability, and determine patient and physician characteristics associated with avoidable CPOU utilization. METHODS Consecutive chest pain patients were evaluated in an Emergency Department-based CPOU. Patients were risk stratified based on the American College of Cardiology/American Heart Association framework, age, and electrocardiogram findings. Very-low-risk was defined as age <35, physician assessment of low-risk, and normal or nondiagnostic electrocardiogram. Patients identified as very-low-risk were considered avoidable CPOU evaluations. Individual physicians' avoidable CPOU utilization rates were calculated. Patients were followed for 30-day major adverse cardiac events, defined as the composite of death, acute myocardial infarction, and coronary revascularization. RESULTS Over 33 months, the registry included 1731 chest pain patients. The study definition of avoidable CPOU evaluations was met by 174 patients (10.1%, 95% confidence interval: 8.7-11.6%). The median rate of physician's avoidable CPOU utilization was 10% (interquartile range: 5.9-13.6%) and varied from 1.9% to 18.4%. None of the patients with an avoidable CPOU evaluation had a major adverse cardiac events within 30 days. Physician predictors of avoidable CPOU utilization included recent residency graduation (<5 years), part-time status, and moderate or high rates of CPOU use. CONCLUSIONS Approximately 10% of CPOU evaluations were avoidable. Wide variability exists among physicians regarding their individual rates of avoidable CPOU utilization. This variability could represent an opportunity to improve the efficiency of CPOU care delivery.
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D'Ascenzo F, Cerrato E, Biondi-Zoccai G, Omedè P, Sciuto F, Presutti DG, Quadri G, Raff GL, Goldstein JA, Litt H, Frati G, Reed MJ, Moretti C, Gaita F. Coronary computed tomographic angiography for detection of coronary artery disease in patients presenting to the emergency department with chest pain: a meta-analysis of randomized clinical trials. Eur Heart J Cardiovasc Imaging 2012; 14:782-9. [PMID: 23221314 DOI: 10.1093/ehjci/jes287] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Haaf P, Twerenbold R, Reichlin T, Faoro J, Reiter M, Meune C, Steuer S, Bassetti S, Ziller R, Balmelli C, Campodarve I, Zellweger C, Kilchenmann A, Irfan A, Papassotiriou J, Drexler B, Mueller C. Mid-regional pro-adrenomedullin in the early evaluation of acute chest pain patients. Int J Cardiol 2012. [PMID: 23199555 DOI: 10.1016/j.ijcard.2012.10.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The purpose of this study was to investigate the utility of mid-regional pro-adrenomedullin (MR-proADM) in the early diagnosis and risk stratification of patients with acute chest pain in comparison with established and novel biomarkers and risk scores. METHODS In this prospective, observational, international, multi-center trial (APACE), MR-proADM was determined in 1179 unselected patients with acute chest pain. Patients were followed for 24 months. RESULTS MR-proADM concentrations at presentation were higher in patients with AMI (median: 0.78 nmol/l, IQR 0.60-1.13) than in patients with other diagnoses (0.64 nmol/l, IQR 0.49-0.86 nmol/l; p<0.001). The diagnostic accuracy of MR-proADM for AMI as quantified by the area under the receiver operating characteristic curve (AUC) was 0.66. Adding MR-proADM to hs-cTnT could not improve its diagnostic accuracy for AMI (p=0.431). Seventy-six percent of all deaths occurred in the fourth quartile of MR-proADM (>0.90 nmol/l). Adding MR-proADM to the TIMI-score (AUC 0.87) predicted 1-year mortality more accurately than the TIMI-score alone (AUC 0.82; p<0.001). Net reclassification improvement (TIMI vs. additionally MR-proADM) amounted to 0.137 (p=0.012). MR-proADM had higher prognostic accuracy as compared to hs-cTnT in patients with AMI (p=0.015) and in those without AMI (p=0.003). MR-proADM at presentation was tantamount to GRACE score and BNP as to its prognostic accuracy for mortality. The AUC for the prediction of cardiovascular events amounted to 0.63. CONCLUSIONS While MR-proADM does not have clinical utility in the early diagnosis of AMI or predicting cardiovascular events in patients with acute chest pain, it may provide prognostic value for all-cause mortality.
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Affiliation(s)
- Philip Haaf
- Department of Internal Medicine, Division of Cardiology, University Hospital, Basel, Switzerland
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Mahler SA, Miller CD, Hollander JE, Nagurney JT, Birkhahn R, Singer AJ, Shapiro NI, Glynn T, Nowak R, Safdar B, Peberdy M, Counselman FL, Chandra A, Kosowsky J, Neuenschwander J, Schrock JW, Plantholt S, Diercks DB, Peacock WF. Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol 2012; 168:795-802. [PMID: 23117012 DOI: 10.1016/j.ijcard.2012.10.010] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 09/03/2012] [Accepted: 10/07/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations. METHODS AND RESULTS A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR. CONCLUSIONS The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.
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Kelly A, Dabee P, Klim S, Soon K. External Validation of the GRACE Freedom from Events Score. Heart Lung Circ 2012; 21:582-5. [DOI: 10.1016/j.hlc.2012.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 04/11/2012] [Accepted: 05/16/2012] [Indexed: 11/16/2022]
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Fesmire FM, Martin EJ, Cao Y, Heath GW. Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score. Am J Emerg Med 2012; 30:1829-37. [PMID: 22626816 DOI: 10.1016/j.ajem.2012.03.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 03/19/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The HEART score uses elements from patient History, Electrocardiogram, Age, Risk Factors, and Troponin to obtain a risk score on a 0- to 10-point scale for predicting acute coronary syndromes (ACS). This investigation seeks to improve on the HEART score by proposing the HEARTS(3) score, which uses likelihood ratio analysis to give appropriate weight to the individual elements of the HEART score as well as incorporating 3 additional "S" variables: Sex, Serial 2-hour electrocardiogram, and Serial 2-hour delta troponin during the initial emergency department valuation. METHODS This is a retrospective analysis of a prospectively acquired database consisting of 2148 consecutive patients with non-ST-segment elevation chest pain. Interval analysis of likelihood ratios was performed to determine appropriate weighting of the individual elements of the HEART(3) score. Primary outcomes were 30-day ACS and myocardial infarction. RESULTS There were 315 patients with 30-day ACS and 1833 patients without ACS. Likelihood ratio analysis revealed significant discrepancies in weight of the 5 individual elements shared by the HEART and HEARTS(3) score. The HEARTS(3) score outperformed the HEART score as determined by comparison of areas under the receiver operating characteristic curve for myocardial infarction (0.958 vs 0.825; 95% confidence interval difference in areas, 0.105-0.161) and for 30-day ACS (0.901 vs 0.813; 95% confidence interval difference in areas, 0.064-0.110). CONCLUSION The HEARTS(3) score reliably risk stratifies patients with chest pain for 30-day ACS. Prospective studies need to be performed to determine if implementation of this score as a decision support tool can guide treatment and disposition decisions in the management of patients with chest pain.
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Rao MP, Panduranga P, Al-Mukhaini M, Sulaiman K, Al-Jufaili M. Predictive value of a 4-hour accelerated diagnostic protocol in patients with suspected ischemic chest pain presenting to an emergency department. Oman Med J 2012; 27:207-11. [PMID: 22811769 PMCID: PMC3394349 DOI: 10.5001/omj.2012.47] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 03/21/2012] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Currently recommended risk stratification protocols for suspected ischemic chest pain in the emergency department (ED) includes point-of-care availability of exercise treadmill/nuclear tests or CT coronary angiograms. These tests are not widely available for most of the ED's. This study aims to prospectively validate the safety of a predefined 4-hour accelerated diagnostic protocol (ADP) using chest pain, ECG, and troponin T among suspected ischemic chest pain patients presenting to an ED of a tertiary care hospital in Oman. METHODS One hundred and thirty-two patients aged over 18 years with suspected ischemic chest pain presenting within 12 hours of onset along with normal or non-diagnostic first ECG and negative first troponin T (<0.010 μg/l) were recruited from September 2008 to February 2009. Low-probability acute coronary syndrome (ACS) patients at 4-hours defined as absent chest pain and negative ECG or troponin tests were discharged home and observed for 30-days for major adverse cardiac events (MACE) (Group I: negative ADP). High-probability ACS patients at 4-hours were defined by recurrent or persistent chest pain, positive ECG or troponin tests and were admitted and observed for in-hospital MACE (Group II: positive ADP). RESULTS One hundred and thirty-two patients were recruited and 110 patients completed the study. The overall 30-day MACE in this cohort was 15% with a mortality of less than 1%. 30-days MACE occurred in 8/95 of group I patients (8.4%) and 9/15 of the in-hospital MACE patients in group II. The ADP had a sensitivity of 52% (95% CI: 0.28-0.76), specificity of 93% (0.85-0.97), a negative predictive value of 91% (0.83-0.96), a positive predictive value of 60% (0.32-0.82), negative likelihood ratio of 0.5 (0.30-0.83) and a positive likelihood ratio of 8.2 (3.3-20) in predicting MACE. CONCLUSION A 4-hour ADP using chest pain, ECG, and troponin T had high specificity and negative predictive value in predicting 30-day MACE among low probability ACS patients discharged from ED. However, 30-day MACE in ADP negative patients was relatively high in contrast to guideline recommendations. Hence, there is a need to establish ED chest pain unit and adopt new protocols especially adding a point-of-care exercise treadmill test in the ED.
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Affiliation(s)
- Mamatha P.R. Rao
- Department of Accident and Emergency, Royal Hospital, Sultanate of Oman
| | | | | | - Kadhim Sulaiman
- Department of Cardiology, Royal Hospital, Muscat, Sultanate of Oman
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Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012; 366:1393-403. [PMID: 22449295 DOI: 10.1056/nejmoa1201163] [Citation(s) in RCA: 490] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Admission rates among patients presenting to emergency departments with possible acute coronary syndromes are high, although for most of these patients, the symptoms are ultimately found not to have a cardiac cause. Coronary computed tomographic angiography (CCTA) has a very high negative predictive value for the detection of coronary disease, but its usefulness in determining whether discharge of patients from the emergency department is safe is not well established. METHODS We randomly assigned low-to-intermediate-risk patients presenting with possible acute coronary syndromes, in a 2:1 ratio, to undergo CCTA or to receive traditional care. Patients were enrolled at five centers in the United States. Patients older than 30 years of age with a Thrombolysis in Myocardial Infarction risk score of 0 to 2 and signs or symptoms warranting admission or testing were eligible. The primary outcome was safety, assessed in the subgroup of patients with a negative CCTA examination, with safety defined as the absence of myocardial infarction and cardiac death during the first 30 days after presentation. RESULTS We enrolled 1370 subjects: 908 in the CCTA group and 462 in the group receiving traditional care. The baseline characteristics were similar in the two groups. Of 640 patients with a negative CCTA examination, none died or had a myocardial infarction within 30 days (0%; 95% confidence interval [CI], 0 to 0.57). As compared with patients receiving traditional care, patients in the CCTA group had a higher rate of discharge from the emergency department (49.6% vs. 22.7%; difference, 26.8 percentage points; 95% CI, 21.4 to 32.2), a shorter length of stay (median, 18.0 hours vs. 24.8 hours; P<0.001), and a higher rate of detection of coronary disease (9.0% vs. 3.5%; difference, 5.6 percentage points; 95% CI, 0 to 11.2). There was one serious adverse event in each group. CONCLUSIONS A CCTA-based strategy for low-to-intermediate-risk patients presenting with a possible acute coronary syndrome appears to allow the safe, expedited discharge from the emergency department of many patients who would otherwise be admitted. (Funded by the Commonwealth of Pennsylvania Department of Health and the American College of Radiology Imaging Network Foundation; ClinicalTrials.gov number, NCT00933400.).
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Affiliation(s)
- Harold I Litt
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVE To investigate the prognostic utility of Heart Foundation (Australia) risk stratification table in an ED chest pain population. METHODS A planned sub-study of a prospective observational study of adult patients with potentially cardiac chest pain who underwent evaluation for acute coronary syndrome (ACS) was conducted. Data collected included demographical, clinical, ECG, biomarker and outcome data. Outcome of interest was diagnostic utility of the classification system for ACS or myocardial infarction (MI) at index presentation and major adverse cardiac events (MACE) within 7 and 30 days. MACE included death, cardiac arrest, revascularization, cardiogenic shock, arrhythmia and prevalent (cause of presentation) and incident (occurring within the follow-up period) MI. Analysis was by descriptive and receiver-operator curve analyses. RESULTS Seven hundred and sixty-eight patients were studied; 109 had MI (14.2%, 95% confidence interval [CI] 11.9-16.8%). There were 88 MACE at 7 days (13.5%, 95% CI 11.1-16.4%) and 93 MACE at 30 days (14.4%%, 95% CI 11.9-17.3%). Diagnostic performance (c-statistic) of the National Heart Foundation risk classification for ACS, MI, 7 and 30 day MACE was 0.74 for each (95% CI 0.71-0.77). Although sensitivity of the high-risk classification for MI, 7 and 30 day MACE was high (99-100%), specificity was low (48-50%). CONCLUSION The Heart Foundation risk classification shows only fair predictive performance for MI, 7 and 30 day MACE. With specificity of approximately 50%, the recommendation for coronary care admission for all high-risk patients is hard to justify.
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Affiliation(s)
- Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research at Western Health, Sunshine Hospital, Melbourne, Furlong Road, St Albans, VIC 3021, Australia.
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