How to improve the management of chest pain: hospitalists and use of prediction rules

Clinical Profile of Acute Coronary Syndrome Presentation to the Ladysmith Provincial Hospital: High Prevalence Among the Minority Indian Population

Background

Cardiovascular diseases were responsible for 17% of the 460236 natural deaths in South Africa in 2015. Previous studies have reported a disproportionately higher incidence of ischemic heart disease (IHD) and its risk factors among individuals of Indian descent residing in South Africa. The aim of this study was to explore the clinical profile of patients presenting with a diagnosis of acute coronary syndrome (ACS) and to compare the characteristics of patients of Indian descent to those of non-Indian descent.

Methods

Retrospective data were derived from the medical charts of 160 consecutive patients presenting to the Ladysmith Provincial Hospital over a 44-month period with a diagnosis of ACS. Findings were described and compared.

Results

The mean (SD) age of study patients was 55.8 (±12.8) years. The majority of subjects were male (n=90, 56.3%) and unemployed (n=98, 62.3%). The racial distribution of the study sample comprised 103 (64.4%) Indian, 36 (22.5%) Black, and 21 (13.1%) White subjects. Compared to non-Indian subjects, a significantly higher proportion (p<0.05) of Indian subjects were male (64.7% vs 41.4%), cigarette smokers (52.0% vs 32.8%), had a previous history of ACS (37.3% vs 10.3%), were diabetic (33.3% vs 17.2%), and were hypertensive (58.8% vs 29.3%).

Conclusion

The disproportionately high frequency of ACS among the minority Indian population of Ladysmith is concerning. There is a need for rigorous public health interventions to create local awareness, encourage lifestyle modification, and thereby improve control of cardiovascular risk factors, especially among high-risk population groups.

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

Background

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

Methods

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

Results

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

Conclusion

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

Cost burden of non-specific chest pain admissions

BACKGROUND

Non-cardiac aetiologies are common among patients presenting with chest pain.

AIM

To determine the cost of non-specific chest pain admissions to a tertiary referral, teaching hospital.

METHODS

Thrombolysis in myocardial infarction risk (TIMI) risk score, lengths of stay (LOS), investigations and diagnoses were recorded for patients admitted with chest pain. Non-specific chest pain was defined as chest pain where cardiac, pulmonary and gastroesophageal aetiologies were excluded. Costs of admissions were calculated.

RESULTS

Of 80 patients, 34 (4%) and 22 (28%) were diagnosed with non-specific chest pain and acute coronary syndrome, respectively. Non-specific chest pain admissions had a mean age of 54 (11; 35-74) years, LOS of 3.8 (2.6; 1-11) days and TIMI risk score of 1.4 (1.5; 0-5). Acute coronary syndrome admissions had a mean age of 67 (14; 43-94) years, LOS of 7.7 (4.3; 2-16) days and TIMI risk score of 3.1 (1.2; 0-5). The mean cost per non-specific chest pain admission was €3,729 (2,378; 1,034-10,468), or 48% of the mean cost per acute coronary syndrome admission of €7,667 (4,279; 1,963-16,071). Bed day costs account for >90% of overall costs. Only 7% of patients were weekend discharges. The mean interval to exercise stress test was 2.7(1.5; 1-7) days.

CONCLUSIONS

The mean costs of admission and LOS for patients with non-specific chest pain are significant. Extrapolating findings, annual national cost is estimated at approximately €71 million for this cohort, with 73,000 bed days consumed nationally. Delays from admission to tests and low percentage of weekend discharges prolong LOS.

Performing stable angina pectoris: an ethnographic study

Symptoms play a crucial part in the formulation of medical diagnoses, yet the construction and interpretation of symptom narratives is not well understood. The diagnosis of angina is largely based on symptoms, but a substantial minority of patients diagnosed with "non-cardiac" chest pain go on to have a heart attack. In this ethnographic study our aims were to understand: (1) how the patients' accounts are performed or enacted in consultations with doctors; (2) the ways in which ambiguity in the symptom narrative is managed by doctors; and (3) how doctors reach or do not reach a diagnostic decision. We observed 59 consultations of patients in a UK teaching hospital with new onset chest pain who had been referred for a specialist opinion in ambulatory care. We found that patients rarely gave a history that, without further interrogation, satisfied the doctors, who actively restructured the complex narrative until it fitted a diagnostic canon, detaching it from the patient's interpretation and explanation. A minority of doctors asked about chest pain symptoms outside the canon. Re-structuring into the canonical classification was sometimes resisted by patients who contested key concepts, like exertion. Symptom narratives were sometimes unstable, with central features changing on interrogation and re-telling. When translation was required for South Asian patients, doctors considered the history less relevant to the diagnosis. Diagnosis and effective treatment could be enhanced by research on the diagnostic and prognostic value of the terms patients use to describe their symptoms.